Nurse Training Program January 2011 Batch

A Case Study
on

DIABETES MELLITUS TYPE II

In partial fulfillment of the requirements of CVMC Training Program

SUBMITTED BY:

Jomar Balisi, RN Krista Caculitan, RN Chinnie Rose Carag, RN Kristel Rashette Catabay, RN Ralph Lourenz Cruz,RN Glenna Mae C. Dumlao, RN Emilia Edillo, RN Joy Guillermo, RN Camille Iringan, RN Jewel Joy Juan, RN Cathlyn Lily Ordillo, RN Keizel Anne P. Sabug, RN Michelle Sagsagat, RN MIchael Soriano, RN Jenica Yabut, RN

INTRODUCTION
Definition Diabetes is a group of diseases characterized by high blood glucose levels that result from defects in the body's ability to produce and/or use insulin. Prevalence and Incidence More than 220 million people worldwide have diabetes and by 2025 this total is expected to increase to over 380 million In 2004, an estimated 3.4 million people died from consequences of high blood sugar In the Philippines, there are about 4 million diabetics, with more than 3 million not knowing they have it. Out of the 1 million who know they have the disease, only 200,000 are undergoing treatment

Risk and Predisposing Factors Age older than 45 Family history of diabetes Overweight Inactive lifestyle Diet Race Hypertension High blood cholesterol levels Heart disease Manifestations Classical symptoms: Excessive thirst (Polydipsia) Frequent urination (Polyuria) Excessive eating Polyphagia Unexplained weight loss Other symptoms include: Fatigue

 Poor wound healing Altered mental status Blurry vision Different types of Diabetes Mellitus Types of Diabetes Mellitus Factors Type 1 Synonyms Insulin-dependent diabetes mellitus (IDDM); juvenileonset diabetes

Type 2 Non-insulindependent diabetes mellitus (NIDDM); or adult-onset diabetes Begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce insulin Usually occurs in clients over 35 years of age but is increasingly being diagnosed in children and adolescents

Gestational Diabetes

Description

Body's immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose

A form of glucose intolerance that is diagnosed in some women during pregnancy

Age of onset

Usually strikes children and young adults, although disease onset can occur at any age (before 30y/o)

Pregnant women

Type of onset Usually abrupt Insidious

After pregnancy, 5% to 10% of women with gestational diabetes are found to have type 2 diabetes

Insulin production Risk Factors

Little or none

Incidence Ketosis Insulin injections

Below normal; or above normal Autoimmune, Associated with genetic, and older age, environmental obesity, family factors history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity 5% to 10% 90% to 95% May occur Unlikely to occur Required Necessary only 20-30% for

Obese women and women with a family history of diabetes

Body weight onset

at Ideal body weight 80% of clients are or thin obese

Management

Diet, exercise, Diet, exercise, and insulin oral hypoglycemic agent (OHA) and/or insulin

20% to 30% May or may not occur Required during pregnancy especially those remain overweight after delivery Some are obese; some with normal weight during pregnancy Diet, exercise, oral hypoglycemic agent (OHA) and/or insulin

Diagnostic Studies 1. Fasting Blood Glucose Test FBS is a diagnostic exam that involves drawing of blood after at least 8 hours of fasting to evaluate circulating amounts of glucose. The normal value for FBS should be 70-99mg/dl. Fasting blood glucose result of greater than or equal to 100 mg/dl demands close follow-up and repeat monitoring.

2. Random Blood Glucose Test Random blood glucose screening involves drawing of blood anytime of the day regardless of whether the person has eaten or not. However, the time and content of the last meal should be noted. Random blood glucose result of greater than or equal to 200mg/dl should be monitored closely. 3. Oral Glucose Tolerance Test The oral glucose tolerance test (OGTT) is principally used for diagnosis when blood glucose levels are equivocal, during pregnancy, or in epidemiological studies. The oral glucose tolerances test (OGTT), also referred to as the glucose tolerance test, measure the bodys ability to metabolize glucose, or clear it out of the bloodstream. The test should be performed in the morning on subjects who have had at least 3 days of unrestricted diet. The subject should have fasted overnight for 10-16 hours and remain seated and not smoke throughout the test. A fasting blood sample should be collected, after which the subject should drink 75 g of glucose in a concentration no greater than 25 g per 100 ml. Commercially prepared carbohydrate loads equivalent to this are available. For 75 grams of glucose, normal blood glucose values are: 1 hour: less than 200 mg/dL 2 hours: less than 140 mg/dL. Between 140-200 mg/dL indicates impaired glucose tolerance (prediabetes). If test results are in this range, a patient is at an increased risk for developing diabetes. Greater than 200 mg/dL indicates diabetes. Management

