Miami Dade College – School of Nursing
Plan of Care
Student Name: Dienifer Gonzalez Santana
Clinical Date: 5/17/2026
CLIENT’S INITIALS: BZ AGE: 63 SEX: Male LANGUAGE: English ADMISSION DATE:
ALLERGIES & REACTIONS: No known drug
allergies
ADMITTING DIAGNOSIS: Type 1 diabetes
mellitus with recent diabetic
ketoacidosis
PATHOPHYSIOLOGY: Type 1 diabetes
mellitus is an autoimmune disorder in
which the pancreas does not produce
enough insulin
PAST MEDICAL/ SURGICAL HISTORY: Type 1
diabetes mellitus diagnosed at 15.
Recent diabetic ketoacidosis.
Depression. Homeless for 4 years.
HISTORY OF PRESENT ILLNESS/ CHIEF COMPLAINT: A
63-year-old male with Type 1 diabetes was
found semi-conscious on the street with a
blood glucose of 510 mg/dL and diagnosed
with diabetic ketoacidosis. Patient was treated
in the emergency department and stabilized
before discharge to the homeless shelter clinic
for follow-up diabetic management
RECENT (SINCE ADMISSION) PROCEDURES/ SURGERY:
Emergency treatment for DKA. IV fluid therapy.
Blood glucose stabilization. Insulin therapy.
DIAGNOSTIC TESTS & LABS ORDERED: Blood glucose monitoring. Basic metabolic panel (BMP).
Complete blood count (CBC). Oxygen saturation monitoring. Capillary blood glucose AC & HS.
Revised by N. Jules_08/06/25
, WHAT MEDICATIONS WAS CLIENT TAKING (PRIOR TO ADMISSION)?
Insulin glargine 20 units at bedtime. Humulin R insulin sliding scale before meals and
bedtime.
Captopril 20 mg twice daily.
SCHEDULED MEDICATIONS ORDERED:
Medication Drug Side Effects Contraindication Nursing
(Dose/Route/ Classification s Interventions
Time/ Frequency) & Action
Insulin glargine Long-acting Hypoglycemi Hypoglycemia Monitor
20 units SUBQ at insulin a Hypersensitivity blood
bedtime lowers blood Weight gain glucose
glucose by Assess for
facilitating Injection
site signs of
glucose hypoglycemi
transport reactions
a
into cells.
Rotate
injection
sites
Captopril 25 mg ACE Hypotension Pregnancy Monitor BP
PO BID inhibitor; Dry cough History of Monitor
lowers blood angiodema potassium
pressure and Hyperkalemi
a levels
protects
kidney Dizziness Assess for
function cough
Monitor renal
function
PRN MEDICATIONS ORDERED: No PRN medications ordered TIME GIVEN (IF
APPLICABLE)
Medication Drug Side Effects Contraindication Nursing
Classification s Interventions
& Action
Revised by N. Jules_08/06/25
Plan of Care
Student Name: Dienifer Gonzalez Santana
Clinical Date: 5/17/2026
CLIENT’S INITIALS: BZ AGE: 63 SEX: Male LANGUAGE: English ADMISSION DATE:
ALLERGIES & REACTIONS: No known drug
allergies
ADMITTING DIAGNOSIS: Type 1 diabetes
mellitus with recent diabetic
ketoacidosis
PATHOPHYSIOLOGY: Type 1 diabetes
mellitus is an autoimmune disorder in
which the pancreas does not produce
enough insulin
PAST MEDICAL/ SURGICAL HISTORY: Type 1
diabetes mellitus diagnosed at 15.
Recent diabetic ketoacidosis.
Depression. Homeless for 4 years.
HISTORY OF PRESENT ILLNESS/ CHIEF COMPLAINT: A
63-year-old male with Type 1 diabetes was
found semi-conscious on the street with a
blood glucose of 510 mg/dL and diagnosed
with diabetic ketoacidosis. Patient was treated
in the emergency department and stabilized
before discharge to the homeless shelter clinic
for follow-up diabetic management
RECENT (SINCE ADMISSION) PROCEDURES/ SURGERY:
Emergency treatment for DKA. IV fluid therapy.
Blood glucose stabilization. Insulin therapy.
DIAGNOSTIC TESTS & LABS ORDERED: Blood glucose monitoring. Basic metabolic panel (BMP).
Complete blood count (CBC). Oxygen saturation monitoring. Capillary blood glucose AC & HS.
Revised by N. Jules_08/06/25
, WHAT MEDICATIONS WAS CLIENT TAKING (PRIOR TO ADMISSION)?
Insulin glargine 20 units at bedtime. Humulin R insulin sliding scale before meals and
bedtime.
Captopril 20 mg twice daily.
SCHEDULED MEDICATIONS ORDERED:
Medication Drug Side Effects Contraindication Nursing
(Dose/Route/ Classification s Interventions
Time/ Frequency) & Action
Insulin glargine Long-acting Hypoglycemi Hypoglycemia Monitor
20 units SUBQ at insulin a Hypersensitivity blood
bedtime lowers blood Weight gain glucose
glucose by Assess for
facilitating Injection
site signs of
glucose hypoglycemi
transport reactions
a
into cells.
Rotate
injection
sites
Captopril 25 mg ACE Hypotension Pregnancy Monitor BP
PO BID inhibitor; Dry cough History of Monitor
lowers blood angiodema potassium
pressure and Hyperkalemi
a levels
protects
kidney Dizziness Assess for
function cough
Monitor renal
function
PRN MEDICATIONS ORDERED: No PRN medications ordered TIME GIVEN (IF
APPLICABLE)
Medication Drug Side Effects Contraindication Nursing
Classification s Interventions
& Action
Revised by N. Jules_08/06/25
