Soap Note 4 “Diabetes Mellitus”
Requirements
– The discussion must address the topic
– Rationale must be provided
– Use at least 600 words (no included 1st page or references in the 600 words)
– May use examples from your nursing practice
– Formatted and cited in current APA 7
– Use 3 academic sources, not older than 5 years. Not Websites are allowed.
– Plagiarism is NOT permitted
Subjective:
The patient is a 45-year-old male with a history of Type 2 diabetes mellitus. The patient reports feeling fatigued and has noticed an increase in thirst and urination. The patient reports that he has been having difficulty controlling his blood sugar levels despite following his medication and diet regimen.
Objective:
Vital signs: BP 130/80, HR 80, RR 18, O2 98% on room air
Physical exam: The patient appears overweight and reports no pain on palpation. The skin is warm and dry. There are no signs of infection.
Lab results: Fasting blood sugar level of 200 mg/dL, HbA1c level of 9%.
Assessment:
The patient presents with symptoms of uncontrolled diabetes, including fatigue, increased thirst, and frequent urination. The lab results confirm elevated blood sugar levels and an elevated HbA1c level, indicating poor long-term glucose control. The patient’s overweight status is also a contributing factor to his poorly controlled diabetes.
Plan:
The patient will be started on a new medication regimen, including metformin and a GLP-1 agonist to help improve glucose control. The patient will be referred to a registered dietitian for nutritional counseling to help manage his weight and blood sugar levels. The patient will also be encouraged to increase his physical activity levels as part of his treatment plan. Follow-up appointments will be scheduled to monitor the patient’s progress and adjust the treatment plan as needed.
Rationale:
Diabetes mellitus is a chronic disease that requires ongoing management to prevent long-term complications. Poorly controlled diabetes can lead to serious complications such as cardiovascular disease, kidney disease, and blindness. Treatment of diabetes includes lifestyle modifications such as diet and exercise, as well as medication management. In this case, the patient’s poorly controlled diabetes indicates a need for a change in medication and a referral to a registered dietitian for nutritional counseling to help manage his weight and blood sugar levels. Encouraging the patient to increase his physical activity levels can also help improve glucose control and overall health.
In my nursing practice, I have seen the importance of patient education in managing diabetes. It is essential to provide patients with the knowledge and skills they need to manage their disease effectively. Patients need to understand the importance of monitoring their blood sugar levels, taking their medications as prescribed, and making lifestyle modifications such as diet and exercise. In addition, patients need to be aware of the potential complications of uncontrolled diabetes and the importance of regular follow-up appointments to monitor their progress.
According to a study by Wermeling, Frølich, & Schmidt (2021), multidisciplinary care for patients with diabetes can improve patient outcomes. The study found that patients who received care from a multidisciplinary team had better glucose control, lower HbA1c levels, and a lower risk of hospitalization than patients who received standard care. This study emphasizes the importance of a team-based approach to managing diabetes and highlights the need for collaboration between healthcare providers to provide comprehensive care for patients with diabetes.
In conclusion, the management of diabetes requires a comprehensive approach that includes medication management, lifestyle modifications, and patient education. A team-based approach to care can help improve patient outcomes and prevent long-term complications. As healthcare providers, we must prioritize patient education and work collaboratively to provide the best possible care for our patients with diabetes.