Blood pressure and cholesterol control Careful self testing of blood glucose levels Education Exercise Foot care Meal planning and weight control Medication or insulin use

PATIENTS PROFILE

Name: Sugar Mommy Age: 56 y/o Sex: Female Address: Bagay, Tuguegarao City Date of Birth: May 25, 1955 Religion: Roman Catholic Nationality: Filipino Civil Status: Married

Educational Attainment: Elementary Graduate Attending Physician: Dr. Jena Lynn M. Alan Chief Complaint: Difficulty of breathing Diet: DM diet Date of Admission: April 6, 2011 Time of Admission: 9:35 PM Clinical Impression: Diabetes Mellitus type 2, poorly controlled; Diabetic Nephropathy Date of Discharge: April 20,2011 Final Diagnosis: Diabetes Mellitus type 2, poorly controlled; Diabetic Nephropathy Initial Vital Signs (when handled): BP= 130/80mmHg T = 37.1C PR= 80 bpm RR= 25 cpm

NURSING HEALTH HISTORY

PAST HEALTH HISTORY

Patient cant remember if she completed her vaccines

1970, had appendectomy at Manila. 1987, the patient felt numbness all over her body and loss of consciousness. She was splashed with a pail of water and was relieved few hours after (according to her relatives). Few months later, the incidence reoccurred. In addition, she felt nape pain and distorted lower lips as observed by her relatives, which made them seek medical consultation at PIPOLs. Her blood pressure upon admission is 140/100 and was admitted for 1 day due to persistent Hypertension. She was referred to CVMC for further management and evaluation and was confined for 3 days. 2009, the patient had chicken pox which made her consult to Makati Hospital. However, she was not able to finish her check up and was not prescribed any medications. PRESENT HEALTH HISTORY IN 2008 The patient was informed by her friend that there would be a free medical check-up at their Barangay Health Center at Paco, Manila, hence submitted herself for check-up. Her blood sugar was taken and it reveals >300 mg/dl. She was prescribed an oral anti-diabetic agent (30 tabs) to be taken 3x a day. 1 Year After Patient seek for check-up at St. Anthonys Hospital (San Andres, Manila) with complaints of swelling of the feet, pain upon urination, however not confined. She was prescribed with CLOXACILLIN to be taken for 1 week. Thereafter the swelling subsides as verbalized by the patient.

February 5, 2011 The patient experienced fever with chills with abdominal pain, hence seek medical consultation at Tuguegarao City Peoples General Hospital and was referred to CVMC for further evaluation and management. She was diagnosed to have Diabetes Mellitus Type 2 and UTI. She was confined for 1 week and discharge on February 13. She went for follow-up check-up on February 17 and was noted to have bipedal edema. She was prescribed with Spironolactone and to continue her previous medications. February 22, 2011 the patient complained of fever and pigsa at her right buttocks hence admitted and confined for less than 1 week. She underwent incision and drainage. Her boil healed. March the patient seek follow-up check-up. She still has bipedal edema and was advised to continue her medications. April 6 2 days prior to admission, the patient experienced pigsa again at her left buttocks and swelling of the feet. Few hours PTA, the patient had difficulty of breathing which made her relatives seek medical consultation at CVMC. She was admitted under the service of Dr. Jena Lynn Alan, yellow team, with admitting diagnosis of Diabetes Mellitus Nephropathy. FAMILY HISTORY (-) DM (+) Hypertension (-) CVD (-) Asthma LIFESTYLE (-) Smoking (-) Drinking Can perform ADLs

SOCIAL Educational Attainment: Elementary graduate Active Filipino Citizen Attends Barangay meetings Attends Barangay activities

GORDONS 11 FUNCTIONAL HEALTH PATTERN

1. HEALTH-PERCEPTION HEALTH MANAGEMENT PATTERN BEFORE HOSPITALZATION

According to the patient,Malusog ang tao kapag kumakain siya ng gulay at kapag wala siyang sakit. She usually skips breakfast and regularly eats her lunch and dinner She self-medicates whenever she has cough and colds. She rarely goes to hospital for check-up unless her condition is getting worse. She does not take any vitamins. She has no known allergies to food and drugs.

