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I.
INTRODUCTION
This case study is all about L.V, a 56 year old patient who diagnose with a Type 2 Diabetes Mellitus along with a urinary tract infection at Bulacan Medical Center on December 19, 2012, with a chief complain of dizziness, weakness and difficulty in breathing. Diabetes Mellitus or simply diabetes, is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Diabetes has its major classification which varies in cause, clinical course, and treatment. These are the type 1 DM, type 2 DM, gestational diabetes, and diabetes mellitus associated with other conditions or syndromes. Type 2 diabetes mellitus or commonly known as Non- insulin dependent or an adult onset type described as a relative deficiency of insulin production and a decreased insulin action and/or increased insulin resistance. It occurs more commonly among people who are older than 30 years of age and obese although its incidence is rapidly increasing in younger people that is because of the growing epidemic of obesity in children, adolescence and young adults. The clinical manifestations are depending on the patients level of hyperglycemia. It includes polyuria (increased urination) and polydipsia (increased thirst) occurs as a result of excess loss of fluid associated with osmotic dieresis. Patients also suffers polyphagia (increased appetite) that is the results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Other manifestations such as fatigue, weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin and recurrent infections are noted. Several procedures like fasting plasma glucose, random plasma glucose and glucose level two hours after receiving glucose (2- hour postload) may indicate an abnormally high blood glucose level which is considered to be the basic criterion for the diagnosis of diabetes. The major goal of the diabetes treatment is to normalize the insulin activity and blood glucose level to reduce the development of vascular and neuropathic complications without patient experiencing hypoglycemia: nutritional therapy, exercise, monitoring, pharmacologic therapy and education which are the essential components of diabetic regimen.
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The incidence of diabetes is growing around the world. It is in the top ten leading causes of deaths. Filipinos are not an exemption to this incidence as more and more Filipinos are affected by the disease. According to the survey conducted by the Philippine Cardiovascular outcome study on Diabetes Mellitus in 2007 found out that 20.6 percent of adults aged 30 and above were found to be diabetic. In 1998 only 3.9 percent of Filipinos living in the Philippines had diabetes. On the other hand, the prevalence of diabetes according to the NNHES (National Nutrition Health Survey) study is 4.8%.
REASONS OF STUDY The group chose type 2 diabetes mellitus as our case study because aside from it is still fresh in our minds; our group was interested in studying this. We are willing to do this case to challenge our own minds in analyzing the problem and to enhance our knowledge, as well as to gain new experiences which could bring new learnings for the group. This case study will also help the group in understanding the disease process of the patient. It would also help the group in identifying the primary needs of the patient with a type 2 Diabetes Mellitus. By identifying such needs and health problems arise the group can now formulate an individualized Nursing care plan for the patient that would address these needs and problems effectively. Management of the identified problem will help the patient to recover faster and maintain holistic sense of wellness. This will also equip the group with knowledge, skills and attitude on how to manage future patient with the same disease.
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II.
OBJECTIVES
STUDENT- CENTERED GENERAL OBJECTIVES The purpose of this case study is to give the much needed knowledge and awareness to the nursing students who have or might have handled cases of Type II Diabetes Mellitus associated with Urinary Tract Infection.
SPECIFIC OBJECTIVES (STUDENT-CENTERED) KNOWLEDGE: To be able to have a better understanding at the case of the patient having a type 2 Diabetes Mellitus associated with Urinary Tract Infection and the occurrence of its signs and symptoms. To be able to know the disease process through its pathophysiology. To be able to be knowledgeable about the patient drug study.
SKILLS:
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To be able to formulate nursing care plans based on the prioritized health needs of the client.
To be able to discuss about the pathophysiology of the disease process. To be able to familiarize on the aggravating factors and specific interventions to prevent complications of Type 2 diabetes Mellitus and Urinary Tract Infection.
ATTITUDE: To be able to change any misconception about the said disease of the patient. To be able to develop awareness in the proper care management for type 2 diabetes mellitus and urinary tract infection. To be able to serve our future clients with a higher level of holistic understanding as well as individualized care.
(CLIENT-CENTERED) GENERAL OBJECTIVES This case study implies knowledge and awareness to people who have or might be at risk of the said disease regarding its fatality and detection.
SPECIFIC OBJECTIVES
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KNOWLEDGE: To be able to impart knowledge regarding type 2 Diabetes Mellitus and Urinary Tract Infection. To be able to determine signs and symptoms and its complications. To be able to familiarize on the appropriate interventions with its rationale to improve patients condition.
