Patient Teaching/Plan of Care of the Newly Diagnosed Type 2 Diabetic

Introduction

Mary L. is a 45 year old, African American female newly diagnosed with Type 2 diabetes. Mary has a history of gestational diabetes with her last pregancy, 10 years ago, which was diet controlled and hypertension. She is a single mother of a 10 and 13 year old, and is employed full-time as a fifth grade teacher. She takes Procardia XL 30mg daily and a multivitamin daily. Today Mary is:

Height: 5' 3"

Weight: 195 lbs

Blood Pressure: 132/81

HbA1C: 8.7%

Fasting Blood Glucose: 252

LFT: normal

Creatinine: 0.9 mg/dL

BUN: 10 mg/dL

She is prescribed Metformin.

Task

Create a SOAP note appropriate for this patient.

Please ensure that the following questions are answered:

What predisposing risk factors does Mary have?

What is the significance of the creatinine level?

What information is relevant for this patient to know since she also takes Procardia XL (nifedipine) daily?

What teaching in regards to diet and exercise are recommended by the AADE?

What would be your follow-up plan for this patient?

What laboratory tests are recommended by the manufacturerer to monitor metformin effectiveness?

What other referrals would be appropriate for this patient (i.e. healthcare providers and healthprofessionals)?

Process

Students are to divide into groups of 3-4. To assist you in your quest to develop a PowerPoint Presentation, create a SOAP note for this patient and answer the questions please click on the following links:

Type
2 Diabetes Nursing Times

Type 2 Diabetes Article
Medscape

Who
Is At Risk For Type 2 Diabetes?

Diabetes Patient
Education Materials

American
Association of Diabetes Educators Patient Education Videos

Metformin Package Insert

Blood
Glucose Testing

Evaluation

Case Study Review Rubric Criteria to Meet
	Excellent 14.3 pts Meets ALL of the required criteria	Good 12.7 pts Meets MOST of the required criteria	Fair 11.5 pts Meets SOME the required criteria	Poor 10 pts Meets VERY LITTLE to NONE of the required criteria
Subjective Information Places appropriate information under the subjective heading; using OLDCARTS acronym	All of the subjective information from the case study is identified using OLDCARTS acronym	Most of the subjective information from the case study is identified using OLDCARTS	Some of the subjective information from the case study is identified but student did not use OLDCARTS	The subjective information from the case study is not appropriately identified and student did not use OLDCARTS
Objective Information Places appropriate information under the objective heading	All of the objective information from the case study is identified	Most of the objective information from the case study is identified	Some of the objective information from the case study is identified	The objective information from the case study is not appropriately identified
Assessment Places appropriate information under the assessment heading	Assessment findings are appropriate for this patient	Assessment findings are somewhat appropriate for this patient	Assessment findings are indicated but are not appropriate for this patient	Assessment findings are not indicated
Plan Appropriate plan of care created; including patient teaching information.	An appropriate and complete plan of care is identified, including, patient teaching, appropriate referrals and follow-up	A somewhat appropriate and mostly completed plan of care is identified, including, patient teaching, appropriate referrals and follow-up	A somewhat appropriate plan of care is identified, and includes two of three of the following: patient teaching, appropriate referrals and follow-up	An appropriate plan of care is not clearly identified, and includes one of three of the following: patient teaching, appropriate referrals and follow-up
Questions Answered required questions	All required questions answered correctly	At least five of seven required questions answered correctly	At least four of seven required questions answered correctly	Less than three required questions answered correctly
Writing Grammar, spelling and clarity	The writing is free of grammatical and spelling errors. The writing is clear and concise, without unnecessary jargon	The writing is somewhat free of grammatical and spelling errors. The writing is somewhat clear and somewhat concise with some unnecessary jargon	The writing is not free of grammatical and spelling errors. The writing is unclear and imprecise, with a considerable amount of unnecessary jargon	The writing has numerous grammatical and spelling errors. The writing is unclear and imprecise, with an unacceptable amount of unnecessary jargon
References Cited using APA format	References are cited using APA format, with no errors	References are cited, using APA format, with minimal errors	References are cited using APA format, with some errors	References are cited using APA format, but with numerous errors