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l. Introduction
Diabetes mellitus, often simply referred to as diabetesis a condition in which a
person has high blood sugar, either because the body does not produce enough insulin,
or because cells do not respond to the insulin that is produced. This high blood sugar
produces the classical symptoms ofpolyuria (frequent urination), polydipsia (increased
thirst) and polyphagia (increased hunger).
The term diabetes, without qualification, usually refers to diabetes mellitus, which
roughly translates to excessive sweet urine (known as "glycosuria"). Several rare
conditions are also named diabetes. The most common of these is diabetes insipidus in
which large amounts of urine are produced (polyuria), which is not sweet (insipidus
meaning "without taste" in Latin).
The term "type 1 diabetes" has replaced several former terms, including
childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus
(IDDM). Likewise, the term "type 2 diabetes" has replaced several former terms,
including adult-onset diabetes, obesity-related diabetes, and non-insulin-dependent
diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standardnomenclature. Various sources have defined "type 3 diabetes" as: gestational diabetes,
[4] insulin-resistant type 1 diabetes (or "double diabetes"), type 2 diabetes which has
progressed to require injected insulin, and latent autoimmune diabetes of adults.
Type 2 diabetes mellitus is characterized by insulin resistance which may be
combined with relatively reduced insulin secretion. The defective responsiveness of
body tissues to insulin is believed to involve the insulin receptor. However, the specific
defects are not known. Diabetes mellitus due to a known defect are classified
separately. Type 2 diabetes is the most common type.
It is a chronic , progressive disease characterized by the bodys inability to
metabolize carbohydrate, fats, and proteins leading to hyperglycemia.Diabetes mellitus
is referred to us high sugars by both clients and health care providers. The notion of
1
http://en.wikipedia.org/wiki/Blood_sugarhttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Polydipsiahttp://en.wikipedia.org/wiki/Polyphagiahttp://en.wikipedia.org/wiki/Glycosuriahttp://en.wikipedia.org/wiki/Diabetes_insipidushttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Gestational_diabeteshttp://en.wikipedia.org/wiki/Diabetes_mellitus#cite_note-3http://en.wikipedia.org/wiki/Latent_autoimmune_diabeteshttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Blood_sugarhttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Polydipsiahttp://en.wikipedia.org/wiki/Polyphagiahttp://en.wikipedia.org/wiki/Glycosuriahttp://en.wikipedia.org/wiki/Diabetes_insipidushttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Gestational_diabeteshttp://en.wikipedia.org/wiki/Diabetes_mellitus#cite_note-3http://en.wikipedia.org/wiki/Latent_autoimmune_diabeteshttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Insulin_receptor8/9/2019 Avatar Final Cp
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associating sugar with diabetes mellitus is appropriate because the passage of large
amounts of sugar laden urine is characteristic of poorly controlled diabetes mellitus.
Other pathologic process and risk factors are just as important and sometimes
independent factors but people with diabetes mellitus can take preventive measures to
reduce the likelihood of such occurrences.
In the early stage of type 2 diabetes, the predominant abnormality is reduced
insulin sensitivity. At this stage hyperglycemia can be reversed by a variety of measures
and medications that improve insulin sensitivity or reduce glucose production by the
liver. As the disease progresses, the impairment of insulin secretion occurs, and
therapeutic replacement of insulin may sometimes become necessary in certain
patients.
For legal purposes and to protect the right of the patient, the researchers used
the name B.E. These data gathered would only be used for this care study and will hold
confidential.
At the end of the care study, the group will be able to assess the client; discuss
the pathophysiology of the clients condition; identity the different factors that aggravate
the condition of the client; plan the nursing independent action basing on the identifiedproblem; implement nursing intervention of each problem; evaluate the effectiveness of
the independent/dependent management to the client.
Objectives of the Study
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1. To be able to describe etiologic factors associated with diabetes
2. Relate the clinical manifestations of diabetes mellitus type ll to the associated
pathophysiologic alterations
3. Identify the diagnostic and clinical significance of blood glucose test.
4. Describe the relationship between diet, exercise, and medication for persons with
diabetes
5. Describe management strategies for a person with diabetes to use during sick
days
6. Use the nursing process as a framework for care of the patient with diabetes.
Scope and Delimitation
The study is limited only to the case of B.E. All the information about the client
was obtained from the Camiguin General Hospital and from actual interview and
assessment with the client, clients family and significant others.
The researchers will only focus on the clients disease, which is Diabetes Mellitus
Type II insulin requiring.
The researchers will try to formulate nursing diagnosis fit for this case in order to
have an effective nursing care plan during the caring process.
II. Demographic Data
Patient BE is a 21 year old woman presently residing at Compol, Catarman,
Camiguin Province. She is a fiancee of Mr.A. She was blessed with 1 child. Although
they are not yet bound by marriage due to financial reasons, Ms.BE and Mr. A is having
their own family whom they called their own and is presently living in the house of her
husbands parents.
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Her husband is a 24 year old jobless undergraduate. He wasnt able to finish
highschool due to lack of financial source. He supports his family by helping his father
and mother in their small farm which is their only means of living. Sometimes, he goes
with his neighbors when they went out for fishing and was able to get some share of
their catch to bring for his family. They own a small farm of which they plant some
vegetables and crops for their viand. According to the client, if they dont have this small
farm of theirs, they have no other source of food to get in since they are both jobless.