SKILLS: To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own. To be able to explain the different factors that may cause type 2 diabetes mellitus and Urinary Tract Infection and its danger. To be able to participate in her plan of care.
ATTITUDE: To help the patient in motivating her to continue the health care provided by the health workers. To be able to complies with the treatment protocol and prevention strategies. To be able to identify different measures to prevent further aggravation of the condition.
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D. Past Health History According to the client, he experienced common diseases like fever, cough and colds. She also had Urinary Tract infection last December and was given medication like Bactrim Forte. According to client she was also confined in the ICU for 1 week because of hyperglycemia associated by hypertension. He is also a hypertensive patient. E. Family Health History According to the patient, her family has a history of Asthma, diabetes Mellitus and Hypertension on the paternal side.
LUNCH
DINNER
TOTAL INTAKE
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tea(250mL)
March 3, 2013
1 glass of water(250m l) bowl of binagoonga ng baboy(150 mL) cup rice 1 glass of water(250m L)
1 cup tea(250mL) bowl of binagoonga ng baboy(150 mL) 1 cup rice 1 glass of water(250 mL) 1 pc Indian mango 1 sachet of skyflakes 1 cup tea(250mL) Approximat ely: 1350mL
March 4, 2013
According to the client she has restriction on his diet. If we noticed her intake in the span of 3 days, she limits her carbohydrates intake as well as fat intake. She also added that she was also limiting herself in eating sweet foods. Our client stated that she drinks a lot everyday approximately 1 liters, she verbalized uhaw na uhaw ako palagi. According to the approximate Total intake per day it is normal, because the normal Total intake is 2500mL per day. And in the 72-hour diet recall it is shown that her
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Elimination Pattern
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once
NONE
once
Dark Yellow
NONE
once
The clients frequency of urination is increase because of her condition; she verbalized ihi ako ng ihi. The color of her urine varies on the drugs that she was taking and according to the client the odor of her urine was like a smell of medications.
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According to the client she sleeps at 2:00AM, she verbalized nahihirapan akong kunin yung tulog ko ba, kaya nanunuod na lang ako ng tv, pero kapag natulog na ako tuloy-tuloy na and she wakes up at 6:00 in the morning. She doesnt take nap because she is busy watching television.
With Diabetes Mellitus According to the client, she was unable to do the things she usually does because of her condition. Now that she has diabetes mellitus she gets easily tired and feels weak. 0- FEEDING 0- HOME MAINTENANCE 0- DRESSING 0- TOILETING N/A- SHOPPING MOBILITY 0- BED MOBILITY 0- BATHING 0- COOKING 0- GROOMING 1- GENERAL
LEGEND: Level 0- Full self Care Level I- Requires Use of Equipment Level II- Requires assistance or supervision from another person
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Level III- Requires assistance from another person and device Level IV- Is Dependent and doesnt participate Role Relationship Pattern With Diabetes Mellitus
The Client feels sad and happy. Sad because she was not able to things that may trigger her condition and happy because her family is very supportive and concern about her present condition.
She is normal in cognitive pattern. In terms of perceptual pattern she rated her condition as 8 out of 10(10 being the highest and 1 is the lowest). The client was also diagnosed before having an early cataract related to DM retinopathy.
With Diabetes Mellitus The client stated that she feels good when he see and feel the presence of her family in the hospital.
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According to her, she became a stronger person because of his faith in God and she was more motivated to do follow the proper regimen for diabetes mellitus.
Sexuality/ReproductivePattern
With Diabetes Mellitus According to the client her faith in God increase and the only person that she could ask for help is God.
GENITAL Puberty-Death
Middle Adulthood: 35 to 55 or 65 During final stage, the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of person's life. Adults need to create/nurture things that will outlast them, often by having children/creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. Can think logically about abstract propositions and test hypothesis systematically, becomes with hypothetical future and ideological problems.
Orientation Few people operate at this stage all the time. It is based on abstract reasoning and the ability to put oneself in other people's shoes. At this stage, people have principled conscience and will follow universal ethical principles regardless of what the official laws and rules are. .
DEFINITION
RESOLUTION
The client was successfully met the psychosexual stage not only because she was able to have children with her husband but also in genital stage affords the person the ability to confront and resolve her remaining psychosexual childhood conflicts.
The client achieves this stage because she knows that she gave back to the society through raising her children and being productive as being a mother to her children.
The client thinks rationally and logically. As a mother and wife she was able to solve the problems by communicating to her children and husband.
