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19 Cards in this Set
- Front
- Back
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Subjective data:
Important Health Info - Past health hx |
Mumps, rubella, conxsackievirus or other viral infections; recent trauma, infection or stress; pregnancy, gave birth to infant weighing more than 9 lbs, chronic pancreatitis; Cushing syndrome; acromegaly; family hx of type 1 or type 2 DM
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Important Health Info - Medications
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Use of & compliance w/insulin or OAs; use of corticosteroids, diuretics, phenytoin (Dilantin)
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Important Health Info - Surgery or other treatments
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Any recent surgery
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Functional Health Patterns:
Health perception-health mgmt |
Positive family hx; malaise; date of last eye & dental exam
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Nutritional-metabolic
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Obesity; weight loss (type 1), weight gain (type 2); thirst, hunger; nausea & vomiting; poor healing esp. involving feet, compliance w/diet in pts w/previously diagnosed diabetes
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Elimination:
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Constipation or diarrhea; frequent urination, frequent bladder infections, nocturia, urinary incontinence
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Activity-exercise
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Muscle weakness, fatigue
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Cognitive-perceptual
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Abdominal pain; headache; blurred vision; numbness or tingling of extremities; pruritus
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Sexuality-reproductive
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Impotence; frequent vaginal infections; decreased libido
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Coping-stress tolerance
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Depression, irritability, apath
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Value-belief
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Commitment to lifestyle changes involving diet, medication & activity patterns
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Objective Data - Eyes
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Soft, sunken eyeballs, vitreal hemorrhages; cataracts
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Obj data - Integumentary
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Dry, warm, inelastic skin; pigmented lesions (on legs); ulcers (esp on feet); loss of hair on toes; acanthosis nigricans
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Obj data - Respiratory
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Rapid, deep respirations (Kussmaul respirations)
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Obj data - Cardiovascular
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Hypotension, weak, rapid pulse
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Obj data - GI
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Dry mouth, vomiting, "fruity breath" (DKA)
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Obj data - Neurologic
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Altered reflexes; restlessness; confusion; stupor; coma
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Obj data - Musculoskeletal
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Muscle wasting
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Possible findings:
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Serum electrolyte abnormalities; FSB greater than or equal to 126mg/dL; glucose tolerance test greater than 200mg/dL; random glucose greater than or equal to 200mg/dL; leukocytosis; increased BUN, CRT, Triglycerides, Cholesterol, LDL, VLDL; decreased HDL; A1C greater than or equal to 6%; glycosuria; ketonuria; albuminuria; acidosis
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