In terms of health facility, the patients residence is just a kilometer away from
Barangay Health Center, so whenever they have a problem, they directly addressed
their needs to the near Health Center for health security. But not at all times, because
according to her, she is having a difficulty visiting the health center because nobody will
look after her child because her partner is in the farm the wholeday. So with regards to
feeling ill, most of the time she ignores it and just take some rest or supplement her
body with herbal plants to feel better.
The house of the patient is made entirely of wood and is about 20 sq. meters.
Their roof is made of nipa and and the flooring is made of bamboo sticks put together.
The clients water source is from the barangay line and they pays about P30.00
monthly. They also have electricity and use it as source for their light at night. They
have one small television and an old style radio that they use to entertain them. Theirhouse is an all- in-one style wherein youll see the kitchen, bedroom and living room all
in one place. They have neighbors as well but their houses are quite distant from one
another.
Brgy. Compol is about 42 km from CPSC to the patients house. You can get
there by riding a jeep or a motorcycle going to Catarman with an estimated fare of
P30.00.
The source of income in their barangay is mostly from farming and fishing. The
barangay is near a small public market and has some few small shops as well. The
barangay has its own health center with a visiting physician and 3 Barangay Health
Workers and 1 midwife on duty. Their barangay hall is also active in maintaining the
peace and order in their area. With regards to the clients sanitation, they throw their
garbage in a small compost pit and sometimes they burn it when there is too much
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plastic in it. Their family is fond of using herbal plants when sick because they dont
have money to buy medicine at the pharmacy.
III. Developmental Data
Sigmund Freuds Psychosexual Development
According to Sigmund Freud, there are 5 stages of psychosexual development, the
oral stage, the anal stage, the phallic stage, the latent stage and the genital stage. As to
the client, she is now on the Genital Stage. It is the final stage of psychosexual
development. It begins at the start of puberty when sexual urges are once again
awakened. Through the lessons learned during the previous stages, adolescents directtheir sexual urges onto opposite sex peers; with the primary focus of pleasure are the
genitals. She has already resolved this stage because she already had a satisfactory
sexual relationship with the opposite sex- her husband
Erik Eriksons theory of psychosocial development
Erik Eriksons theory of psychosocial development is one of the best-known theories
of personality in psychology. Erikson believed that personality develops in a series of
stages. Eriksons theory describes the impact of social experience across the whole
lifespan. In each stage, Erikson believed people experience a conflict that serves as a
turning point in development. In Eriksons view, these conflicts are centered on either
developing a psychological quality or failing to develop that quality. During these times,
the potential for personal growth is high, but so is the potential for failure. These are the
stages of the development according to Erikson.
Trust vs. Mistrust
Autonomy vs. Shame or Doubt
Initiative vs. Guilt
Industry vs. Inferiority
Identity vs. role confusion
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Intimacy vs. Isolation
Generativity vs. Stagnation
Ego-Integrity vs. Despair
Ms. BE is 21 year old, so she belong to INTIMACY VS. ISOLATION stage. This
stage covers the period of early adulthood when people are exploring personal
relationships.
Erikson believed it was vital that people develop close, committed relationships
with other people. Those who are successful at this step will develop relationships that
are committed and secure.
Remember that each step builds on skills learned in previous steps. Erikson
believed that a strong sense of personal identity was important to developing intimate
relationships. Studies have demonstrated that those with a poor sense of self tend to
have less committed relationships and are more likely to suffer emotional isolation,
loneliness, and depression. Thus, Ms.BE build a strong relationship with his husband to
be. They are commited with each other. And found out to be secured with each other.
Sullivans Stages of Healthy Interpersonal Development
Ms. BE belongs to Late Adolescence Stage ( 14-21 y/o). The task for these Stage. It
focus on achievement of independence within the society and the formation of a lasting,
intimate relationship with a selected member of the opposite sex. Masters expression of
sexual impulses. Forms satisfying and responsible associations. Uses communication
skills to protect self from conflicts with others. Relating to Ms. BE. She was able to
achieved the task for these stage, evidenced by having friends and selected member of
the society that care for her. She was able to communicate with other people around
them
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IV. Nursing Assessment
First Assessment
July 4, 2010, 12:30 pm
Patient was awake lying on bed with an ongoing IVF of PNSS 1 L @ 350 cc level;
regulated at 40 gtts/min infusing well at the left arm.. Researchers introduced
thereselves and explained the purpose of the visit as well as the procedures the
researchers would performed. Researchers made an interview with Ms.B.E and asked
questions that was answered by the patient. Through the researchers interview with
Ms.B.E, the researchers was able to obtain the following data;
vital signs:
Temperature : 36.30C
RR : 18 cpm
PR : 90 bpm
BP : 120/80 mmHg
The patient has a family history of Diabetes Mellitus. The patient doesnt have
known allergies to food and drugs. During the researchers assessment, patient
complained about numbness of both lower extremities and verbalizes hawoy keu ako
ani mga tiel ug kamot as verbalized by the patient. During the asssessment, the patient
felt body malaise and experienced blurred vision. According to the patient, the doctor
said she was diabetic. During the assessment, the researchers imparted health
teachings, with emphasis on proper diet and increase fluid intake.