She lives autonomously and defines the moral personal identification with group values and principle that are universally agreed on the considers appropriate that for life. She makes decision according to what her conscience dictates.
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Nola J. Pender
Dorothea E. Orem
Lydia Hall
We use this theory as a guide for our care plan to the client because the major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core. Client is composed of body, pathology, and person. People set their own goals and are capable of learning and growing.
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PHYSICAL ASSESSMENT
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ASSESSMENT
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS/INTERPRET ATION
GENERAL APPEARANCE BODY BUILT POSTURE OVER-ALLHYGIENE BODY AND BREATH ODOR SIGNS OF DISTRESS OBVIOUS SIGN OF HEALTH OR ILLNESS MENTAL STATUS LEVEL OF CONSCIOUSNE SS ORIENTATION INSPECTION INSPECTION Conscious and coherent Oriented to time, place, situation Conscious and coherent Oriented to time, place, situation Normal Normal INSPECTION INSPECTION INSPECTION INSPECTION INSPECTION INSPECTION Proportionate, varies with lifestyle Not on an Erect posture Clean and neat appearance No body and breath odor No signs of distress No signs of illness or disease Proportionate ( mesomorph ) Not on an erect posture Clean and neat appearance No body and no breath odor Weak in appearance Obvious signs of illness or disease Normal Normal Normal Normal Deviation from Normal due to aging Deviation from Normal due to the presence of the disease.
NORMAL FINDINGS Uniform in color, no presence of edema ,no skin lesions, normal temperature, long skin turgor, dry skin Convex curvature about 160, smooth in texture, have an intact epidermis tissue surrounding the nails, less than 4 sec. returning to its normal color (pink) when performing blanch test
ACTUAL FINDINGS Dry skin and theres presence of skin pigmentations on the body Convex curvature about 160, smooth in texture, have an intact epidermis tissue surrounding the nails, having a normal blanch test with pale color of nail beds. & presence of dead toe nail.
ANALYSIS Deviation from Normal due to hydration status & melatonin deficiency of the client. Deviation from Normal due to decrease of oxygen in the tissue cells.
b.)
NAILS
INSPECTION PALPATION
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SUMMARY OF SIGNIFICANT FINDINGS: Weak in appearance due to aging Dry skin and poor skin turgor due to hydration status of the cliet. Presence of skin pigmentation over the body due to melatonin deficiency. Obvious sign of illness or disease because of his resent condition. Paleness of lip/ buccal mucosa caused by decreased oxygen in the tissue cells. Presence of dentures Visual acquity with the grade of 250 in both eyes. Nails are pale in color due to decreased oxygen supply in the tissue cells and dead toe nail.
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VIII. DRUGS/MEDICATIONS
DRUG NAME MECHANISM OF ACTIONS Decreases blood glucose by transport of glucose into cells; conversion of glucose to glycogen . INDICATION CONTRAINDICATI ON Hypoglycemia and hypersensivity reactions SIDE EFFECTS NURSING RESPONSIBILITIE S Obtain patience history, including drug history and any known allergies. Monitor fasting blood glucose, 2hrs after meals. Monitor urine ketones during illness. Monitor body weight Monitor for hypoglycemic /hyper glycemic reactions. Prior: Assess BP and apical pulse before the initial dose Monitor baseline for renal, liver functions tests before therapy begins.
Generic Name: HUMULIN 70/30 Classification: Antihyperglycemic / Antidiabetic Route/Dosage: Subcutaneous; 10ml
Generic Name: Simvastatin Classification: Antihyperlipidemic agent/HMG-CoA reductase inhibitor Route/Dosage: 40mg/tab OD
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Treatment of Hyprlipidemias
During: Assess for symptoms of CHF ,edema,dyspnea wet rales. BP weight gain, report significant changes. After: Note for allergic rteactions monitor blood pressure. Generic Name: Telmisartan (micardis) Classification: Angiotensin II antagonist/ Antihypertensive Route/Dosage: 80mg/tab OD Blocks the Treatment for vasoconstrictive Hypertension and aldosteronesecreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues Pregnancy and lactation. Biliary obstructive disorder. hypersensivity Diarrhea; headache; fatigue; Urinary tract infection Prior: Assess BP and apical pulse before the initial dose Monitor baseline for renal, liver functions tests before therapy begins. During: Assess for symptoms of CHF ,edema,dyspnea wet rales. BP weight gain, report significant changes. After: Note for allergic rteactions monitor blood pressure.
