Anda di halaman 1dari 76

ANGELES UNIVERSITY FOUNDATION

Angeles City

College of Nursing

Academic Year 2008-2009

A CASE STUDY OF PATIENT WITH


DIABETES MELLITUS II
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
IN RELATED LEARNING EXPERIENCE III

Presented By:
(Section)
(Group no.)
(Members)

Presented to:
ERCEL JAY G. GAMBOA, RN.
I. Introduction

"The health of the people is really the foundation upon which all their happiness and all
their powers as a state depend."
Benjamin Disraeli (1804-1881)

Insulin is necessary for the body to be able to use glucose for energy. When you eat
food, the body breaks down all of the sugars and starches into glucose, which is the basic
fuel for the cells in the body. Insulin takes the sugar from the blood into the cells. When
glucose builds up in the blood instead of going into cells, it can cause two problems:
(1)right away, your cells may be starved for energy and (2)over time, high blood glucose
levels may hurt your eyes, kidneys, nerves or heart. (www.diabetes.org)

Diabetes Mellitus (DM) or simply diabetes is a disease in which the body doesn’t
produce or properly use insulin. Insulin is the hormone that is needed to convert sugar,
starches and other food into energy needed for daily life. This is the reason why diabetics
need an insulin injection if the disease is already severe. The cause of diabetics continues
to be a mystery, although genetics and environmental factor such as obesity and lack of
exercise appear to play roles.

Untreated or inappropriately-treated diabetes can cause problems with the kidneys,


legs, feet, eyes, heart, nerves, and blood flow, which could lead to kidney failure,
gangrene, amputation, blindness, or stroke. For these reasons, it is important to follow a
strict treatment plan.

Statistics on Diabetes Mellitus is startling. In the United States a report says that two
out of three (66.6%) Adult Americans, and 15% of the children, are overweight. In the
United States alone, there are about 17 million diabetics. Five to 10% have type I
(juvenile), and the rest, Type II (adult onset) diabetes. Before insulin was discovered in
the early 1920’s, type I diabetes has 100% mortality. In the past 10 years, there has been
a 33% increased in the number of diabetic patients. (www.jpsimbulan.com)
Of the 17 million Americans with diabetes, 90 percent to 95 percent have type II
diabetes. Of these, half are unaware they have the disease. People with type II diabetes
often develop the disease after age 45, but are not aware they have diabetes until severe
symptoms occur, or they are treated for one of its serious complications. Type II diabetes
is more prevalent among African American, Hispanic/Latino American, and Native
Americans. Type II diabetes is nearing epidemic proportions, due to an increased number
of older Americans, and a greater prevalence of obesity and a sedentary lifestyle.
(www.medicalcenter.osu.edu)

Roughly 4.6 % of the population in the Philippines (or about 3.5 million) are diabetics.
Not included in these statistics are the 4%-5% who are undiscovered and about 8 % pre-
diabetics, or future diabetics. All these predicted to be twice as many in two decades.
More than 65% of diabetics will die of some form of heart disease or stroke.
(www.malaya.com.ph)

Advances in diabetes research have led to improved methods of managing diabetes


and treating its complications. However, scientists continue to explore the causes of
diabetes and ways to prevent and treat the disorder. Other methods of administering
insulin through inhalers and pills are currently being studied. Scientists are investigating
gene involvement in type 1 and type 2 diabetes and some genetic markers for type 1
diabetes have been identified. Pancreas transplants are also being performed.
(www.medicalcenter.osu.edu)

The group has chosen Diabetes mellitus (DM) as their case study. This disease is a
common condition not only in the Philippines. It afflicts people around the world and is
now actually a pandemic disease. Despite of its prevalence, still a lot of people don’t
have enough knowledge regarding the disease. They are not aware about the
complications that the disease may cause and as a result, they don’t take any preventive
measures or early screening procedures. They only recognize the condition when it is
already severe. Because of this, the group finds a keen interest in choosing DM to be the
topic of their case study. The group wants to help those people specially those who are at
a high risk of acquiring the disease to be knowledgeable enough so that they may be
compliant and take the disease seriously. Because the group believe that nurses are not
only persons who administers medications ordered by the doctors but passionate persons
who have concern to the people committed to their care. Also as an advocate of the
patient’s well-being, the group can use the pieces of information gathered in the study in
their future career as nurses and may be able to put these knowledge into practice.

II. NURSING ASSESSMENT

A. Personal History
1. Demographic Data

Ms. Sugar is a 40 years old female Filipino patient who was born on July 27, 1968 at
Angeles City, Pampanga. She is still single. She currently resides at Brgy. Claro M. Recto,
Angeles City with her siblings, niece and nephews. He was admitted to a secondary
hospital in Angeles City, Pampanga last September 14, 2008 with an admitting diagnosis of
Diabetes Mellitus II t/c Chronic Renal Failure 2o to Diabetic Nephropathy.

2. Socio-Economic and Cultural Factors

Ms. Sugar is a undergraduate of highschool(3rd year) in a public school in Angeles City.


She used to work as a researcher in a food and beverage corporation at San Fernando but
already retired and currently unemployed. The source of income comes from her siblings,
who works in a casino and earns approximately P5000.00 monthly and her sibling’s
husband who works as a street sweeper in Clark, Pampanga and earns P7000.00 monthly.
According to her, their income is just enough for their daily needs. But they are
considered poor because according to Maglaya (2003); the requirement of expenses of
each individual should be P 2, 768.60/month to be considered as not poor but the family
where Ms. Sugar resides only has P1, 500/individual/month, therefore, they did not reach
the required amount. She was an active member of Jehovah’s Witnesses and follows
strictly to their beliefs and practices such as refusing in blood transfusion. She believes in
manghihilot and consults to them whenever she experiences any alterations in health. But
in severe cases, she directly goes to the nearest hospital. She is also utilizing some herbal
medicines such as Pandan Lalaki and Banaba. In their family, they don’t usually believe in
superstitious beliefs or pamahiin.
B.

P. Grandfather M. Grandfather M. Grandmother


Asthma War HPN

Uncle S1 Aunt S2 Uncle S3 Father S1 Uncle S2 Uncle S3


Accident DM Emphysema HPN * *

Uncle S4 Mother S5 Uncle S4 Uncle S5


Gun shot DM, HPN * *

Uncle S6 Aunt S7 Aunt S6


Uncle S7
DM Paralyzed *

Sister S4
Brother S1 Sister S2 Ms. Sugar S3
36 yrs old
43 yrs old 42 yrs old 40 yrs old DM
Asthma
b. Family Health-Illness History

Paternal side Maternal side

P. Grandfather P. Grandmother M. Grandfather M. Grandmother


Asthma DM War HPN

Uncle S1 Aunt S2 Uncle S3 Father S1 Uncle S2 Uncle S3


Accident DM Emphysema HPN * *

Uncle S4 Mother S5 Uncle S4 Uncle S5


Gun shot DM, HPN * *

Uncle S6 Aunt S7 Aunt S6


Uncle S7
DM Paralyzed *

Sister S4
Brother S1 Sister S2 Ms. Sugar S3
36 yrs old
43 yrs old 42 yrs old 40 yrs old DM
Asthma
Legend:
*= died from an unknown cause
= Deceased
S1= 1st sibling
S2= 2nd sibling
S3= 3rd sibling
S4= 4th sibling
S5= 5th sibling
S6= 6th sibling
S7= 7th sibling