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1st Assessment
NURSING SYSTEM REVIEW CHART
Name: E.B Date: July 4, 2010Vital Signs:
Pulse: 90 bpm Temp: 36.3C RR: 18cpm Weight:32kgs Height:158cm
EENT: impaired vision blind _____________________ pain reddened drainage _____________________ gums hard of hearing deaf _____________________
burning edema lesion teeth _________ ____________Asses eyes, ears, nose _____________________
throat for abnormality no problem_____________________
RESP: _____________________
asymmetric tachypnea _____________________
apnea rales cough barrel chest _____________________ bradypnea shallow rhonci _____________________ sputum diminished dyspnea _____________________ orthopnea labored wheezing _____________________
pain cyanotic _____________________ Asses resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort no problem
_____________________CARDIO VASCULAR _____________________
arrhythmia tachycardia numbness _____________________ diminished pulses edema fatigue _____________________ irregular bradycardia murmur _____________________
tingling absent pulses pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort _____________________
no problem
_____________________GASTRO INTESTINAL TRACT _____________________
obese distention mass _____________________
dysphagia rigidly pain _____________________ Asses abdomen, bowel habits, swallowing, _____________________ bowel sounds, comfort no problem
_____________________GENITO-URINARY and GYNE _____________________
pain urine color vaginal bleeding _____________________ hermaturia discharge noctoria _____________________
Asses urine freq., color, control, odor, comfort/ _____________________ Gyn-bleeding, discharge no problem
NEURO
paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripAsses motor function, sensation, LOC, strength,
Grip, galt, coordination, orientation, speech, no problem
MUSCULOSKELETAL and SKIN
appliance stiffness itching petechiae hot drainage prosthesis swelling
lesion poor turgor cool deformity wound rash skin color flushed
8
Impaired
vision
Numbness felt on
both hands
Numbness felt on
both feet
Body malaise
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Second Assesment
July 5, 2010
3:00 pm
The researchers had their second assessment to Ms. B.E, the researchers was
able to obtained the following data.
Temperature : 36.80C
RR : 18 cpm
PR : 72 bpm
BP : 110/70 mmHg
The patient has an increased Capillary Blood Glucose level of 388mg/dl. The
researchers referred it to Dr. Ma. Tecelyn Castilla and ordered for Humulin R 70/30 12
u SQ and repeat CBG monitoring after 1 hour. Capillary Blood Glucose level
rechecked 366mg/dl. During assessment, the researchers had observed poor skin
turgor and swelling on both feet of the patient. The researchers weigh the patient and
found out, Ms. B.E had increased weight into 39.6kg. Dr. Gerry Cabalang ordered to
increased dosage of Humulin R 70/30 to 25 u SQ 6am and 15 u SQ 6pm. The
researchers had explain the importance of exercise in maintaining weight and proper
diet.
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2nd Assessment
NURSING SYSTEM REVIEW CHART
Name: Ms. B.E Date: July 5, 2010Vital Signs:
Pulse: 72 bpm Temp: 36.8C RR: 18cpm Weight:39.6kgs Height:158 cmEENT:
impaired vision blind _____________________ pain reddened drainage _____________________
gums hard of hearing deaf _____________________ burning edema lesion teeth _________ ____________
Asses eyes, ears, nose _____________________ throat for abnormality no problem
_____________________RESP: _____________________
asymmetric tachypnea _____________________ apnea rales cough barrel chest _____________________ bradypnea shallow rhonci _____________________ sputum diminished dyspnea _____________________
orthopnea labored wheezing _____________________
pain cyanotic _____________________ Asses resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort no problem
_____________________CARDIO VASCULAR _____________________
arrhythmia tachycardia numbness _____________________ diminished pulses edema fatigue _____________________
irregular bradycardia murmur _____________________ tingling absent pulses pain _____________________
Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort _____________________
no problem_____________________
GASTRO INTESTINAL TRACT _____________________
obese distention mass _____________________
dysphagia rigidly pain _____________________ Asses abdomen, bowel habits, swallowing, _____________________
bowel sounds, comfort no problem_____________________
GENITO-URINARY and GYNE _____________________
pain urine color vaginal bleeding _____________________
hermaturia discharge noctoria _____________________ Asses urine freq., color, control, odor, comfort/ _____________________ Gyn-bleeding, discharge no problem
NEURO
paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision grip
Asses motor function, sensation, LOC, strength,
Grip, galt, coordination, orientation, speech, no problem
MUSCULOSKELETAL and SKIN
appliance stiffness itching petechiae
hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed
atrophy pain ecchymosis
diaphoretic moistAsses mobility, motion. Galt, alignment, joint function/skin color, texture, turgor, integrity no problem
10
Bipedal edemaObserved (-1cm)
Body
malaise
Poor skin
turgor
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Third Assessment
July 6, 2010
3:00 pm
The researchers had their third assessment. The patient was awake lying on bed
with an ongoing IVF of PNSS newly hooked, regulated at 40gtts/minute infusing well at
left arm. During this time, the researchers obtained the following data:
Temperature : 36.7
0
C
RR : 19 cpm
PR : 95 bpm
BP : 110/80 mmHg
The patient still have increased Capillary Blood Glucose Level of 270mg/dl. The
researchers administered Humulin R 70/30 10 u SQ as prescribed. The patient still
complained on her swelling feet, experienced blurred vision and verbalizes nganu
nanghubag ni ako teel? Tungod ni sa tambal na ge-inject sah ako?. The researchers
provide health teaching with emphasis on explaining thoroughly the procedure for
insulin self-injection and its adverse effect. Help patient to achieve mastery of technique
by taking step by step approach.
