SOAP note

Subjective Analysis

Chief complaints: The patient mainly complains of excessive urination. In addition, she complains of pronounced hunger and excessive thirst.

History of presenting illness: The patient is a 53-year-old lady who was diagnosed with type 2 diabetes five years ago. Recently she discovered that a cut she had was taking so much time to heal back after being injured. Also, she reported that she is eating much more quantity of food than usual and that she is always feeling thirsty and having excessive urination. She says that after being diagnosed with the illness she was advised to follow up a particular diet, but she admits she does not follow it up, and worse she smokes at times.

Neuropathy: Neuropathy refers to the damage of nerves and diabetes is among the diseases that cause such. The most common diabetes neuropathy is known as peripheral neuropathy since it affects the legs and hands in most cases(Merlino et al., 2007). The damaging of nerves causes loss of reflexes, weakens the muscles and worse even the failure of the internal organs. Reviewing of the system shoe that the woman has been attacked by neuropathy since she complains numbness and tingling in the extremities. The symptoms lay in the somatic nervous system. Autonomic nervous system is also attacked which is responsible for eyesight, and it is pretty evident that the patient has diminished visual acuity(Zammitt & Frier, 2005).

Hereditary factor in diabetes: in most cases type 2 of diabetes is caused by inherited genes. Research has shown that there are about 36 genes that contribute to inheriting diabetes from the family lineage(Zammitt & Frier, 2005). Although, they are many genes they only constitute 11% of what causes the disease(McCarthy, 2010).

 

Objective Analysis

Observation of vital signs: the first contact with the patient the vital signs were; blood pressure 168/100, Pulse rate at 80 beats per minute, Respiratory rate: 20 breaths per minute and finally the core temperature: 39.5 degree Celsius oral.

General evaluation: the patient looks sick especially with the struggle of the eyesight and also from the obesity nature.

The progress of patient to diabetes: the main complaints that the patient had were excessive thirst, increased appetite, and excess urine(Inzucchi et al., 2012). Polyuria and polydipsia go hand in hand since when there is a high percentage of glucose in the blood, it is forced to come out with the urine which is accompanied with water hence the excessive urination causes the thirst to the patient. The high appetite, on the other hand, is due to strong demand of glucose in the system to keep the blood sugar high(Zammitt & Frier, 2005).

Diabetes nephropathy: this is a progressive kidney disease that is caused by Mellitus when it is in the systems for a long time. The worst part about this disease is that the symptoms do not show up until 5-10 years that is when one realizes they are old(Versnel, Welschen, Baan, Nijpels, & Schellevis, 2011). The late symptoms include; tiredness, headache, vomiting and nausea. The real cause of the disease is not known but is associated with high blood sugar and also the cytokines may be involved in its development(Donath & Shoelson, 2011). Kidney failure is most likely to happen if the patient has high blood sugar, has a history in cigarette smoking and is over thirty years of age and suffering from diabetes type 2(Versnel et al., 2011).

 

 

Assessment Analysis

Diagnosis: Uncontrolled Diabetes

Uncontrolled diabetes arises from high levels of blood sugar in the system than the recommended target(Inzucchi et al., 2012). The disease is accompanied by certain symptoms that clearly indicates that the patient is suffering from it. Loss of vision is one of the signs; the patient might complain of having blurry vision at times. The musculoskeletal is also affected whereby the patient feels numb and tingling in the hands and feet. Also if the patient is injured the wound might take a longer period than usual to heal since the excess sugar in the system weakens the immune system(Merlino et al., 2007).

Plan

The plan of care for the patient is relevant since it gives a guideline on the actions and the medication that should be administered to the patient to control the disease they are suffering from and in this case diabetes. If the patient follows the stated plan by the physicians, they will be able to monitor the levels of blood sugar and prevent further and more critical symptoms of the disease such as heart attack(Van Nielen et al., 2014). The patient should be first educated on periodic monitoring of blood sugar levels. 3 to 4 times per day readings will give usable data for prognosis. The patient should take Metformin 500 mg after every meal. The tablet is aimed at reducing the blood sugar to controlled amounts and is also very helpful in the control of cardiovascular diseases for patients with weight problems. Humalog also known as Insulin lispro is an artificial insulin that is aimed to lower the blood sugar levels of the patients suffering from type 2 diabetes and acts up within the first few minutes after injection(Inzucchi et al., 2012). The patient should be administered with Lantus 20 units which are also an artificial insulin but it last for long compared to Humalog hence keeps the appropriate level up to 24 hours. Other drugs to prevent complications will include Lisinopril an ACE inhibitor to control blood pressures and Atorvastatin, a statin, to prevent accumulation of cholesterol in the blood. Besides these mediations fish liver oil should be recommended as a rich source of omega 3. Finally,  the patient should be referred to a diabetes nurse and support groups to assist with positive prognosis (Zammitt & Frier, 2005).

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