Interpretation:
The diagram shows the history and prevalence of the disease. In this diagram
we can trace the origin of DM and HPN in which we can conclude that DM and HPN is a
genetically acquired disease wherein it is a non modifiable factor. In this diagram we
could see the disease and cause of death of Ms. Sugar’s relatives. Here we have traced
that the source of DM of Ms. Sugar was her paternal grandmother. On her paternal side
we can see the prevalence of the disease here we can see that 3 out of 7 of her aunts
and uncles have the disease including her mother who also have the disease. Her
mother has DM and HPN which are also the diagnosis of her daughter. On her maternal
side we can see the prevalence of HPN that 2 out of 7 relatives acquired it. Here we
have concluded that based on the diagram Ms. Sugar was at very high risk of acquiring
this disease. Among Ms. Sugar’s sibling she was the only one who acquired the disease.
c. History of Past Illness

When Ms. Sugar was 23 years old (1985), she diagnosed to have diabetes mellitus. The
physicians prescribed medications and diabetic diet and according to Ms. Sugar, she complied
strictly with these interventions. Four years ago (2004), Ms. Sugar was hospitalized with a
diagnosis of pneumonia. And also in that year, she was admitted to a public hospital in
Angeles with positive hydrothorax. According to her, she has undergone chest thoracotomy to
remove the fluid accumulation in her lungs. And in the year 2007, she had three separate
hospitalizations again because of DM.

d. History of Present Illness

One week prior to admission, Ms. Sugar experienced cough. She did not take any
medications or consultations. MS. Sugar’s condition became persistent and a prompted
decision to seek consultation was made which brings her to the nearest hospital. She was
admitted in a secondary hospital in Angeles City with fever, cough and body malaise and a
chief complaint of difficulty of breathing and chest tightness.

e. Physical Examination

The following physical examination results were done upon admission of the patient
(September 14, 2008):

B/P= 140/90 mmHg HR= 128 bpm RR= 32 bpm TEMPERATUR E= 38.80C

General Appearance (Physical Assessment done by the resident on duty)


(LIFTED FROM THE CHART)
HEENT – Pale palpebral conjunctiva; anicteric slera (-) Cervical Lymphadenopathy (CLAD)
Chest and Lungs – SCE, clear breath sounds

Heart – Adynamic precordium

Abdomen – flabby, Normo Active Bowel Sounds (NABS)

Genitalia – (-) D/C

Extremities – (+) wound, Left big toe

September 15, 2008

*Legend: all abnormal findings are bolded.

Vital signs:
T – 37.9o C
PR - 81 bpm
RR - 21 bpm
BP – 130/80 mmHg

Skin

• Poor skin turgor


• Dark spots in the face
• Absence of cyanosis and pallor
• Absence of bruises
• Fair complexion
• Dry and scaly skin

Hair

• Evenly distributed
• Thin and short
• With presence of dandruff
• Absence of lesions, mass upon palpation

Nails
• Short, normal color and has intact epidermis
• Dirty fingernails and toenails
• Normal capillary refill time

Skull

• Has smooth rounded contour


• Absence of nodules or masses

Eyes

• Eyebrows are evenly distributed, aligned and equal in movement


• Eyelashes are evenly distributed and slightly curled outward
• Has symmetrical and normal eye movement
• With blinking reflex
• Pale palpebral and bulbar conjunctiva
• Pupils are equally round and reactive to light and accommodation
• Both eyes move in a smooth, coordinated manner in all directions
• Client can see objects in the periphery when looking straight ahead

Ears

• Symmetrical and aligned


• Tip of the earlobe is aligned to the outer cantus of the eye
• No lesions
• With minimal dry cerumen

Nose

• Uniform in color
• No changes in nares with respiration
• Septum located at midline
• Mucosa pink and moist with uniform color and no lesions
• No lesions
• Absence of tenderness and secretions
Lips

• Bluish hue
• Dry lips
• No lesions upon palpation

Mouth

• Pink mucous membrane


• Incomplete set of teeth, with dental caries
• Without lesion

Neck

• Neck muscles are equal in size


• No palpable or enlarged lymph nodes
• No masses noted upon palpation

Chest

• With intact skin uniform in color


• Absence of tenderness
• No masses
• Has clear breath sounds upon auscultation

Abdomen

• Flat, normal abdominal bowel sounds


• Soft, non-tender
• No pain upon palpation

Upper extremities

• Symmetrical
• No deformities, tenderness or swelling
• No edema

Lower extremities

• symmetrical
• No edema
• Small wound present on left big toe

September 16, 2008

Vital signs:
T – 38o C
PR - 92 bpm
RR - 22 bpm
BP – 130/70 mmHg

Skin

• Poor skin turgor


• Dark spots in the face
• Absence of cyanosis and pallor
• Absence of bruises
• Fair complexion
• Dry and scaly skin

Hair

• Evenly distributed
• Thin and short
• With presence of dandruff
• Absence of lesions, mass upon palpation

Nails
• Short, normal color and has intact epidermis
• Dirty fingernails and toenails
• Normal capillary refill time

Skull

• Has smooth rounded contour


• Absence of nodules or masses

Eyes

• Eyebrows are evenly distributed, aligned and equal in movement


• Eyelashes are evenly distributed and slightly curled outward
• Has symmetrical and normal eye movement
• With blinking reflex
• Pale palpebral and bulbar conjunctiva
• Pupils are equally round and reactive to light and accommodation
• Both eyes move in a smooth, coordinated manner in all directions
• Client can see objects in the periphery when looking straight ahead

Ears

• Symmetrical and aligned


• Tip of the earlobe is aligned to the outer cantus of the eye
• No lesions
• With minimal dry cerumen

Nose

• Uniform in color
• No changes in nares with respiration
• Septum located at midline
• Mucosa pink and moist with uniform color and no lesions
• No lesions
• Absence of tenderness and secretions
Lips

• Bluish hue
• Moist and smooth lips
• No lesions upon palpation

Mouth

• Pink mucous membrane


• Incomplete set of teeth, with dental caries
• Without lesion

Neck

• Neck muscles are equal in size


• No palpable or enlarged lymph nodes
• No masses noted upon palpation

Chest

• With intact skin uniform in color


• Absence of tenderness
• No masses
• Has clear breath sounds upon auscultation

Abdomen

• Flat, normal abdominal bowel sounds


• Soft, non-tender
• No pain upon palpation

Upper extremities

• Symmetrical
• No deformities, tenderness or swelling
• Edema noted in the right hand due to infiltration

Lower extremities

• symmetrical
• No edema
• Small wound present on left big toe

September 17, 2008

Vital signs:
T – 36.9o C
PR - 80 bpm
RR - 21 bpm
BP – 140/90 mmHg

Skin

• Poor skin turgor


• Dark spots in the face
• Absence of cyanosis and pallor
• Absence of bruises
• Fair complexion
• Dry and scaly skin

Hair

• Evenly distributed
• Thin and short
• With presence of dandruff
• Absence of lesions, mass upon palpation
Nails

• Short, normal color and has intact epidermis


• Dirty fingernails and toenails
• Normal capillary refill time

Skull

• Has smooth rounded contour


• Absence of nodules or masses

Eyes

• Eyebrows are evenly distributed, aligned and equal in movement


• Eyelashes are evenly distributed and slightly curled outward
• Has symmetrical and normal eye movement
• With blinking reflex
• Pale palpebral and bulbar conjunctiva
• Pupils are equally round and reactive to light and accommodation
• Both eyes move in a smooth, coordinated manner in all directions
• Client can see objects in the periphery when looking straight ahead

Ears

• Symmetrical and aligned


• Tip of the earlobe is aligned to the outer cantus of the eye
• No lesions
• With minimal dry cerumen

Nose

• Uniform in color
• No changes in nares with respiration
• Septum located at midline
• Mucosa pink and moist with uniform color and no lesions
• No lesions
• Absence of tenderness and secretions