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3rd Assessment
NURSING SYSTEM REVIEW CHART
Name: Ms. B.E Date: July 6, 2010Vital Signs:
Pulse: 95 bpm Temp: 36.7C RR: 19cpm Weight:39.6kgs Height:158 cm
EENT: impaired vision blind _____________________ pain reddened drainage _____________________ gums hard of hearing deaf _____________________
burning edema lesion teeth _________ ____________Asses eyes, ears, nose _____________________
throat for abnormality no problem_____________________
RESP: _____________________
asymmetric tachypnea _____________________
apnea rales cough barrel chest _____________________ bradypnea shallow rhonci _____________________ sputum diminished dyspnea _____________________ orthopnea labored wheezing _____________________
pain cyanotic _____________________ Asses resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort no problem
_____________________CARDIO VASCULAR _____________________
arrhythmia tachycardia numbness _____________________ diminished pulses edema fatigue _____________________ irregular bradycardia murmur _____________________
tingling absent pulses pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort _____________________
no problem
_____________________GASTRO INTESTINAL TRACT _____________________
obese distention mass _____________________
dysphagia rigidly pain _____________________ Asses abdomen, bowel habits, swallowing, _____________________ bowel sounds, comfort no problem
_____________________GENITO-URINARY and GYNE _____________________
pain urine color vaginal bleeding _____________________ hermaturia discharge noctoria _____________________
Asses urine freq., color, control, odor, comfort/ _____________________ Gyn-bleeding, discharge no problem
NEURO
paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripAsses motor function, sensation, LOC, strength,
Grip, galt, coordination, orientation, speech, no problem
MUSCULOSKELETAL and SKIN
appliance stiffness itching petechiae hot drainage prosthesis swelling
lesion poor turgor cool deformity wound rash skin color flushed
atrophy pain ecchymosis diaphoretic moist
Asses mobility, motion. Galt, alignment, joint function/skin color, texture, turgor, integrity no problem
12
Impaired
vision
Bipedal edemaobserved (-1cm)
Polyuria
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Fourth Assessment
July 7, 2010
3:00 pm
The researchers performed her fourth assessment; the author received her
patient awake sitting on bed without IVF. The author was able to obtained the following
vital signs;
Temperature : 36.0
0
C
RR : 18 cpm
PR : 94 bpm
BP : 110/80 mmHg
The researchers
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4th Assessment
NURSING SYSTEM REVIEW CHART
Name: Mrs. E Date: December 29, 2009Vital Signs:
Pulse: 61 bpm Temp: 36C RR: 11 Weight:41kgs Height:152 cm
EENT: impaired vision blind _____________________ pain reddened drainage _____________________ gums hard of hearing deaf _____________________
burning edema lesion teeth _________ ____________Asses eyes, ears, nose _____________________
throat for abnormality no problem_____________________
RESP: _____________________
asymmetric tachypnea _____________________
apnea rales cough barrel chest _____________________ bradypnea shallow rhonci _____________________ sputum diminished dyspnea _____________________ orthopnea labored wheezing _____________________
pain cyanotic _____________________ Asses resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort no problem
_____________________CARDIO VASCULAR _____________________
arrhythmia tachycardia numbness _____________________ diminished pulses edema fatigue _____________________ irregular bradycardia murmur _____________________
tingling absent pulses pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort _____________________
no problem
_____________________GASTRO INTESTINAL TRACT _____________________
obese distention mass _____________________
dysphagia rigidly pain _____________________ Asses abdomen, bowel habits, swallowing, _____________________ bowel sounds, comfort no problem
_____________________GENITO-URINARY and GYNE _____________________
pain urine color vaginal bleeding _____________________ hermaturia discharge noctoria _____________________
Asses urine freq., color, control, odor, comfort/ _____________________ Gyn-bleeding, discharge no problem
NEURO
paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripAsses motor function, sensation, LOC, strength,
Grip, galt, coordination, orientation, speech, no problem
MUSCULOSKELETAL and SKIN
appliance stiffness itching petechiae hot drainage prosthesis swelling
lesion poor turgor cool deformity wound rash skin color flushed
atrophy pain ecchymosis
diaphoretic moistAsses mobility, motion. Galt, alignment, joint function
/skin color, texture, turgor, integrity no problem
14
dyspnea
Diaphoretic
WeaknessFatigue
Cyanosis
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Fifth Assessment
January 17, 2010
10:00 am
The author had her first assessment to the patient at their residence in Soro-Soro,
Mabajao Camiguin. When the author arrived at their house the patient is doing light household
chores. The patients then stope what shes doing and accommodates the author. The patient then
verbalize Day unza diay nang hypertension, nganong daghan man bawal na sa akung pagkaon
ug uban pa? then the author explained independent nursing interventions, after 45 minutes the
patient understand something about disease process and treatment.