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Prior: Assess BP and apical pulse before the initial dose Monitor baseline for renal, liver functions tests before therapy begins. During: Assess for symptoms of CHF ,edema,dyspnea wet rales. BP weight gain, report significant changes. After: Note for allergic rteactions monitor blood pressure. Prior: Assess BP and apical pulse before the initial dose Monitor baseline for renal, liver functions tests before therapy begins. During: Assess for
Generic Name: Valsartan Classification: Angiotensin II receptor blocker / Antihypertensive agent Route/Dosage: 80mg OD
Blocks the Treatment for vasoconstrictive Hypertension and aldosteronesecreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues.
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symptoms of CHF ,edema,dyspnea wet rales. BP weight gain, report significant changes. After: Note for allergic rteactions monitor blood pressure. Generic Name: Clonidine Classification: AntiHypertensive agent Route/Dosage: 750mcg/Tab BID Stimulates central alpha-adrenergic receptors to inhibit symphatetic cardioaccelerator and vasoconstrictor centers Management of all grades of hypertension Hypersensitivity to clonidine Drowsiness, dry mouth, headache, urinary retention hypotension Prior: Assess BP and apical pulse before the initial dose Monitor baseline for renal, liver functions tests before therapy begins. During: Assess for symptoms of CHF ,edema,dyspnea wet rales. BP weight gain, report significant changes. After: Note for allergic rteactions monitor blood pressure.
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Analytes
Result
Normal
Interpretation
Nursing responsibilities
14.7
4.1-11.1
Lymphocytes% 14.1
16.0-46.0
Prior to examination: Check the doctors order. Explain the procedure to the client. Assess for the presence of hematophobia. Check the medications of the patient that may affect the result. During: Provide comfort to lessen patients anxiety while waiting for the result. After: Secure laboratory result to the chart of the patient. ( refer result to the physician)
Monocytes %
2.9
2.3-8.5
hemostasis. To identify persons who may have an infection. To identify acute and chronic illness, bleeding tendencies.and number of circulating white blood cells.
Granulocytes %
83.0
48.7-81.2
The result is above normal level it indicates: The patient may develop an anemia The result is within normal The result is within normal. The result is within normal. The result is above normal it indicates: The patient may suffer from anemia. The result is above normal it indicates: That the patient develop cardiovascular disease. The result is within normal. The result is below normal it indicates that :
14.7
11.9-14.4
402 6.7
169-418 7.0-10.5
The patient may develop leukemia. Laboratory procedure Urinalysis Date ordered/ date result December 19,2012 Indication/ purpose
Analytes Color
Normal
Interpretation Normal
Nursing consideration
Prior: 1. Review
It is an essential procedure for patients undergoin g hospital admission or physical examinati on. It is a useful indicator of a healthy or diseased state and has remained an integral
Transparency
Slightly turbid
Normal
Negative
Specific gravity
1.030
1.010-1.025
Positive result of glucose in the urine may indicate: high blood glucose level undiagnosed or uncontrolled diabetes mellitus The result is above normal level it indicates that: Urine is concentrated
needed. 3. Explain the procedure to the patient. 4. 4 .Instruct the patient to void directly into a clean, dry container. Sterile, disposable
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containers are
Faint aromatic
Rare
Bacteria
Rare
Negative
The result is abnormal it indicate that: the patient eats food cause musty odor. Infected urine Urine that have glucose. Abnormal result indicates: Infection process.
recommend ed. Women should always have a cleancatch specimen if a microscopic examination is ordered. Feces, discharges, vaginal secretions and menstrual blood will contaminate the urine specimen. After: 1. Cover all specimens tightly, label properly and send
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The process of urinalysis determine s the abnormal constituen ts revealed by microsco pic examinati on of the urine sediment.
immediately to the laboratory. 2. If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen port with antiseptic before aspirating the urine sample with a needle and a syringe. 3. Observe
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standard precautions when handling urine specimens. 4. If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an appropriate preservative added.
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X. NURSING PRIORITIZATION
NURSING PROBLEM 1. Altered Tissue Perfusion JUSTIFICATION We consider this problem as our first priority because diabetes mellitus has a primary feature of constricted blood vessels which caused by an inadequate oxygenated blood circulate in the body which is the reason of having a fatigue in relation to the decrease muscle strength
2. Fatigue
We choose the fatigue as our 2nd priority because it is more important than the deficient knowledge and considered to be a physiologic needs of an individual.