Lips

• Bluish hue
• Dry lips
• No lesions upon palpation

Mouth

• Pink mucous membrane


• Incomplete set of teeth, with dental caries
• Without lesion

Neck

• Neck muscles are equal in size


• No palpable or enlarged lymph nodes
• No masses noted upon palpation

Chest

• With intact skin uniform in color


• Absence of tenderness
• No masses
• Has clear breath sounds upon auscultation

Abdomen

• Flat, normal abdominal bowel sounds


• Soft, non-tender
• No pain upon palpation
Upper extremities

• Symmetrical
• No deformities, tenderness or swelling
• No edema

Lower extremities

• symmetrical
• No edema
• Small wound present on left big toe
F. Diagnostic and Laboratory Procedures

Diagnostic/ Date Indication(s) Results Normal Analysis and


Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date results of results
IN
Random 09-13-08 This test is 192 60-140 The results
Blood 09-14- used to mg/dl mg/dl are above the
Sugar 08(4am) measure 243 normal range.
09-14- plasma glucose mg/dl This may
08(12nn) level usually to 185 indicate that
09-14- screen for mg/dl there is
08(6pm) diabetes 175 deficiency of
mellitus, in mg/dl insulin which
which absence allows
or deficiency persistently
of insulin high glucose
allows level.
persistently
high glucose
levels.
Fasting DO: 09-16-08 This test is 128 65-105 The result is
Blood DR: 09-16-08 used to mg/dl mg/dl above the
Sugar measure normal range.
plasma glucose This may
level after a indicate that
12-14 hr fast. there is
This test is deficiency of
commonly insulin which
used to screen allows
for DM, in persistently
which absence high glucose
or deficiency level.
of insulin
allows
persistently
high glucose
level.
Nursing Responsibilities
Prior:
 Explain to the patient that this test is used to detect disorders of glucose
metabolism and aids in the diagnosis of diabetes.

 Tell the patient that the test requires a blood sample and a venipuncture will
be done.

 Explain to the patient that he may experience slight discomfort from the
needle puncture and the tourniquet.

 Instruct the client not to eat for 8-12 hours before the test (FBS)

During:
 Place the patient in a comfortable position.

 Maintain aseptic technique. Tie the tourniquet snugly. Perform a venipuncture


and collect the sample in a 5-ml clot-activator tube.

 After:

 Apply direct pressure to the venipuncture site until bleeding stops.

 If a hematoma develops at the puncture site, apply warm soaks.

 After obtaining the result, secure it to the patient’s chart and refer it to the
physician if necessary
Diagnostic/ Date Indication(s) Results Normal Analysis and
Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date results of results
IN
Complete 09-14-08 Complete Hgb: 90 120-160g/L The result is
Blood blood count is below normal.
Count a routine Low Hgb
diagnostic concentration
procedure that may indicate
determines the that the
condition of kidney
patient problem has
whether already
infection, affected the
anemia, production of
polycythemia, new blood
and other cells.
Hct: 0.27 0.37-0.47 The result is
hematologic
below normal
disorders are
which may
present or not.
indicate that
the kidney
problem has
already
affected the
production of
new blood
cells.
WBC: 5-10x109/L The WBC
27.6 count is
elevated
which signals
infection and
inflammation.
RBC: 3.0 4.2- The RBC count
5.4x1012/L is below
normal which
may indicate
that the
kidney
problem has
already
affected the
production of
new blood
cells.

Nursing Responsibilities
Prior:
 Check doctor’s order.

 Verify patient’s name in the chart with the actual patient.

 Explain to the patient that small amount of blood will be drawn from her.

 Inform the client that there are no fluid restrictions or fasting.

 Inform the client that she will experience mild pain at the site of extraction
during the collection of blood sample.

During:
 Provide comfort measure to decrease client’s anxiety.

 Place the patient in a comfortable position.

 Maintain aseptic technique.


 Assist the medical technologist if necessary.

After:
 Instruct the patient to apply pressure at the extraction site until bleeding
stops.

 If a hematoma develops at the puncture site, apply warm soaks.

 Document the time and the procedure done.

 After obtaining the result, secure it to the patient’s chart and refer it to the
physician if necessary.
Diagnostic/ Date Indication(s) Result Normal Analysis and
Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date results of results
IN
Potassium 09-14-08 Potassium test 4.21 3.5-5.3 The serum
is used to meq/L meq/L potassium
measure serum level of the
levels of patient is
potassium, the within normal
major range.
intracellular
cation.
Potassium
helps to
maintain
cellular
osmotic
equilibrium
and to
regulate
muscle
activity,
enzyme
activity, and
acid-base
balance. It also
influences
renal function.

Nursing Responsibilities
Prior:
 Explain to the patient that the serum potassium test is used to determine the
potassium content of the blood.

 Tell the patient that the test requires a blood sample.

 Explain to the patient that she may experience slight discomfort from the
needle puncture and the tourniquet.

 Inform the patient the he need not restrict food and fluids.

 Notify the laboratory and physician of medications the patient is taking that
may affect the test results.

During:
 Place the patient in a comfortable position.

 Maintain aseptic technique.

 Tie the tourniquet snugly. Perform the venipuncture and collect the sample in
a 3- or 4-ml clot-activator tube.

After:
 Apply direct pressure to the venipuncture site until bleeding stops.

 If a hematoma develops at the puncture site, apply warm soaks.

 Document the time and the procedure done.

 After obtaining the result, secure it to the patient’s chart and refer it to the
physician if necessary.
Diagnostic/ Date Indication(s) Result Normal Analysis and
Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date results of results
IN
Calcium 09-14-08 This test is 8.6 8.5-10.5 The serum
used to meq/L meq/L calcium level
evaluate of the patient
calcium is within
metabolism, normal range.
and acid-base
balance. And
also to guide
therapy in
patients with
renal failure.
Nursing Responsibilities
Prior:
 Explain to the patient that the serum calcium test is used to determine the
calcium content of the blood.

 Tell the patient that the test requires a blood sample.

 Explain to the patient that she may experience slight discomfort from the
needle puncture and the tourniquet.

 Inform the patient the he need not restrict food and fluids.

During:
 Place the patient in a comfortable position.

 Maintain aseptic technique.


 Perform the venipuncture (without tourniquet if possible) and collect the
sample in a 3- or 4-ml clot-activator tube.

After:
 Apply direct pressure to the venipuncture site until bleeding stops.

 If a hematoma develops at the puncture site, apply warm soaks.

 Document the time and the procedure done.

 After obtaining the result, secure it to the patient’s chart and refer it to the
physician if necessary.
Diagnostic/ Date Indication(s) Result Normal Analysis and
Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date results of results
IN
Blood 09-14-08 The blood urea 75.5 7-17 mg/dL The BUN
Urea nitrogen test is mg/dL result is
Nitrogen used to elevated.
measure the Elevated BUN
nitrogen levels
fraction of indicates the
urea, the chief presence of
end product of renal disease,
protein reduced renal
metabolism. blood flow,
The BUN and increased
reflects protein
protein intake catabolism.
and renal
excretory
capacity .
Nursing Responsibilities
Prior:
 Tell the patient that this test is used to evaluate kidney function.

 Inform the patient that he need not restrict food and fluids, but should avoid a
diet high in meat.

 Tell the patient that the test requires blood sample and explain to the patient
that she may experience slight discomfort from the needle puncture and the
tourniquet.
 Notify the laboratory and physician of medications the patient is taking that
may affect the test results.

During:
 Place the patient in a comfortable position.

 Maintain aseptic technique.

 Perform the venipuncture and collect the sample in a 3- or 4-ml clot-activator


tube.

After:
 Apply direct pressure to the venipuncture site until bleeding stops.

 If a hematoma develops at the puncture site, apply warm soaks.

 Inform the patient that he may resume his usual medications discontinued
before the test, as ordered.

 Document the time and the procedure done.