DURING HOSPITALZATION

She perceives herself as unhealthy because she is diagnosed with diabetes. In order to manage her condition, she follows the orders of the doctor which are to strictly adhere to her medication regimen and diet. She said that she takes her medication always. Her IVF is PNSS 1L X KVO.

2. NUTRITIONAL-METABOLIC PATTERN BEFORE HOSPITALIZATION

The patient sad she has a good appetite. Matakaw po akong kumain, nakakadalawang cup ako ng rice pag lunch. Ang paborito kong pagkain ay isda at pinakbet. She skips breakfast but regularly have lunch and dinner. Her snacks are usually juice or coke and junk foods.

She consumes about 5 bottles of 8 oz coke and 3 cups of coffee in a day. Her water intake is at least 10 full glasses of water a day.

DURING HOSPITALIZATION

Sugar Mommy is under DM diet. She said that her appetite has decreased. She usually eats the food served at CVMC. Her snacks usually consist of lugaw and juice. Her water intake is 5 glasses of water a day. She doesnt drink coffee or coke anymore since it is prohibited.

3. ELIMINATION PATTERN BEFORE HOSPITALIZATION

According to the patient, she passes stool every other day. She described her stool as brown, formed and aromatic. She urinates about 4 -5 times a day. She described her urine as yellow and aromatic. She said that she does not experience difficulty in passing stool and urine.

DURING HOSPITALIZATION

According to Sugar Mommy, she still defecates every day with her stool as yellow and semi-formed. She urinates 4-5 times a day with her urine as yellow and aromatic.

She does not experience difficulty in passing stool. She complains of pain during urination.

4. ACITIVITY-EXERCISE PATTERN BEFORE HOSPITALIZATION

According to the patient, she does not exercise but does the household chores such as cleaning the house and washing the dishes. She is capable of performing her daily activities. She is also capable of doing her job as a cook. She verbalizes that she doesnt get tired easily.

DURING HOSPITALIZATION

The patient said that she does not exercise since shes at the hospital. She just lies on bed to rest and sleep because she feels weak. She is still unable to perform her self-care activities She gets tired easily.

5. SLEEP REST PATTERN BEFORE HOSPITALIZATION

According to Sugar Mommy, she usually sleeps at around 9-10 in the evening and wakes up at 5- 6 in the morning. She does not take a nap because she prefers to play cards with her neighbors. She does not experience difficulty in sleeping not until she had boil in her gluteal area. Before sleeping, she watches television and pray.

DURING HOSPITALIZATION

According to the patient, she still sleeps at around 9 10 pm and wakes up at 5 in the morning. She has more time to sleep and usually takes a nap at around 1-3 in the afternoon. She experiences difficulty in sleeping because of the pain she experiences at her gluteal area.

6. COGNITIVE-PERCEPTUAL PATTERN BEFORE HOSPITALIZATION

According to the patient, she is an elementary graduate. She does not see clearly anymore. She cannot read newsprints. She wears eyeglasses to aid her in reading. Unfortunately, she broke eyeglasses and was not able to buy a new one. She is oriented to person, place, and time but unable to recall past events especially exact dates, places and person. She can speak Itawes, Ybanag, Ilocano and Tagalog.

DURING HOSPITALIZATION

The patient has poor eyesight. She only sees clearly when the object is near. She is oriented to person, place and time. She is able to comprehend instructions well.

7. SELF-PERCEPTION SELF-CONCEPT PATTERN BEFORE HOSPITALIZATION

Sugar Mommy describes herself as a diligent and a friendly individual. She works hard in order to provide for her family. Moreover, she is a God-fearing person. She admitted that she is hot-tempered at times.

Her family is her source of happiness.