3. Deficient Knowledge
We consider the deficient knowledge as the 3 rd priority because it is very important to know the care, course and the treatment of her condition, for her to be aware in her body. Intolerance of activity is our 4th priority because if we resolved the problems in the circulation or the fluid volume, fatigue and the
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possible unstable blood glucose level, our client will have a capacity to tolerate activities just like before because our client has a sufficient energy to perform desired activities.
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
NURSING INTERVENTION/S
RATIONALE
EVALUATION
OBJECTIVE CUES:
After 8 hours of nursing intervention, the patient will be able to achieve a normal circulation in the peripheral.
Vital Signs:
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heart (the position of elevation at rest), avoid crossing legs, avoiding tight bandage, avoid the use of pillows, hamstrings and so forth.
Teach about the modification of risk factors such as: Avoid a diet high in cholesterol, relax ation techniques, smokin g cessation, and drug use vasoconstriction.
High cholesterol can accelerate the occurrence of atherosclerosis; smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.
Giving vasodilators will increase the dilation of blood vessels so that tissue perfusion can be improved, while checking blood sugar regularly to know the progress and state of the patient.
Collaborate with other health team in giving vasodilators and checking blood sugar regularly
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SUBJECTIVE: OBJECTIVE: generalized weakness increased respiratory rate of 25cpm body weakness weight loss fatigue -limited ROM inability to perform ADL altered VS altered sensorium
After 3 days of nursing interventions, the patient will be free from signs of fatigue SHORT TERM GOAL: After 2-3 hours of nursing interventions, the patient will be able to identify measures to conserve and increase body energy. Response to an activity can be evaluated to achieve desired level of tolerance. To determine the level of activity
Assess response to activity Asses muscle strength of patient and functional level of activity. Discuss with patient the need for activity
Education may provide motivation to increase activity level even though patient may feel too
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weak initially
Monitor pulse, respiration rate and blood pressure before/after activity Perform activity slowly with frequent rest periods
Interventions should be directed at delaying the onset of fatigue and optimizing muscle efficiency. Symptoms of fatigue are alleviated with rest. Also, patient will be able to accomplish more
Promote energy
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conservation techniques by discussing ways of conserving energy while bathing, transferring and so on.
Provide adequate ventilation Provide comfort and safety Instruct patient to perform deep breathing exercises Instruct client to increase -
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Vitamins A, C and D and protein in her diet. Instruct also patient to increase iron in diet Administer oxygen as ordered.
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
NURSING INTERVENTION/S
RATIONALE
EVALUATION
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OBJECTIVE CUES:
Deficient knowledge related to the disease process due to lack of information or information misinterpretation
After 8 hours of nursing intervention, the patient will be able to verbalize accurate information, report understanding of condition and discuss process and treatment.
Provide explanations of reasons for the procedure and the preparation needed. Identify individual restrictions such as too sugar in the food.
XII. CONCLUSION
At the end of our case study, our group learned things about Type II Diabetes Mellitus and Urinary Tract Infection that are needed for us to know. We therefore conclude that we, as nursing students must give time in knowing disease or illness like our case. These things would help us further in giving or disseminating information to people who are concerned or involved in this condition.
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On the other hand, this case study is not only for nursing student but this can be also helpful to other professionals and ordinary people. We studied about the risk factors, its sign and symptoms, treatment, medication for Type II Diabetes Mellitus and Urinary Tract Infection. Hence, we learned that any individual is prone to this condition if their lifestyle puts them to a higher risk. Thats why we must all be well-informed to prevent its occurrence. Lastly, at the end of our case study we, student nurses apprehend all essential things about Type II Diabetes Mellitus and Urinary Tract Infection. Avoid exposure, proper lifestyle, proper hygiene and proper nutrition is the best way to prevent the acquiring of Type II Diabetes Mellitus and Urinary Tract Infection and any other diseases.
XII. BIBLIOGRAPHY
Kozier B. et al: Fundamentals of Nursing 10th edition Pearson education Inc. New jersey Copyright 2004 p.434
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Moorhouse , Doenges, M.: Nurses Pocket Guide: Nursing Diagnoses with Interventions Brunner and Suddart: textbook of Medical and Surgical Nursing 12 th edition, hippincott, Williams & Wilkins -http://www.justmommies.com/articles/anemia-during-pregnancy.shtml#ixzz1lN1GVpZL http://en.wikipedia.org/wiki/Pain#Management http://www.livestrong.com/article/202712-a-nursing-diagnosis-of-limited-mobility/ http://nurseslabs.com/d5w-iv-fluid-study/\
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