 After obtaining the result, secure it to the patient’s chart and refer it to the
physician if necessary.
Diagnostic/ Date Indication(s) Result Normal Analysis and
Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date results of results
IN
Creatinine 09-14-08 Creatinine is a 8.0 0.5-1.2 The serum
nonprotein end mg/dL mg/dL creatinine
product of level is
creatinine elevated
metabolism which
that appears in generally
serum in indicates renal
amounts disease that
proportional to has seriously
the body’s damaged.
muscle mass.
This test is
used to assess
glomerular
filtration and
screen for
renal damage.
Nursing Responsibilities
Prior:
 Tell the patient that the serum creatinine test is used to evaluate kidney
function.

 Inform the patient that he need not restrict food and fluids, but should avoid a
diet high in meat.
 Tell the patient that the test requires blood sample and explain to the patient
that she may experience slight discomfort from the needle puncture and the
tourniquet.

 Notify the laboratory and physician of medications the patient is taking that
may affect the test results.

During:
 Place the patient in a comfortable position.

 Maintain aseptic technique.

 Perform the venipuncture and collect the sample in a 3- or 4-ml clot-activator


tube.

After:
 Apply direct pressure to the venipuncture site until bleeding stops.

 If a hematoma develops at the puncture site, apply warm soaks.

 Inform the patient that she may resume his usual medications discontinued
before the test, as ordered.

 Document the time and the procedure done.

 After obtaining the result, secure it to the patient’s chart and refer it to the
physician if necessary.
Diagnostic/ Date Indication(s) or Result Normal Analysis and
Laboratory ordered Purpose(s) Values Interpretation
Procedure Date results of results
IN
Renal DO: 09-16- Renal Right The kidneys Both kidneys
Ultrasound 08 ultrasonography kidney = are located are normal in
DR: 09-16- is used to 100.6 x between size and
08 determine the 47.8 mm the superior configuration.
size, shape, (9.2mm); iliac crests Mild diffuse
and position of Left and the increase in
the kidneys, kidney = diaphragm. parenchymal
their internal 101.2 x The renal echogecity is
structures, and 43.6 mm capsule noted
perirenal (6 mm) should be bilaterally.
tissues. outlined Several
sharply. In calcific foci
the center are noted in
of each both kidneys.
kidney, the
renal
collecting
systems
appears as
irregular
areas of
higher
density than
surrounding
area.
Nursing Responsibilities
Prior:
 Explain to the patient that renal ultrasonography is used to detect kidney
abnormalities.

 Inform the patient that she need not restrict foods and fluids.

 Tell the patient who will perform the test where it will take place, and that
it’s safe and painless.

During:
 The patient is placed in the prone position, the area to be scanned is exposed,
and conductive gel is applied.

 During the test, may be asked to breathe deeply to visualized upper portions of
the kidney.

After:
 After the test, remove the conductive gel from the patient’s skin.
Diagnostic/ Date Indication(s) Result Normal Analysis and
Laboratory ordered or Purpose(s) Values Interpretation
Procedure Date of results
results IN
Electrocardiography 09-15-08 This Normal Normal Normal
(ECG) procedure is sinus sinus results, there
used to rhythm rhythm are no
identify abnormalities
primary in the electric
conduction current
abnormalities, produced by
cardiac the heart.
arrhythmias, There are no
cardiac dysrhythmias
hypertrophy, noted
electrolyte
imbalances,
myocardial
ischemia and
the site and
extent of
myocardial
infarction.
Nursing Responsibilities
Prior:
 Explain to the patient that an ECG evaluates the heart’s electrical activity.

 Describe the test including who will perform it, where it will take place and
how long it will last.
 Tell the patient’s that electrodes will be attached to her arms, legs and chest
and that the procedure is painless. Explain that during the test, she’ll be asked
to relax, lie still, and breathe normally.

 Advice the patient not to talk during the test because the sound of her voice
may distort the ECG tracing.

 Check the patient’s medication history for use of cardiac drugs and note the
use of such drugs on the test request form.

During:
 Place the patient in supine position. If he can’t tolerate lying flat, help her to
assume semi-Fowler’s position.

 Have the patient expose her chest, both ankles, and both wrists for electrode
placement. If the patient is a woman, provide a chest drape until the chest
leads are applied.

 Turn on the machine and check the paper supply.

After:
 Label each ECG strip with the patient’s name and room number (applicable),
date and time of the procedure, and the physician’s name. Note whether the
ECG was performed during or on the resolution of a chest pain episode.

 Disconnect the equipment. The electrode patches are usually left in place if
the patient is having recurrent chest pain.

 Report any abnormal ECG findings to the physician.


III. ANATOMY AND PHYSIOLOGY

ENDOCRINE and EXCRETORY SYSTEM


The excretory system is an organ system that performs the function of excretion, the
bodily process of discharging wastes. It is responsible for the elimination of the waste
products of metabolism as well as other non-useful materials. The main components of the
excretory system are your two kidneys, two tubes that carry urine called ureters, the
bladder, and the urethra.

Kidney

The most important organs of the excretory system are the kidneys. The kidneys are placed
on either side of the spinal column near the lower back. The kidneys are bean-shaped and
they have an important job. They are responsible for removing wastes from the blood and
they also keep your blood pressure in check and help with the making of red blood cells. The
kidneys filter the blood and remove any wastes. The Kidney does this via its three lauers
which are the Cortex, the medulla and the pelvis. In the Cortex and Medulla there are
Nephrons. These Nephrons comprise of a Glomerulus (bundle of capilaries), a Bowman's
Capsule, a Proximal Convoluted Tubuale, the decending and ascending Loop of Henle, the
Distal Convoluted Tubual and Collecting Ducts. The collecting ducts come together in the
Pelvis. When your body gets ready to pass waste products, it goes through the kidneys and
mixes with water and urine. Then, the waste travels into the bladder through tubes. These
tubes are called Ureters. Now, the bladder holds all of that urine until it feels so full that you
need to get rid of it. That's called urination. When this happens, a tube called the Urethra
takes the urine to the outside of the body.
b. Synthesis of the Disease

b.1. Definition of the disease

*legend: all underlined items were client-centered.

Diabetes mellitus type 2 or Type 2 Diabetes was formerly called non-insulin-dependent


diabetes (NIDDM), obesity-related diabetes, or adult-onset diabetes, is a metabolic disorder
that is primarily characterized by insulin resistance, relative insulin deficiency, and
hyperglycemia. Insulin resistance means that body cells do not respond appropriately when
insulin is present. This is due to increased hepatic glucose production such as in glycogen
degradation, especially at inappropriate times, decreased insulin-mediated glucose transport
in muscle and adipose tissues and impaired beta-cell function or loss of early phase of insulin
release in response to hyperglycemic stimuli

Diabetes mellitus is a lifelong disease that affects the way the body uses food for
energy. The disease develops when the pancreas cannot make enough insulin or when the
body is not able to use insulin correctly. When insulin is not adequate or not used correctly,
the level of sugar in the blood gets too high and cells do not get the energy they need. If
blood sugar stays high for a long time, it can led to the development of problems that may
affect the eyes, heart, blood vessels, nerves, and kidneys.