Health teaching imparted were the following;
- Low sodium diet
- Low fat diet
- exercise everyday (like walking every morning)
- avoid stressful activities
The author then take the patients vital signs:
Temperature: 37 0C
RR : 20 cpm
PR : 70 bpm
BP : 130/80 mmHg
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5th Assessment
NURSING SYSTEM REVIEW CHART
Name: Mrs. E Date: January 17, 2010Vital Signs:
Pulse: 70 bpm Temp: 37C RR: 20 Weight:41kgs Height:152 cm
EENT: impaired vision blind _____________________ pain reddened drainage _____________________ gums hard of hearing deaf _____________________
burning edema lesion teeth _________ ____________Asses eyes, ears, nose _____________________
throat for abnormality no problem_____________________
RESP: _____________________
asymmetric tachypnea _____________________
apnea rales cough barrel chest _____________________ bradypnea shallow rhonci _____________________ sputum diminished dyspnea _____________________ orthopnea labored wheezing _____________________
pain cyanotic _____________________ Asses resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort no problem
_____________________CARDIO VASCULAR _____________________
arrhythmia tachycardia numbness _____________________ diminished pulses edema fatigue _____________________ irregular bradycardia murmur _____________________
tingling absent pulses pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort ____________________
no problem
_____________________GASTRO INTESTINAL TRACT _____________________
obese distention mass _____________________
dysphagia rigidly pain _____________________ Asses abdomen, bowel habits, swallowing, _____________________ bowel sounds, comfort no problem
_____________________GENITO-URINARY and GYNE _____________________
pain urine color vaginal bleeding _____________________ hermaturia discharge noctoria _____________________
Asses urine freq., color, control, odor, comfort/ _____________________ Gyn-bleeding, discharge no problem
NEURO
paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision gripAsses motor function, sensation, LOC, strength,
Grip, galt, coordination, orientation, speech, no problem
MUSCULOSKELETAL and SKIN
appliance stiffness itching petechiae hot drainage prosthesis swelling
lesion poor turgor cool deformity wound rash skin color flushed
atrophy pain ecchymosis
diaphoretic mois
Asses mobility, motion. Galt, alignment, joint function/skin color, texture, turgor, integrity no problem
16
Request for
information
Apathetic behavior
Inaccurate follow
through ofinstruction
Misinterpretation
of information
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V. History of Past Illness:
The patient has a family history of Diabetes Melllitus. They have no other knownhereditary diseases such as Cancer and Hypertension. According to the patient, she had
undergone a minor surgery which was removal of her cataract at the right eye last May 2009 and
in her left eye last December 2009.
Present Illness:
The patient felt numbness of both upper and lower extremities, excessive thirst, excessive
hunger, excessive urination, body malaise and fatigue for six months. The patient went to the OutPatient Department of Camiguin General Hospital for check-up. The doctor then prescribed the
patient to take multivitamins. The patient failed to take the multivitamins because of some
financial problem. The following day, July 2, 2010, the patient came back to the Out Patient
Department for check-up. The doctor then advised the patient for admission based on the data
seen.
Patient has a family history of Diabetes Mellitus.
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Medical Management
Date Time Physician Doctors Order Rationale of Doctors Order
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7-2-10
7-4-10
7-5-10
11:30am
12:30PM
11:24pm
Dr.Castilla
Dr.Castilla
Dr.Castilla
Please admit under medicalService
Secure consent to care
Monitor V/S every hour
Diabetic diet
Start venoclysis with PNSS1L
IVTF: PNSSlllL @ 60 gtts/min
Labs:
CBC with platelet
UA Sodium, Potassium
determination
Hb
Creatinine
For KUB UTZ
CBG now then q hour
Meds.
Give insulin 20 u: IV now
then start insulin drip 100ccPNSS + 100 u regularinsulin @ 10 gtts/min, thenhold if CBG
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NAME OFDRUG(GENERICAND BRANDNAME)
DATEORDERED
DRUGCLASSIFICATION
DOSE/FREQUENCY
MECHANISM OFACTION
SPECIFICINDICATION
CONTRAINDICATION and CAUTION
SIDE E FFECTS NURSINGPRECAUTION
Cefuroxime(Ceftin)
7-2-10 AntibioticCephalosporin(2nd
Generation)
750 mg q 8hr,IVTT
Bactericidal:Inhibitssynthesis ofbactreial cellwall, causingcell death
Lowerrespiratoryinfectionscaused by S.pneuminia
Contraindicatedwith allergy tocephalosporins orpenicillins.
Use cautiouslywith renal failure,lactation,pregnancy.
CNS:-headache-dizziness-lethargy
GI:-nausea-vomiting-diarrhea-anorexia-abdominalpain-liver toxicity
GU:-nephrotoxicity
Hypertensitivity:-rash to fever-serumsicknessreaction
Local:-pain-abcess atinjection site-phlebitis
1.Cultureinfection, andarrange forsensitivity testsbefore and duringtherapy ifexpectedresponse is notseen.
2.Have vitamin Kavailable in casehypoprothrombinemia occurs.
3.Discontinue ifhypersensitivityoccurs.
4.Report severediarrhea, difficultybreathing,unusual tirednessor fatigue, pain atinjection site.
NAME OFDRUG(GENERICAND BRANDNAME)
DATEORDERED
DRUGCLASSIFICATION
DOSE/FREQUENCY
MECHANISM OFACTION
SPECIFICINDICATION
CONTRAINDICATION and CAUTION
SIDE E FFECTS NURSINGPRECAUTION
Humulin R70/30
7-3-10 AntidiabeticHormone
25 u 6AM15 u 6PM
Insulin is ahormonesecreted by betacells of thepancreas that, byreceptor-mediated effects,promotes thestorage of thebodys fuels,facilitating thetransport of themetabolites andions (potassium)through cellmembranes andstimulating thesynthesis ofglycogen fromglucose, of fatsfrom lipids, andproteins fromamino acids.
Treatment oftype 2 (non-insulin-dependent)diabetesmellitus thatcannot becontrolled bydiet or oraldrugs.