DURING HOSPITALIZATION

She perceives herself as unhealthy. She prays hard for her condition to get better. Her source of strength and happiness are still his friends and family. Moreover she verbalized. Tanggap ko na po may sakit ako. Wala naman po akong sinisisi sa nangyari.

8. ROLE-RELATIONSHIP PATTERN BEFORE HOSPITALIZATION

Patient Sugar Mommy is the 3rd child among the 4 children in the family. She has harmonious relationship with her siblings and still maintains communication with them. As a mother and wife, she is very responsible and loving. She never fails to keep in touch with her children even if they are in Manila and have their own families already. Moreover, she has good relationship with her neighbors.

DURING HOSPITALIZATION She is very overwhelmed by the support her family is giving her since she got hospitalized. Her children provides for her financial needs. Her relationship with her family, friends and neighbors did not change at all. In fact, they have become more supportive. 9. SEXUALITY-REPRODUCTIVE PATTERN

According to Sugar Mommy, has her first menstruation when she is 13 years old. She had her thelarche when she was 10 years old. She got married when she was 25 years old and had her first sexual contact at the same age. She has 8 children.

She and her husband tried different methods of family planning such the rhythm method, withdrawal, IUD and oral contraceptive pills.

10. COPING-STRESS PATTERN BEFORE HOSPITALIZATION

According to Sugar Mommy, whenever she has problems, she shares it to her husband right away. She also talks to her friends and children to ask for advice. She prays and watches television whenever she feels stressed.

DURING HOSPITALIZATION

She copes with her situation by saying her problems to her husband and children. She also sticks with her treatment regimen in order to manage her situation. Moreover, she asks God for help and guidance.

11. VALUE-BELIEF PATTERN BEFORE HSOPITALIZATION

Sugar Mommy is a Roman Catholic. She goes to mass every Sunday. She prays every day especially before going to bed. She highly respects and observes the practices of the Catholic Church. She believes in voodoo or kulam.

DURING HOSPITALIZATION

According to the patient, she became more prayerful when she was hospitalized. She always prays to God that shell be able to get well.

COURSE IN THE WARD

Date/Time 04-06-11

Doctors Order Admit to medical ward under the service of yellow team.

Rationale For further evaluation, treatment and mgt. on the condition of the patient for the continuity of holistic care. For legal basis and documentation

Nursing Responsibility Assisted the patient in the ward, perform initial assessment and vital signs. Clarified patients understanding regarding content of consent for admission and witnessed. >Instructed patient to avoid eating too much carbohydrates and sweets. >Informed Nursing Aide about the diet of the patient Monitored and recorded vital signs taken hourly and reported any alterations from normal ranges. >Facilitated laboratory requests.

Secure consent for admission and management

DM diet

To control further increase of patients blood sugar level.

V/s q hourly and record

To assess any deviation in the vital signs and for baseline purposes.

Diagnostics: CBC withAPC Na, K, Ca BUN, CREA SGPT, SGOT HGT now then Q 4 HBA1c

UA

CXR PA

12L ECG ABGs

>To determine levels of blood component >To determine Na, K, & Ca levels in the blood >To determine &/assess kidney functions >To determine &/assess liver functions >To determine blood sugar level >To determine patients compliance on treatment and mgt of diabetes for the past 3 months >To determine presence of bacteria, albumin, sugar, and other substances abnormally present in the urine. >To determine any deviation and

>Observed clean technique

>Provided urine specimen bottle and instructed patient to get the midstream urine.

ANATOMY AND PHYSIOLOGY

THE ENDOCRINE SYSTEM The endocrine system consists of ductless glands. Some glands of the endocrine system perform more than one function. Major functions 1. Regulates metabolism and growth 2. Regulates absorption of nutrients 3. Regulates fluid balance and ion concentration 4. Regulates the bodys response to stress 5. Regulates sexual characteristics, reproduction, birth and lactation ENDOCRINE GLANDS AND THEIR HORMONES Pancreas, insulin, and diabetes
The pancreas is an elongated organ located toward the back of

the abdomen behind the stomach. The pancreas has digestive and hormonal functions. One part of the pancreas, the exocrine pancreas, secretes digestive enzymes. The other part of the pancreas, the endocrine pancreas consists of pancreatic islets (Islets of Langerhans) dispersed among the exocrine portion and secretes hormones called insulin and glucagon. These hormones regulate the level of glucose (sugar) in the blood. The pancreas secretes insulin in response to elevated levels of blood glucose and amino acids. Insulin increases the rate at which many tissues, including adipose tissue, liver, and skeletal muscles, take up glucose and amino acids. The pancreas secretes glucagon in response to reduced blood glucose and increases the rate at which the liver releases glucose into the blood.