It is often managed by engaging in exercise and modifying one's diet. It is rapidly


increasing in the developed world, and there is some evidence that this pattern will be
followed in much of the rest of the world in coming years. The CDC has characterized the
increase as an epidemic.

b.2. Predisposing and precipitating factors

There are some things that cannot change that may increase the chances of getting type 2
diabetes and this includes:

• Family history - If you have a parent, brother, or sister who has type 2 diabetes, you
have a greater chance of developing the disease.
• Race - Type 2 diabetes mellitus is more prevalent among Hispanics, Native Americans,
African Americans, and Asians/Pacific Islanders than in non-Hispanic whites.
• Age - Type 2 diabetes mellitus typically affects individuals older than 40 years old and
above. The risk of developing type 2 diabetes increases with age; however, the
number of children being diagnosed with the disease is increasing.
• Diet - Foods rich in carbohydrates can easily promote the increasing level of glucose
along the bloodstream.
• Emotional Stress - The body responds to overwhelming stress by releasing epinephrine
and norepinephrine that in turn promotes the secretion of glucose leading to
hyperglycemia.
• Obesity - Elevated levels of fatty acids, a common feature of obesity, may contribute
to the pathogenesis of DM type 2 by impairing glucose utilization in skeletal muscles
and promote glucose production by the liver and impair beta cell function.
Approximately 90% of patients with type 2 diabetes are obese.
• Having gestational diabetes or delivering a large baby - Women who have gestational
diabetes or who had delivered a baby who weighs more than 9 lb at birth are at
greater risk of developing type 2 diabetes.
• Sedentary Lifestyle – a risk factor that had contributed in the occurrence of DM due
to the fact that lack of muscle activities decrease the need for the body to utilize
glucose as a form of energy.

b.3. Signs /Symptoms

At first, blood sugar level may rise so slowly that it may not know that anything is wrong.
One-third of all people who have diabetes do not know that they have the disease.

Symptoms for type 2 diabetes may includes:

• Hyperglycemia- diabetes Mellitus type II may be due to lack of physiologically active insulin
that stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an
accumulation of glucose in the intravascular space. The glucose is not utilized by the body
and it remains in the blood stream.
• Feeling thirsty (polydipsia) - This may be due to the activation of the thirst center in
the hypothalamus resulting from the intracellular dehydration or volume depletion
caused by excessive urine production.
• Having to urinate more than usual (polyuria) - this may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.
• Feeling more hungry than usual (polyphagia) - because glucose cannot enter cells of
the satiety center of the brain without insulin, the satiety center in the hypothalamus
is stimulated resulting in a “hunger sensation” as if there were very little blood
glucose, resulting in an exaggerated appetite.
• Losing weight without trying to - despite eating more than usual to relieve constant
hunger by the stimulation of satiety center, weight loss may still exist. Without the
glucose supplies, muscle tissues and fat stores may deplete.
• Body malaise - This is due to the decreased glucose uptake by the tissues leading to
decreased energy production.
• Glucosuria - The kidney filters the blood, making it to its normal state. Glucose
was filtered out and excreted in the urine. Due to the excess glucose ad
compared to the kidney threshold, which results to the excretion of glucose in
the urine.
• Blurred vision- Diabetes can affect the lens, vitreous, and retina, causing visual
symptoms. Visual blurring may develop acutely as the lens changes shape with
marked changes in blood glucose concentrations. This effect, which is caused
by osmotic fluxes of water into and out of the lens, usually occurs as
hyperglycemia increases.
• Slow-healing sores or frequent INFECTIONS - High levels of blood sugar impair
your body's natural healing process and your ability to fight infections. For
women, bladder and vaginal infections are especially common.
• Tingling hands and feet - Excess sugar in your blood can lead to nerve damage.
You may notice tingling and loss of sensation in your hands and feet, as well as
burning pain in your arms, hands, legs and feet.
• Diabetic foot - Diabetic Foot is a complex of symptoms and signs which arise
due to changes in the feet of persons who have Diabetes Mellitus for a long
duration. These changes occur due to progressive loss of blood supply to the
feet as a result of microangiopathy or macroangiopathy i.e. a diseased
condition of either the small or larger blood vessels respectively. These vessels
get progressively diseased due to the process of atherosclerosis which occurs at
a faster rate in Diabetic individuals especially if the blood sugar levels are not
within normal limits. These changes also occur in the blood vessels supplying
the nerves called Vasa Nervosum.This leads to Neuropathy(disease of the
nerves).The combined changes of angiopathy and neuropathy give rise to
Diabetic Foot whose salient features are described below:

Signs and Symptoms include :


a. Tip top toes or hammer toes & disfigurement of the toes.
b. Horny nails.
c. Smooth shiny and dry skin.
d. Loss of hair.
e. Ulcers on the foot.
f. Decreased skin temperature.
g. Loss of sensation etc.
These changes can lead to corns, callouses, non-healing
ulcers and trophic ulcers Gangrene is the most dreaded
complication of Diabetic Foot.

Some people have already developed more serious health problems by the time they are
diagnosed with type 2 diabetes. Over time, diabetes can lead to problems with the eyes,
kidneys, heart, blood vessels, and nerves. Signs of these problems may include:

• Numbness, tingling, burning pain, or swelling in your feet or hands. This condition is called
diabetic neuropathy.
• Diabetic retinopathy which is characterized by blurred or distorted vision or seeing flashes
of light; seeing large, floating red or black spots; or seeing large areas that look like
floating hair, cotton fibers, or spider webs.
• Chest pain or of breath. This may be a sign of heart or blood vessel problems.
3. HEALTH PROMOTION AND PREVENTIVE ASPECTS OF THE DISEASE

The aim of treatment in all types of diabetes is to keep the blood glucose level as
normal as possible by administering insulin, or by providing glucose reduction therapy.
Diet involves ensuring that meals and snacks are so timed that the body’s insulin levels do
not become overwhelmed. The success of any treatment depends on the patient’s
willingness to comply with the right diet, right medications, right exercise; that is a
healthy lifestyle.
V. THE PATIENT AND HIS CARE
A. Medical Management
a. (IVF, BT, NGT feeding, Nebulization, TPN, Oxygen therapy etc.)
Medical Date ordered General Indication(s) or Client’s
Management Date Description Purpose(s) response to
performed the treatment
Date changed
5% Dextrose in DO: 09-14-08 D5W is an Used to aid in The patient
Water (D5W) DP: 09-14-08 isotonic renal excretion improves
DC: 09-16-08 solution that of solutes and hydration
supplies 170 also to provide status as
cal/L and free intravenous line evidenced by
water which is for IV good skin
used in medications. turgor.
treatment of
hypernatremia,
0.9% NaCl DO: 09-16-08 fluid loss,
(PNSS) DP: 09-17-08 dehydration
DC: and excretion Used for diabetic
of solutes. ketoacidosis The patient
had
0.9% NaCl is an maintained
isotonic normal
solution that hydration
expands the status
extracellular manifested by
fluid (ECF) good skin
volume, used turgor and
in hypovolemic absence of
states. PNSS is pallor.
the only that
may be
administered
with blood
products.
Salbutamol 09-14-08 q6 Sympathomimetic The patient
Nebulizer show signs of
(Ventolin) Stimulates beta-2 improved
receptors of the breathing
bronchi, leading pattern.
to
bronchodilation.
Causesless
tachycardia and
is longer-
actingthan
isoproterenol.
Has minimal
beta-1activity.

Nursing Responsibilities
1. IVF

Prior:
 Verify doctor’s order.

 Explain the procedure to the client and client’s SO.

During:
 Established rapport to the patient.

 Explain the importance and purpose of IVF.

 Prepare the patient and place in comfortable position.


 Maintain aseptic technique.

After:
 Secure the needle properly after inserting.

 Regulate IVF properly as ordered.

 Observe the client closely for the first 5-10 minutes especially the vital signs.

 Document the procedure done.

2. Salbutamol Nebulizer

Prior:
 Observe 10 R’s.

 Assess for any reaction to drug

 Check doctor’s order.

 Check expiration date.

 Importance of compliance in medication regimen.

 Assess lung sounds, pulse, and blood pressure

 Monitor pulmonary function

 Observed for paradoxical bronchospasm

During:
 Administer correctly

 Be sure that the patient will take all the medication


 Stay at the bedside of the patient

After:
 Note for any reaction to drug

 Note findings

 Document procedure done. Countersign.