Contraindicatedwith allergy to porkproducts; history ofsmoking or lungdisease.
Use cautiously withpregnancy;lactation (monitormother carefully;insulinrequirements maydecrease duringlactation).
Hypertensitivity:-rash-angioedema
Local:-allergy-redness-itching-pruritis-lipodystropy
Metabolic:-hypoglycemia-ketoacidosis
Respiratory:-decline inpulmonaryfunction
1.Givemaintenancedosessubcutaneously, rotatinginjection sitesregularly todecreaseincidence oflipodystrophy.
2.Store insulinin a coolplace awayfrom directsunlight.
3.Monitorserumglucose levelfrequently todetermineeffectivenessof drug anddosage.
4.Reportfever, sorethroat,vomiting,hypoglycemicorhyperglycemic reactions,rash.
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NAME OFDRUG(GENERICAND BRANDNAME)
DATEORDERED
DRUGCLASSIFICATION
DOSE/FREQUENCY
MECHANISM OFACTION
SPECIFICINDICATION
CONTRAINDICATION and CAUTION
SIDE EFFECTS NURSINGPRECAUTION
Pregabalin 7-5-10 Calcium channelmodulatorAnalgesicAntiepileptic
50 mg 1tabletODHS
Binds to alpha2-delta sites on thenerves in theCNS, whichreduces thecalcium influxinto the cell anddecreases therelease ofneurotransmitters into thesynaptic cleft,resulting in lessstimulation of thenerves; in labstudies, it alsoincreases thetrasnport anddensity of GABA,which is knownto suppressnerve activity.
Managementof acute painassociatedwith diabeticperipheralneuropathy
Contraindicationwith knownhypersensitivity topregabalin or anycomponent of thedrug, lactation.
Use cautiously withdiabetes, CHF,pregnancy.
CNS:-dizziness-somnolence-ataxia-vertigo-confusion-tremors
GI:-dry mouth-constipation-flatulence
Other:-peripheraledema-weight gain-back pain-chest pain
1.Do notadministerdrug after afatty or largemeal,absorptioncan beaffected.
2.Monitorweight gainand fluidretention;adjusttreatment fordiabetes.
3.Providesafetymeasures ifdizziness,somnolence,changes inthinkingoccurs.
4.Report rash,changes invision,increasedbleeding,suddenmuscle pain,or weakness.
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NAME OFDRUG(GENERICAND BRAND
NAME)
DATEORDERED
DRUGCLASSIFICATION
DOSE/FREQUENCY
MECHANISM OFACTION
SPECIFICINDICATION
CONTRAINDICATION and CAUTION
SIDE E FFECTS NURSINGPRECAUTION
Pioglitazone 7-5-10 AntidiabeticThiazolidinedione
30 mg 1tabletOD afterbreakfast
Resensitizetissues toinsulin;stimulatesinsulinreceptors sitesto lower bloodglucose andimprove theaction ofinsulin;decreaseshepaticgluconeogenesis andincreases
insulin-dependentmuscle glucoseuptake.
Monotherapyas anadjunct todiet andexercise toimproveglucosecontrol inpatients withtype 2 (non-insulindependent)diabetes.
Contraindicationwith allergy to anythiazolidinedione;type 1 (insulin-dependent)diabetes,ketoacidosis,lactation.
Use cautiouslywith advancedheart disease,liver failure,pregnancy.
CNS:-headache-myalgia
CV:-fluid retention
Endocrine:-hypoglycemia-hyperglycemia
GI:-diarrhea
-liver injury
Respiratory:-sinusitis-URI-rhinitis
Other:-infection-fatigue-toothdisorders
1.Monitorurine andbloodglucoselevelsfrequently todeterminetheeffectiveness of the drugand dosagebeing used.
2.Administerdrug withoutregard to
meals.
3.Reportfever, sorethroat,unusualbleeding orbruising,rash, darkurine, andlight-coloredstools.
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Date Ordered/Date Performed
DiagnosticExam
Result Normal Values Interpretationof result
07-02-10 Urinalysis
Color Yellow Yellow Normal
Character Hazy Hazy Normal
Specific Gravity 1.010 1.010- 1.025 NormalpH 6.5 4.6- 8.0 Normal
Protein Negative Negative Normal
Glucose Positive Negative Possiblediabetic
Bilirubin Negative Negative Normal
Urobilinegen Negative Negative Normal
Nitrates Negative Negative Normal
Blood Negative Negative Normal
Leukocytes Negative Negative Normal
Ketones Negative Negative Normal
Epithelial cells Few Few NormalWBC 0-2/HPF 0-1/HPF Normal
BloodChemistry
FBS(Fasting
Blood Sugar)
338.2 60-110mg/dL Possiblediabetic
07-02-10 Special testreport:Hb A1c
GlycosylatedHgb
12.1 4.5-6.3 % Possiblediabetic
07-03-10 Urinalysis
Color Yellow Yellow Normal
Character Hazy Hazy Normal
Specific Gravity 1.010 1.010- 1.025 Normal
pH 6.5 4.6- 8.0 Normal
Protein Negative Negative Normal
Glucose Positive Negative Normal
Bilirubin Negative Negative NormalUrobilinegen Negative Negative Normal
Nitrates Negative Negative Normal
Blood Negative Negative Normal
Leukocytes Negative Negative Normal
Ketones Negative Negative Normal
Epithelial cells Few Few Normal
WBC 0-1/ HPF 0-1/HPF Normal
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Date Ordered/Date Performed
DiagnosticExam
Result Normal Values Interpretationof result
07-06-10 Serum
ElectrolytePotassium 3.49mmol/c 3.5- 5.0 mg/dL Normal
BloodChemistry
FBS(Fastingblood sugar)
177.3 mg/ dL 60-110mg/dL Possiblediabetic
CBG 388.0mg/dL 60-110mg/dL Possiblediabetic
CBG 286mg/dL 60-110mg/dL Possiblediabetic
Normal anatomy
PATHOPHYSIOLOGY
Precipitating Factors: Predisposing Factors:
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Diet age
SedentaryLifestyle heredity
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Nursing Care PlanCues
(S= Subjective;O= Objective)
NursingDiagnosis
Objectives Interventions Rationale Evaluation
Sub:Usahaymakahuna-hunako nga dili
magkaun para dilimagtaas akosugar asverbalized by thepatient
Obj:-
ImbalancedNutrition; lessthan bodyrequirements
related to utilizenutrients to meetmetabolic needs.