 Insulin is released from beta cells primarily in response to the

elevated blood glucose levels and increased parasympathetic stimulation that is associated with digestion of a meal. Increased blood levels of certain amino acids also stimulate insulin secretion. Decreased insulin secretion results from decreasing blood glucose levels and from stimulation by the sympathetic division of the nervous system. Sympathetic stimulation of the pancreas occurs during physical activity. Decreased insulin levels allow blood glucose to be conserved to provide the brain with adequate glucose and to allow other tissues to metabolize fatty acids and glycogen stored in the cells.
Glucagon is released from the alpha cells when blood glucose levels

are low. Glucagon binds to membrane-bound receptors primarily in the liver and cause the conversion of glycogen stored in the liver to glucose. The glucose is then released into the blood to increase blood glucose levels. After a meal, when blood glucose levels are elevated, glucagon secretion is reduced.
Insulin and glucagon function together to regulate blood glucose

levels. When blood

glucose

level increase, insulin secretion

increases, and glucagon secretion decreases. When blood glucose levels decrease, the rate of insulin secretion declines, and the rate of glucagon secretion increases. Other hormones, such as to epinephrine, decrease, cortisol, and growth hormone, also function hormones are secreted at a greater

maintain blood levels of nutrients. When blood glucose levels these rate. Epinephrine and cortisol cause the breakdown of protein and fat and the synthesis of glucose to help increase blood levels of nutrients. Growth hormone slows protein breakdown and favors fat breakdown.

LABORATORY EXAMINATION
April 7, 2011 1. Hematology Result Form

NORMAL RESULT ACTUAL RESULT Hemoglobin Mass (male- 135-145; 87 g/dl concentration female-120-160 g/dl) Erythrocyte (male-0.40; 0.26 volume fraction female0.380.47) Erythrocyte number concentration Thrombocyte number Leukocyte number concentration (4.5/L) 6.0x10^9 3.26 x 508 27.53

ANALYSIS Due to decrease oxygen in the blood. Due to decreased hemoglobin synthesis Due to decreased hemoglobin synthesis Due to benign reaction to infection Due to benign reaction to infection

(150-400 10^9/L)

(4.5-11 x 10^9/L)

2. WBC Differential Count

Neutrophils Lymphocyte Monocyte Eosinophil Basophil

NORMAL RESULT (0-.05) (0.20-.40) (0.02-.08) (0-.05) (0-.01)

ACTUAL RESULT 86.2 5.3 7.8 0.5 0.2

ANALYSIS Due to infection and stress Due to bacterial infection Due to bacterial infection Due to bacterial infection Due to bacterial infection

2. Blood Chemistry NORMAL RESULT BUN Creatinine ALT AST NA K (1.70-8.30 mmol/L) (44-97) (0.00-41.00 u/L) (0.0-42.0 u/L) (135-145 mmol/L) (3.5-5.4 mmol/L) ACTUAL RESULT 19.87 200.09 24.41 17.1 140.4 3.19 ANALYSIS Due to impaired kidney function Due to renal insufficiency NORMAL NORMAL NORMAL Due to metabolic imbalance

3. Clinical Chemistry Glycosylated HgbA NORMAL RESULT (4.0-6.3) ACTUAL RESULT 13.79 ANALYSIS Due to incompliance of medication and diet

4. ABG Analysis PH PCO PO HCO O saturation NORMAL RESULT 7.35-7.45 mmHg 35-45 mmHg 80-100 mmHg 22-26 mmol/L 95-100% ACTUAL RESULT 7.43 mmHg 29.0 mmHg 53.6 mmHg 19.1 mmol/L 89.5% ANALYSIS NORMAL Due to hyperventilation Due to renal dysfunction Due to renal dysfunction Due to hypoxia