B. Drugs
Name of Drug Date Route and General Client’s
Ordered Frequency of Action/Classificatio response to
Date Taken Administration n the
Date Mechanism of medication
Changed action with actual
side effects
Ceftriaxone DO: 09-14-08 SIVP, O.D. Third generation No adverse
(Rocephin) DT: 09-14-08 cephalosphorin reactions
DC: (anti-infective) manifested by
the patient.
The cephalosphorins
interfere with the
final step in the
formation of the
bacterial cell wall,
resulting unstable
cell membrane that
undergo lysis.

Sodium DO: 09-14-08 1 tab, Oral, Antacid The patient


Bicarbonate TID had decrease
(Neut) The antacid action is gastric
due to neutralization discomfort
of hydrochloric acid due to
by forming NaCl and hyperacidity.
CO2. It is also a
systemic and urinary
alkalinizer by
increasing plasma
and urinary
bicarbonate.
Furosemide DO: 09-14-08 SIVP with BP Loop diuretic The patient
(Lasix) DT: 09-14-08 increase had enhanced
Inhibits the dieresis.
reabsorption of
sodium and chloride
in the proximal and
distal tubules
as well as the
ascending loop of
Henle; this results in
the excretion of
sodium,
chloride, and, to a
lesser degree,
potassium and
bicarbonate ions.
Has a slight
antihypertensive
effect.
Clonidine DO: 09-14-08 75mg/tab, Anti-hypertensive Patient had
(Catapres) oral, BID decreased her
Stimulates alpha- BP gradually.
adrenergic receptors
of the CNS, resulting
in inhibition of the
sympathetic
vasomotor centers
and decreased
nerve impulses.
Thus, bradycardia
and a fall in both
SBP and DBP occur.
Paracetamol DO: 09-14-08 300mg IV q 4 Anti-pyretic A feeling of
(Tylenol) DT: 09-14-08 for fever of 38o burning when
c Decreases body administering
temperature. the
Works in the brain to medication via
prevent the release IV route.
of substances that The patient
increase pain and had decreased
temperature. Thus temperature.
paracetamol is
widely used for pain
control and at times,
in particular
circumstances, for
temperature control.
Paracetamol DO: 09-14-08 500mg/tab, 1 Anti-pyretic The patient
(Tylenol) tab q 4 P.O had decreased
Decreases body her
temperature. temperature.
Works in the brain to
prevent the release
of substances that
increase pain and
temperature. Thus
paracetamol is
widely used for pain
control and at times,
in particular
circumstances, for
temperature control.

NURSING RESPONSIBILITIES:
1. Ceftriaxone

Prior:
• Observe 10 R’s.

• Assess for any reaction to drug

• Check doctor’s order.

• Check expiration date.

• Importance of compliance in medication regimen.

• Perform skin test.

• IV infusions contain concentrations of 10-40 mg/ml. Reconstitute 500mg in 4.8


ml of sterile water, NSS or D5W. Then further dilute in 5.-100 ml D5W or NSS
and infuse over 30-60 min.
• Do not mix drug with other antibiotics.
• Stability of solutions for IM or IV use varies depending on the diluent used;
check package insert carefully.
• Maintain dosage for at least 22 days after symptoms of infection have
disappeared.
• Note any penicillin reactions.

During:
• Monitor caoagulation studies, drug may alter PTs. Use Vitamin K (10 mg/week)
prophilactically if bleeding occurs.

After:
• Note for any reaction to drug
• To report sore throat, bruising, bleeding, joint pain, may indicate blood
dyscrasias (rare)
• To report persistent diarrhea.
• Document procedure done. Countersign.

2. Sodium Bicarbonate

Prior:

• Observe 10 R’s.

• Assess for any reaction to drug

• Check doctor’s order.

• Check expiration date.

• Importance of compliance in medication regimen.

• Monitor urine pH frequently when used for urinary alkalinisation


• Arterial blood gases (ABG) should be obtained frequently in emergency
situations and during parenteral therapy

During:
• Administer the drug correctly
• Tablets must be taken with a full glass of water

After:
• Note for any reactions to drug
• Note any improvement of acidosis
• Note if gastric discomfort
• Document procedure done. Countersign

3. FUROSEMIDE

Prior:
• Observe 10 R’s.

• Assess for any reaction to drug

• Check doctor’s order.

• Check expiration date.

• Importance of compliance in medication regimen.

• Monitor daily weight, intake and output ratios, amount and location of edema,
lung sounds, skin turgor, and mucous membrane. Notify physicians.

• Monitor BP and pulse

During:
• Administer the drug correctly

• Give medication on time

After:
• Note for any reactions to drug

• Note findings

• Document procedure done. Countersign.

4. Clonidine

Prior:
• Observe 10 R’s.

• Assess for any reaction to drug

• Check doctor’s order.

• Check expiration date.

• Importance of compliance in medication regimen.

• Monitor intake and output

• Monitor VS specially BP and pulse

• Monitor for fever

During:
• Administer the drug correctly

• Stay at the beside of the patient


After:
• Note for any reactions to drug

• Note findings

• Document procedure done. Countersign.

5. Paracetamol

Prior:
• Observe 10 R’s.

• Assess for any reaction to drug

• Check doctor’s order.

• Check expiration date.

• Importance of compliance in medication regimen.

• Monitor blood pressure, ECG, and pulse frequently

• Monitor intake and output

During:
• Administer the drug correctly

• Administer with food or with empty stomach

After:
• Note for any reaction to drug

• Note findings

• Document procedure done. Countersign.


C. Diet
Type of Date General Indications or Specific Client’s
diet ordered
description purposes foods taken response
Date
started and/or
Date
reaction to
changed
the diet
Diabetic 09-14-08 It is a diet It is indicated fish, The patient
low in to prevent vegetables, tolerated
diet
sugar, further pork and ½ the diet and
indicated increase in cup rice decreased
for diabetic blood sugar of blood sugar
patient. a patient thus levels.
preventing
hyperglycemia.

Nursing Responsibilities:
 Check the doctor’s order

 Enumerate the foods that the patient may or may not take

 Explain the importance of complying to the diet


D. Activity/Exercise

Type of Date General Indications or Client’s


activity/exercise ordered description purposes response and/or
Date started reaction to the
Date activity/exercise
changed
Complete bed rest DO: 09-14-08 Confined in To promote The patient is
without bathroom DS: 09-14-08 her bed to rest to the non-compliant to
privileges DC: 09-16-08 rest and patient. the orders type
cannot do of exercise.
even some
light activities
like going to
the bathroom
and walking.

Nursing Responsibilities:
Prior:
• Check Physicians order

• Inform the pt’s S.O about the type of activity

• Explain purpose of the activity ordered the consequences of not following such
exercise and how it will be implement.