Short-term goal:At the end of 3days duty, the
patient will able todemonstratebehaviors, lifestylechanges tomaintain or regainappropriateweight.
Long-term goal: At the end of 1week, the patientdemonstrate
progressiveweight gain
Ascertainunderstanding ofindividualnutritional needs.
Discuss eatinghabits, includingfood preferences,intolerance oraversion.
Note total dailyintake. Maintaindairy of calorieintake, patternsand times ofeating.
Develop regular
exercise.
Weight weeklyand documentresult.
Collaboration:Take
To determinewhat informationto provide client
To appeal toclients like
To revealchanges thatshould be made inclients dietaryintake
To promote
wellness
To monitoreffectiveness ofdietary plan
To keepnourished.
At the end of 3days, the patientwas able todemonstrate
behaviors.Lifestyle changesto regain/ maintainappropriate weightas evidenced byincreased weight=39kg.
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multivitamins asprescribed
Cues(S= Subjective;O= Objective)
NursingDiagnosis
Objectives Interventions Rationale Evaluation
S= sukad pagkaadmit naku, mgalima na siguro nika adlaw ki ninggitupokan para sadextrose, asverbalized by thepatient
OBJ:-decreasedWBC=0-2/HPF-decreased bodyweight=32.2kls
Risk for Infectionrelated todecreasedleukocyte function
Long-term goal: At the end of 1week, the patientwill able todemonstratetechniques,lifestyle changesto promote safeenvironmentShort-term goal:At the end of 3days duty, thepatient will identifyinterventions to
prevent/ reducerisk for infection.
.
Observe forlocalized signs ofinfection atinsertion site ofinvasive line
. Monitor visitorsor caregivers
Maintainadequatehydration, stand/sit to void
Provide regular
perineal care
Instruct client intechniques toprotect theintegrity of theskin
Collaboration: Administer
To assesscausative orcontributingfactors
To preventexposure of client
To avoidbladder distention
Reduces risk ofascending UTI
To promotewellness
To reduce/correct existingrisk factors
Goals were met.At the end of 3days duty, thepatient identifiedinterventions toprevent risk forinfection. Thepatientdemonstratedlifestyle changesto promote safeenvironment.
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prophylacticantibiotics asindicated
Cues(S= Subjective;O= Objective)
NursingDiagnosis
Objectives Interventions Rationale Evaluation
S= Nganonaghubag ni akotiil?tungod ni satambal nga gi-inject sa ako?, asverbalized by thepatient
OBJ:
Knowledge Deficitrelated tocognitive limitation
Long-term goal: At the end of 8hours, the patientwill verbalizeunderstanding ofdisease processand treatment
Short-term goal:At the end of 1-2hours duty, thepatient will exhibitincreased interestfor own learningand begin to lookfor informationand asksquestions
.
Determineclients ability tolearn
.Provide anenvironment thatis conducive forlearning
Determineclients method ofaccessinginformation tofacilitate learning
Begin withinformation theclient alreadyknows and moveto what the client
To assessreadiness to learn
To facilitatelearning
Limits sense ofbeingoverwhelmed
Provides rolemodel and sharingof information
Goals were met.At the end of 2hours duty, thepatient exhibitedincreased interestfor own learningand began to lookfor informationand askedquestions aboutthe disease. Sheverbalizedunderstanding ofdisease processand treatment.
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does not know
Involve otherswith who have thesame problem
Provide activerole for client inlearning process
Promotes senseof control oversituation
Actual Nursing ManagementReadiness for enhanced self-care related to desire to learn about diabetes mellitus and management options, physical activity for
diabetes mellitus management, and dietary management of diabetes mellitus.
S
O
P
I
E
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XIII. Prognosis
CRITERIA RESULT GOOD POOR
A. ONSET OFILLNESS
The onset of illness started 6
months prior to patients
admission
B. DURATIONOF ILLNESS
The span of the duration ofthe illness is long-term
C. PRECIPITATING FACTOR/PREDISPOSINGFACTOR
The precipitating factor and
predisposing factor wereidentified.
D. ATTITUDEANDWILLINGNESS TOTAKE MEDICATIONTREATMENT
The patient was very muchwilling to follow every
medication and instruction ofthe doctor.
E. FAMILLYSUPPORT
The husband of the patient is
always present at her side andis providing both physical
and emotional support.
