How to write nursing rounds for diabetes

First: Case report

1. History of current illness

For example: 2 months ago, there was dry mouth without obvious inducement, excessive drinking, and drinking 3000~4000ML of water every day. , accompanied by polyuria, urine output equal to water intake, no polyphagia, and weight loss. . . . . etc.

2. Past history

For example: usually in good health, no high blood pressure, coronary heart disease, diabetes and other diseases, no pneumonia, tuberculosis, bacillary dysentery and other infectious diseases, no surgery' Blood transfusion, history of trauma. Allergy to cefradine. . . . etc.

3. Personal history

For example: country of birth, no history of long-term residence in other places. No history of exposure to toxic substances, radiation, or special chemicals, no history of exposure to epidemic areas, epidemic water, or pastoral areas. He has a smoking history of 10 years, 20 cigarettes a day. Married, no sexually transmitted diseases, no travel history. . . Wait

4. Vital signs

For example: body temperature 36.8 degrees, pulse: 96 beats/min, respiration: 18 times/time blood pressure: 120/80mmHg

5. General conditions

For example: normal development, good nutrition, and free expression. Skin and mucous membranes: normal color, no rash, no bleeding spots or ecchymoses on the skin all over the body, no ulcers on the oral mucosa, no palpable enlargement of superficial lymph nodes throughout the body, chest: light tone upon immediate diagnosis, regular breath sounds on auscultation, and bilateral lungs Dry and wet rales were heard. Heart: The apical pulse is normal and the heart rate is uniform. Abdomen: Flat, the liver and spleen are not palpable under the ribs, there is no doubt that there is dullness and hyperactive bowel sounds, and there are no deformities in the limbs.

6. Auxiliary examinations

For example:

1. Blood sugar on 2011.7.17 20.4MMOL/L

2. Blood sugar on 2011.7.18 Routine N%49%, RBC5.58*109/L, hemoglobin 176G/L, glycosylated hemoglobin 8.4%, urine routine GLU10000MG/DL. Biochemistry: triglyceride 4.91MMOL, HDL 0.92MMOL/L, LDL 1.99MMOL/L, Blood sugar 13.09MMOL/L.

3. 2011.7.19 Abdominal part B: fatty liver (moderate), splenomegaly

7. Admission diagnosis

2 Type 2 diabetes

8. Current treatment

Secondary care, diabetes diet, total calories 1625KCAL, protein 65G, fat, 52G, sugar 224G, three meals at 1/5, 2/ 5 allocation. Monitor fasting and post-meal blood glucose.

Treatment: Novolin R 8U in the morning, 8U in the afternoon, 6U Novolin N in the evening, 14U before bedtime

Oral administration: metformin hydrochloride 0.5, Tid Acarbose 50MG before meals and chewed during meals Tid fenofibrate 0.2QN

Main nursing issues

P1: Nutritional disorders: lower than body requirements

Objective: patients eat and drink more during hospitalization Symptoms of polyuria were relieved and blood sugar levels were normal.

Measures: 1. Inject insulin as directed by the doctor and take medicine on time.

2. Frequently change the injection site to promote insulin absorption.

3. Follow your doctor’s advice. A low-sugar diet can increase the release of insulin from the pancreatic islet glands, which has a certain therapeutic effect on patients with non-insulin-dependent diabetes.

4. Provide meals for each meal according to the nutritionist’s consultation requirements, and tell the patient that he must eat the food on my plate.

5. Insulin injection must be performed strictly aseptic to prevent infection.

6. Provide three meals on time.

7. During the application of insulin, monitor blood sugar changes at any time to avoid hypoglycemia.

8. If hypoglycemia occurs, measures should be taken immediately and the doctor should be notified to adjust the insulin dose in a timely manner.

Effectiveness evaluation: Goal achieved

P2: Sleep pattern disorder - related to environmental changes - manifested as multiple dreams at night and easy awakening.

Goals: 1. The patient can sleep for more than five hours continuously within a week.

Measures: 1. Evaluate the reasons why the patient has many dreams and is easy to wake up.

2. Keep the ward quiet and clean, and reduce unnecessary treatment-level operations at night.

3. Nurses should be careful in the corridors of the ward to reduce the impact on patients.

4. Encourage patients to soak their feet in hot water or drink a hot drink before going to bed to facilitate sleep.

5. Inform patients of the importance of reducing daytime sleep and not to do too many activities before going to bed.

Effectiveness evaluation: Target achieved

P3: Risk of infection

Goal: No infection occurs during hospitalization

Measures: 1, Instruct the patient on skin care: ever bathe with mild soap and warm water. Avoid skin scratches or other injuries.

2. Instruct patients on foot health care: Check the feet every day. If there is pain, color and temperature changes, or symptoms of infection, seek medical attention immediately. Take a warm bath every day. Cut your nails flat and don't cut too deep into the corners of your toenails. Do not use sharp objects to pick at calluses and corns. Wear clean socks every day, and do not wear socks or stockings with tight elastic cuffs. Wear shoes that fit your feet. Exercise every day to promote blood circulation, or do foot exercises.

3. Maintain the patient’s dental care: check teeth regularly and maintain oral hygiene.

4. Instruct the patient to quit smoking. Both smoking and diabetes can narrow blood vessels and cause poor circulation.

Effectiveness evaluation: Goal achieved

The above are all handwritten and excerpted by me. I am exhausted. Please forgive me if there are any mistakes. I hope it can be helpful to you!