• Provide proper positioning

During:
• Assist the client in doing any activities

After:
• Document response of the client
Problem #1: Altered Tissue Perfusion

Assessment Nursing Scientific Objectives Nursing Rationale Expected


Diagnosis Explanation Intervention Outcome/Evaluation

S> May report: Altered Tissue Capillaries are Short term: >Assess pt’s >Serves as a > the patient shall
>body Perfusion R/T an integral part After 2 hours of condition baseline data have understood the
weakness decreased of nephrons and NI, the patient >monitor intake >To assess health teachings
O>the pt hemoglobin 2o are destroyed in will understand and output and change in fluid given and
manifested DM II T/C CRF CRF. There will the health VS identify and volume participate willingly
manifested: be progressive teachings given individual status to treatment
>decreased decline in and participate factors that >helps planning regimen
H&H results kidney willingly to contributes to of care >Pt should have
>pale and weak perfusion treatment decreased develop an
appearance thereby regimen perfusion improvement in lab
>Bp elevated decreasing the Long term: >Monitor lab >to assess for results, a normal
>140/90mmHg production of After 3 days of results for BUN, progressing BP, good muscle
erythropoietin NI pt will Creatinine, PH renal strength and
factor leading develop an Electrolytes, dysfunction absence of pallor.
to decreased improvement in and CBC
RBC production lab results, >Carefully >Due to
which results to normal BP and monitor client impairement of
decreased O2 absence of for desired and renal function,
Supply to the pallor and good adverse side drugs are
body. muscle eliminated
strength. effects of inefficiently
medication which increases
administered.
the risk for its
toxic effects
Problem #3: Impaired skin integrity

Assessment Nursing Scientific Objectives Nursing Rationale Expected


Diagnosis Explanation Intervention Outcome
S> may report: Impaired skin Pruritus is >after 3 hrs of >assess skin >to provide > the pt & So
> itchiness integrity R/T usually NI the pt & So integrity baseline data should know and
O> pt may accumulation of maintained in will be able to for interventions understand the
manifest: chemical the uremic stage know and >assess for >peripheral cause of pruritus
>pruritus irritants (body wherein the BUN understand the presence of neuropathy and be able to
>poor skin waste) and Creatinie cause of pruritus peripheral includes changes promote ways to
turgor are at and be able to neuropathy in sensation prevent skin
>dry skin and exceedingly high promote ways to such as breakdown.
scaly skin level. The BUN prevent skin parasthesia
and Creatinine breakdown. weakness and > pt should not
should be twitching. develop any skin
excreted, but >after 3 days of >assess for >this is due to problems as
due to renal continuous NI, dryness and the decreased evidenced by
impairment they pt will not scaling of skin oil in sweat absence of
are left develop any skin glands pruritus, dry
circulating in problems as >assess for >pruritus can be skin and with
the blood and evidenced by pruritus caused by dry good skin turgor.
accumulates absence of >stress the skin BUN and
under the skin pruritus, dry importance of creatinine
keeping the
and the sweat skin and with fingernails short accumulation in
glands tends to good skin and not the skin
excrete them turgor. scratching the >to prevent
through skin lesion
perspiration. >encourage to >warmth
These toxins can use tepid water promotes
be irritating to for bathing dryness of the
the skin which skin and
lead to pruritus. itchiness
Problem #2: Hyperthermia

Assessment Nursing Scientific Objectives Nursing Rationale Expected


Diagnosis Explanation Intervention Outcome
S> Ø Hyperthermia >in response to Short term: >Assess pt’s >serves as a > the pt shall
O>Pt may a bacterial or After 3o of NI, condition baseline data have
manifest: viral infection, the pt will be > Provide TSB >to lower down demonstrated
>increased in the body will able to >Administer body temp, used a reduction in
body temp raise its demonstrate a antipyretic as as a non body
above normal temperature to reduction in ordered pharmacologic temperature
range allow the body >Provide regimen from 38.4 to
>Flushed skin; immune system temperature comfort >to lower down 37oC
warm to touch to work better from 38.4 to measures body temp with > the patient
> body malaise and to 37oC >Encourage use of shall have
>lethargy deteriorate the Long term: compliance to pharmacologic demonstrated
condition of the After 2 days of treatment regimen effective ways
invaders. NI, the patient regimen >to make the pt in managing
will especially med pt free from hyperthermia.
demonstrate intake stress and
effective ways fatigue
in managing > to meet the
hyperthermia. set value of
range (temp)
Problem # 4: Activity intolerance

Assessment Nursing Scientific Objectives Nursing Rationale Expected


Diagnosis Explanation Intervention Outcome

S> pt may Activity >due to ST: > Assess pt > serves as a > pt should have
report: body intolerance R/T inadequate > after 2o of NI condition baseline data participate
weakness imbalance tissue perfusion the pt will be > note clients >serves as a willingly in
O>pt may between oxygen r/t decreased able to reports of base for clients necessary
manifest: supply and hemoglobin participate weakness, need of /desired
>abnormal BP demand count the body’s willingly in fatigue, and assistance activity
>generalized compensation is necessary pain >to reduce or
weakness weakness /desired > Provide rest avoid fatigue to >pt should have
>imbalance because of low activity period to reduce client demonstrate a
between oxygen oxygen supply fatigue >to ensure decrease in
supply and and greater LT: > provide safety of pt physiological
demand oxygen demand comfort >so that the signs of
> after 2days of measures client may be at intolerance
NI the pt will >assist with safety when AEB increase of
be able to activities alone pulse rate @ 105
demonstrate a >assist client in >to prepare the and 30 RR
decrease in learning and client so that in
physiological demonstrating the future he
signs of appropriate may move by

intolerance safety measures him self


AEB increase of to prevent
pulse rate @ 105 injuries
and 30 RR >plan for
progressive
increase of
activity level as
client tolerates
Problem # 5: Risk for Infection

Assessment Nursing Scientific Objectives Nursing Rationale Expected


Diagnosis Explanation Intervention Outcome
ST: ST:
S>Ø Risk for >due to DM >after 2o of NI pt >assess pt’s > serves as a > pt should
O> pt may infection blood becomes will be able to condition baseline data identify
manifest: viscous thus identify >note risk >to have a plan intervention to
>leucopenia decreasing intervention to factors for for care to avoid prevent/ reduce
> decreased leukocytes prevent/ reduce occurrence of infection risk of infection
hemoglobin function, risk of infection infection >to treat
>broken skin circulatory >observe for infection LT:
integrity changes and LT: localized sign of >precaution to > pt should
>delayed wound delayed healing >after 3 days of infection on prevent achieve timely
healing making the thorough NI, pt wounds contamination wound healing;
>inflammation wound or the will be able to >stress proper and spread of be free of
person more achieve timely hand washing infection purulent
susceptible to wound healing; >change >to clean the drainage or
microbes. be free of dressing as wound erythema; be
purulent needed >to stop spread afebrile
drainage or >administer or kill microbes
erythema; be prophylactic on infection
afebrile antibiotics and >to hasten
immunizations health of

as indicated individual
>review
individual
nutritional
needs,
appropriate
exercise
program, and
need for rest.
SOAPIEs:

9-15-08 (7-3pm)
1st SNPI
8am 12n 4pm
T 38.2oC 37.9oC 36.1oC
P 94bpm 96bpm 85bpm
R 23bpm 20bpm 21bpm
BP 140/90 130/80 130/90

S>Ø
O> Received pt lying on bed conscious, coherent and awake
> Pt with an IVF of #1B D5w 500cc x KVO at 150cc level infusing well on L hand
> With nausea and altered skin characteristics, with generalized weakness, with low Hgb
count of 90 (120-100 g/l)
A> Ineffective Tissue Perfussion R/T decreased Hgb
P> After 2o of NI pt will verbalize understanding of condition of theraphy regimen, side effects
of medication and when to contact health care provider
I> Established rapport
> Assessed pt condition
> Monitored and recorded VS
> Provided am care
> Determined factors related to individual situation
> Identified changes related to systemic or peripheral alteration in circulation
> Noted reports of N&V, location, type, intensity of pain
> Provided small / easily digested food and fluids when tolerated
> Identified necessary changes of lifestyle and assist client to incorporate disease
management into ADL’s
> Above IVF consumed and changed to IVF #2 D5w 500 cc x KVO
> Reinforced nephritic diabetic diet
> Encouraged compliance to treatment regimen especially with intake of meds
E> Goal met; pt verbalized understanding of condition, therapy regimen side effects on
medications and when contact health care provider.
Add:
> O2 at 3-4 lpm via NC – Requested
> For ECG – Done
> CBR w/o BP – Instructed
> Isurdil 5mg/ tab 1 tab SL for chest pain – P
> Continue meds – Instructed
> Continue monitoring
> Refer