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Prognosis:
Patient B.E had shown progress from the time that the patient was admitted to Camiguin
General Hospital. The clients prognosis will largely depend on her willingness to follow her
treatment regimen religiously. The patient was taught of health maintenance by providing
strategies to decrease complications of diabetes mellitus, preventing hypoglycemia or
hyperglycemia by taking early action, she was also taught meal planning and physical activity
programs, follow-up visits to assess for complications of diabetes mellitus
DISCHARGE PLAN AND RECOMMENDATION
Preparation of the patient treatment plan is the best approach as a collaborative
effort of the medical team, which includes the family and or significant others, as the
patient embarks into the world outside the facility. The prognosis is somehow good . An
adequate discharge program aims to make the patient less dependent; and eventually
foster socials skills, work or job skills, and involvement in the community. Initial
discharge plan is as follows:
Medications:
Humulin 70/30 25 u SQ 6 am,15 u SQ 6 pm, this would decrease blood glucose inthe body.
Pioglitazone 30 mg 1 tab after
Exercise:
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Schedule routine activities such as walking, jogging and participation of activities, etc,
which should also correspond to the activities as scheduled in the facility.
Treatment:
Encouraged patient to participate in therapy sessions and other activities
conducted as scheduled in the facility and allow client to interact with other residents
during the evaluation process of every therapy session.
Health teachings on hygiene:
Allow self-care activities like bathing, grooming, and toileting with or without
assistance as minimal as possible; make it a routine activity to promote practice and
encourage less dependence. These activities will become a habit and eventually, the
patient will be able to follow through.
Outpatient:
If scheduled for discharge, explain the instructions to the patient or significant
others to adhere to medical check-ups one week after discharge and At least once or
twice a month, as well as compliance to medication regimen. Encouraged the significant
others or family to situate the patient to an enhanced vicinity than on where he is
currently living now.
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Diet:
There are specific diet restrictions just like foods that have high sugar content.
Recommendations:
Patient B.Es family was encouraged to support her and to be an alley for
patients recovery. Diabetes management is the responsibility of the clients and her
family. The pt should be empowered to accept self-management and become the focus
of the team approach to treatment. They should also be required to have a consistent
follow-up, updating, and reinforcement.
Health TeachingsM Medication The pt was given take home medications which includes
Humulin 70/30 25 u SQ 6 am,15 u SQ 6 pm,Pioglitazone 30 mg 1 tab after ,the pt was encouraged to report anyadverse effects just like dizziness,nausea, vomiting,diarrhea and the like
Take medications with meals to prevent GI upset
Do not overdose drug
Take medication at right time
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E Exercise Walk at least 30 minutes per day
Encouraged to ambulate, flex arm and legs
T Treatment Follow drug regimen as prescribed to prevent reoccurrence of
symptoms
Do not stop taking insulin, even if you are vomiting and unable to eat.
Encouraged to self monitor blood glucose.
Notify your doctor when you have any of the ff. problems.
- Severe abdominal pain
- Temperature greater than 100 F
- Persistent diarrhea
- Vomiting with inability to consume fluids for more then 4 hours
H Home Care Observe proper hygiene;
Take a bath regularly wash hands before and after eating
Proper wound care must observe to prevent infection
Encouraged to have adequate fluid intake every 15 to 30 minutes to
prevent dehydration
O Out-Patient
Department
Come back for follow-up check-up on July 19,2010
D Diet Eat lot of fruits and vegetables.
Instructed to eat foods rich in carbohydrates, eating 10 to 15g of
carbohydrate every 1 to 2 hours. Avoid foods high on sugar like chocolate
Drink plenty of water at least 8 glass of water a day.
DISCHARGE PLAN AND RECOMMENDATION
Preparation of the patient treatment plan is the best approach as a collaborative
effort of the medical team, which includes the family and or significant others, as the
patient embarks into the world outside the facility. The prognosis is somehow good . An
adequate discharge program aims to make the patient less dependent; and eventually
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foster socials skills, work or job skills, and involvement in the community. Initial
discharge plan is as follows:
Medications:
Humulin 70/30 25 u SQ 6 am,15 u SQ 6 pm, this would decrease blood glucose inthe body.
Pioglitazone 30 mg 1 tab after
Exercise:
Schedule routine activities such as walking, jogging and participation of activities, etc,
which should also correspond to the activities as scheduled in the facility.
Treatment:
Encouraged patient to participate in therapy sessions and other activities
conducted as scheduled in the facility and allow client to interact with other residents
during the evaluation process of every therapy session.
Health teachings on hygiene:
Allow self-care activities like bathing, grooming, and toileting with or without
assistance as minimal as possible; make it a routine activity to promote practice and
encourage less dependence. These activities will become a habit and eventually, the
patient will be able to follow through.
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Outpatient:
If scheduled for discharge, explain the instructions to the patient or significant
others to adhere to medical check-ups one week after discharge and At least once or
twice a month, as well as compliance to medication regimen. Encouraged the significant
others or family to situate the patient to an enhanced vicinity than on where he is
currently living now.
Diet:
There are specific diet restrictions just like foods that have high sugar content.
Recommendations:
Patient B.Es family was encouraged to support her and to be an alley for
patients recovery. Diabetes management is the responsibility of the clients and her
family. The pt should be empowered to accept self-management and become the focus
of the team approach to treatment. They should also be required to have a consistent
follow-up, updating, and reinforcement.
Bibliography: