Nurse's Pocket Guide

SECTION 3
CLIENT SITUATION AND
PROTOTYPE PLAN OF CARE
Client Situation
Mr. R.S., a client with type 2 diabetes (non–insulin-dependent) for
8 years, presented to his physician’s office with a nonhealing ulcer of
3 weeks’ duration on his left foot. Screening studies done in the doctor’s
office revealed blood glucose of 356/fingerstick and urine
Chemstix of 2%. Because of distance from medical provider and
lack of local community services, he is admitted to the hospital.
ADMITTING PHYSICIAN’S ORDERS
Culture/sensitivity and Gram’s stain of foot ulcer
Random blood glucose on admission and fingerstick BG qid
CBC, electrolytes, serum lipid profile, glycosylated Hb in AM
Chest x-ray and ECG in AM
DiaBeta 10 mg, PO BID
Glucophage 500 mg, PO daily to start—will increase gradually
Humulin N 10 U SC q AM and HS. Begin insulin instruction for
post-discharge self-care if necessary
Dicloxacillin 500 mg PO q6h, start after culture obtained
Darvocet-N 100 mg PO q4h prn pain
Diet—2400 calories, 3 meals with 2 snacks
Up in chair ad lib with feet elevated
Foot cradle for bed
Irrigate lesion L foot with NS tid, then cover with wet to dry
sterile dressing
Vital signs qid
CLIENT ASSESSMENT DATABASE
Name: R.S. Informant: Client
Reliability (Scale 1–4): 3
Age: 70 DOB: 5/3/36 Race: White Gender: M
Adm. date: 6/28/2007 Time: 7 PM From: home
Activity/Rest
SUBJECTIVE (REPORTS)
Occupation: farmer
Usual activities/hobbies: reading, playing cards. “Don’t have
PUTTING THEORY INTO PRACTICE 47
Plan of Care