Nursing Case Study: Management of a Post-Operative Patient with Type 2 Diabetes Mellitus

Introduction:

Ms. Anita Gomez, a 58-year-old female with a history of Type 2 Diabetes Mellitus, was admitted to the surgical ward following a right total knee replacement. She has been on oral hypoglycemic agents for diabetes management and has a BMI of 31, indicating obesity.

Patient History and Demographics

Ms. Gomez is a retired school teacher who lives with her husband. She has a history of hypertension, for which she takes medication, and her family history includes her mother with Type 2 Diabetes Mellitus and a father who passed away from a myocardial infarction. She does not smoke but leads a sedentary lifestyle.

Current Assessment

On post-operative day one, Ms. Gomez reported pain at the surgical site with a rating of 7/10 on the pain scale. Her vital signs were: blood pressure 135/85 mmHg, pulse 88 bpm, respiratory rate 18 breaths/min, and temperature 37.2°C. Her blood glucose level was 180 mg/dL.

Nursing Diagnosis:

The primary nursing diagnoses for Ms. Gomez include:

Risk of infection related to surgical procedures and diabetes.
2. acute pain related to tissue trauma and surgical procedure, as evidenced by patient reporting.
3. Risk for unstable blood glucose levels related to type 2 diabetes and post-operative stress response.
Planning:
The care plan for Ms. Gomez includes goals to prevent infection, manage pain effectively, and maintain blood glucose levels within her target range.

Implementation:
The following nursing interventions were implemented:

Ensured meticulous hand hygiene and aseptic technique during dressing changes to prevent infection.
Administered prescribed analgesics to manage pain and monitored the effectiveness of pain relief measures.
Regularly monitored Ms. Gomez’s blood glucose levels and coordinated with the dietician for post-operative meal planning to maintain glycemic control.
Evaluation:
Ms. Gomez’s pain was reduced to 3/10 after medication, and her blood glucose levels remained between 140-180 mg/dL with dietary adjustments and insulin administration as needed. No signs of infection were noted at the surgical site.

Conclusion and Reflection:
Ms. Gomez’s post-operative recovery was successful, with managed pain levels and maintained blood glucose control without complications. Reflecting on this case, it is evident that comprehensive diabetes management and pain control are vital components of post-operative care for patients with Type 2 Diabetes Mellitus.

This case study provides insight into the complexity of managing a patient with multiple health concerns, emphasizing the importance of a personalized and evidence-based approach to nursing care. The scenario also highlights the critical role of nursing assessments and interventions in achieving positive patient outcomes.