A peek into Kris Kringle’s care plan

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Care Plan: K.K.

Male, age unknown

Height: 154 cm

Weight: 115 kg

Total cholesterol: 396

Triglycerides: 300

Hemoglobin A1C: 14.5

Current Medical Diagnoses: Obesity, DM II, tobacco abuse, rosacea, osteoarthritis

Social History: Denies drug use. Social alcohol. Manages herd of ruminants. Hobbies include woodworking and toy making (toxic paint exposure). In the past has had extensive exposure to soot and ash in the performance of job duties. Married, lives with wife and a number of unrelated short people. No stairs in home. Patient states his diet consists mostly of cookies and warm milk.

Nursing Diagnoses:

1. Imbalanced nutrition: greater than body requirements
2. Knowledge deficit: diabetes management
3. Risk for hypo-oxygenation related to tobacco abuse
4. Knowledge deficit: nutrition
5. Role stress related to management of herd and unrelated short adults
6. Risk for toxicity related to hobby—painting toys and dolls for little children

Goals for This Hospitalization:

1. Patient will list three foods other than cookies that can make up a healthy diet.
2. Patient will demonstrate use of glucometer.
3. Patient will verbalize goal blood sugars (150 mg/dl or less).
4. Patient will verbalize two strategies for overcoming binge eating.
5. Patient will verbalize use of protective mask when painting toys.

Notes from Other Disciplines:

PT: Patient has belly like bowl full of jelly. Good standing balance, walked 300’ unassisted. Discharged from PT; please reconsult if necessary.

OT: Patient performs all ADLs without assistance. Discharged from OT.

Psychiatry consult service: Patient shows tendency to laugh inappropriately, wink and place finger on the side of his nose. Consider dementia, chronic microvascular changes in DD.

Expected Discharge Dispo: Discharge to home no later than a.m. of 12/24.