09-16-08 (7-3pm)
2nd SNPI
8am 12n 4pm
T 38.4oC 38oC 37.6oC
P 116bpm 104bpm 105bpm
R 33bpm 28bpm 30bpm
BP 140/80 130/70 120/80

S>Ø
O> Received pt sitting on bed conscious, coherent and awake
> With an IVF of #2 D5W 500cc x KVO at 150cc level infusing well on L hand metacarpal vein
> Skin is warm to touch
> With body malaise
> Lethargic
> With vs of: T 38.4oC, P= 116bpm, R= 33bpm, BP=140/80mm/Hg
A > Hyperthermia
P> after 3o of NI, the pt will demonstrate a reduction in body temperature from 38.4 to 37oC
I> Established rapport
> Assessed pt condition
> Monitored and recorded VS
> Provide am care
> Provided TSB
> Administered antipyretic as ordered
> Provided comfort measures
> Regulated IVF to KVO
> Reinforced diabetic diet and CBR w/o BP
> Encouraged compliance to treatment regimen especially med intake
E> Goal partially met; AEB body temp reduction of 38.4 to 38oC

ADD:
> See on rounds by ROD w/ orders made and carried out
> Follow up UTZ results - instructed/ results in
>Continue meds – instructed
> FTF PNSS 1L x KVO – P
> Refer
>IVO @ 10:30 am because of infiltration, reinserted IV on the R hand @ 11:55 am

09-17-08 (7-3pm)
3rd SNPI
8am 12n 4pm
T 38 Co
37.9 37.8
P 87bpm 79 80
R 28bpm 77 81
BP 130/100 140/90 130/80

S>Ø
O> Received pt lying on bed conscious, coherent and awake
> W/ an IVF of #4 PNSS 1L x KVO at 550cc level infusing well on R hand
> With pruritus and altered skin characteristics, with high BUN and Creatinine (BUN: 75.5(7-
17) Creatinine 8.0(.5-1.2) ) with dry and scaly skin
A> Impaired skin integrity R/T accumulation of chemical irritants (body waste)
P> After 3o of NI the pt and SO will be able to know and understand the cause of Pruritus and
be able to promote ways to prevent skin breakdown
I> Established rapport
> Assessed pt condition
> Monitored and recorded VS
> Provided am care
> Assessed skin integrity
> Assessed for dryness and scaling of skin
> Assessed for Pruritus
> Stressed the importance of keeping the finger nails short and not scratching skin
> Encouraged to use tepid water for bathing
> Regulated IVF #3 PNSS 1l x KVO
> Reinforced Nephrotic diabetic diet
> Encouraged compliance to treatment regimen especially med intake
E> goal met; pt and SO understood the cause of pruritus and promoted ways to prevent skin
breakdown

ADD:
>for repeat CBC and plt – requested
>continue meds – instructed
>FTF D5W 500cc x KVO – P
>for referral to MCOD
>refer
VI. CONCLUSIONS AND RECOMMENDATIONS
In this case study, we have learned the 2 types of Diabetes Mellitus which
includes type 1 (IDDM) and type 2 (NIDDM). Type 1 diabetes occurs when the pancreas
is no longer able to secrete insulin and it is a hereditary factory. Type 2 diabetes
happened because of failure of pancreatic beta cells to produce sufficient amount of
insulin as well as resistance of the body to the effects of insulin. This insulin is a
hormone secreted by islet cells of the pancreas. It is required to convert fuel (glucose)
to energy. This disease condition enables us to identify the modifiable and non-
modifiable factors that may lead to the occurrence of the disease as a consequence.
To avoid further complications, we have researched different inventions such as
diabetic diet, regular exercise and giving or administering diabetes drugs and patient
teachings. These interventions made us to enhance our stills in clinical setting and
giving the best care to the DM patient.
As student nurses, we could now be able to impart our knowledge to other
people, specifically those patients who are at risk with this condition. We should help
them to prevent the occurrence of diabetes or to prevent its complications.
The case study gave us information about the reasons of the occurrence of the
disease. We became health conscious, choosy for the foods we eat. We are prioritizing
the good or well balanced diet rather than the foods we want to eat.
Through this study, we became aware of our health and daily lifestyles. We
knew that diabetes mellitus gives many complications and may lead to death.
Therefore, diet and lifestyles are the best way to modify or prevent this disease.

Mark Rovin C. Malit


Through this case study, I’ve learned many things about the disease diabetes
mellitus type 2 and come up with a lot of realizations. I’ve learned how to distinguish
type 2 diabetes from type 1, enumerate the risk factors of the disease and I also
learned its etiology. Also, doing this case study gives me the opportunity to interact
and mingle with a real diabetic patient. Being diabetic is really a serious problem in
the part of an individual specially because there is no absolute treatment of the
disease but only maintenance of certain glucose level. That is why it is really
important for us, health care providers to give proper health teachings regarding the
disease and not to give false hopes to our patients. As a student nurse and at the same
time as productive members of the society, the information about this case can be of a
great use for us as future nurses to carry out our responsibility as an advocate of our
patient’s total health and well-being, awareness of the clinical manifestations and
possible complications is one of the keys that would allow us to make early recognition
of the disease. No matter what the case of the patients is, even if it’s just a minor
condition of disease or major disease problems, it should always be dealt with a TLC
(Tender loving care).

Eric T. Panganiban
Doing case study requires both the time and effort of the student nurses and the
patient. It also demands discipline, patience, hardships, courage, determination, sincerity,
genuineness, sacrificial giving and knowledge and skills of the student nurse.

I was able to impart health teachings and interventions to the patient, though; it really
requires extra effort and time. I know that how simple my actions were but the thing is they
were coming out of love and commitment. I gave what they called TLC.

Lastly, I gained a lot of knowledge about the disease condition, some theories and
concepts, of course. With that, when I handle the same case again, for sure, I will really
appreciate the disease condition. At the end, I know better what nursing process I need to do.

Jamil Jovert E. Ticsay

Diabetes Mellitus is a condition where in the pancreas secrete insufficient


insulin that has a side effect that glucose in circulation is not metabolized so that the
body can use it as energy. Insulin is necessary for the body to be able to use glucose
for energy. When you eat food, the body breaks down all of the sugars and starches
into glucose, which is the basic fuel for the cells in the body. Insulin takes the sugar
from the blood into the cells. When glucose builds up in the blood instead of going into
cells, it can cause two problems: right away, your cells may be starved for energy and
over time, high blood glucose levels may hurt your eyes, kidneys, nerves or heart. In
our case study we chose this case to improve our knowledge about the said condition
for our future careers as nurses and also so that we may impart the knowledge we gain
from this experience to our colleagues. In this case study we observed and handled a
DM type II patient we observed how doctors and Registered nurses handled the
patient. In this scenario we observed and learned management to DM patient’s their
medications and management like CBR.

Sheena Louwella V. Basilio


This case study makes me realize that counselling patients on how to
incorporate healthy eating and physical activity into their life shows a define concern
for the client’s therapeutic progress. Aside from assessing the patient’s health history
and present conditions, a determined student also have to understand how their
medications work, how to maintain their blood glucose in normal levels to avoid the
risk of complications, and give them the ability to facilitate problem solving and adjust
emotionally to diabetes. Appropriate nursing interventions must prioritize non-
pharmacologic means such as use of relaxation techniques, wound care and safety
measures. Finally, providing clients with TLC coupled with respect and warm sincerity
is obliged in every aspiring health care professionals.
VII. BIBLIOGRAPHY

Book References

• Brunner and Sudrath’s Textbook of Medical-Surgical Nursing

• Nurses’ handbook of health assessment, Janeth R. Weber

• Kozier and Erb’s Fundamentals of Nursing

Internet References

• www.diabetes.org

• www.jpsimbulan.com

• www.medicalcenter.osu.edu

• www.malaya.com.ph

• www.medicalcenter.osu.edu