O delivery system: FiO: 4 LPM

 Cannula (check)

April 8, 2011 1. Hematology Result Form

NORMAL RESULT ACTUAL RESULT Hemoglobin Mass (male- 135-145; 130 g/dl concentration female-120-160 g/dl) Erythrocyte (male-0.40; 0.39 volume fraction female0.380.47) Erythrocyte number concentration Thrombocyte number Leukocyte number concentration (4.56.0 10^9 /L) (150-400 10^9/L) x 4.61 x 477 32.6

ANALYSIS NORMAL NORMAL

NORMAL Due to reaction infection Due to reaction infection benign to benign to

(4.5-11 x 10^9/L)

2. WBC Differential Count

Neutrophils Lymphocyte Monocyte

NORMAL RESULT (0-.05) (0.20-.40) (0.02-.08)

ACTUAL RESULT 89.1 8.6 2.3

ANALYSIS Due to bacterial infection Due to bacterial infection Due to bacterial infection

April 16, 2011 1. Hematology Result Form

WBC RBC HgB Hct MCY

NORMAL RESULT 4.5-11 X 10^9/L 4.5-6.0 120-160 g/L 0.38-0.47 80-100 fL

ACTUAL RESULT 27.5 X 10^9/L 4.71 131 g/L 0. .427 91 fL

ANALYSIS Due to bacterial infection NORMAL NORMAL NORMAL NORMAL

2. WBC Differential Count

Neutrophils Lymphocyte Monocyte Eosinophil Basophil

NORMAL RESULT (35-65) (20-40) (0-5) (2-8) (0-5)

ACTUAL RESULT 87.3 6.1 1.5% 4.5% 0.6

ANALYSIS Due to bacterial infection Due to bacterial infection Due to bacterial infection Due to bacterial infection Due to bacterial infection

3. Blood Chemistry Creatinine NORMAL RESULT (44-97) ACTUAL RESULT 104.47 ANALYSIS Due to renal insufficiency

PHYSICAL ASSESSMENT Date assessed: April 09, 2011 General assessment: The patient is awake, conscious and coherent The patient is on green blouse and brown shorts. She is not well groomed with hair unkempt. With ongoing IVF of PNSS IL X KVO Vital signs: T=37.1 o C, RR=25 cpm, BP=130/80 mmHg, PR=80 bpm Area Assessed Skin Color Technique Inspection Normal Findings Light brown, tanned skin (vary according to race) Intact skin, no lesions or abrasion Lighter colored palms and soles Skin normally dry Normally warm Smooth and soft Skin snaps back immediately Transparent, smooth and convex Trimmed and clean to look at Pinkish Firm White color of Actual Findings Evaluation Tanned skin Normal

Presence of Inspection lesions and other skin abnormalities Soles and Inspection palms Moisture Temperature Texture Inspection/ Palpation Palpation Palpation

With boils at the left gluteal area Lighter colored palms and soles Skin normally dry Normally warm Slightly rough skin Skin snaps back immediately Transparent, smooth and convex, untrimmed and dirty nails Pinkish Firm White color of

Due to abscess at the left gluteal area Normal Normal Normal Due to presence of scars 2 chicken pox Normal

Turgor Skin appendages a. Nails

Palpation

Inspection

Due to selfcare deficit

Nail beds Nail base

Inspection Inspection

Normal Normal

Capillary refill

Inspection/ Palpation

nail bed under pressure should return to pink within 2-3 seconds Evenly distributed Black (varies with age and race) Smooth Parallel to each other PERRLA- Pupils equally round react to light and accommodation Able to read letter or news print

nail bed under pressure returned to pink within 2-3 seconds

Normal

b. Hair Distribution Color Texture Eyes Eyes Reaction to light

Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight)

Evenly Normal distributed Black with grey Normal hair Coarse Parallel to each other PERRLA- Pupils equally round react to light and accommodatio n Unable to read letter or news prints; with the aid of eyeglasses Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Same color as the skin Blinks involuntarily Do not cover Due to selfcare deficit Normal Normal

Visual Acuity

Inspection

Due aging

to

Eyebrows

Inspection

Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Same color as the skin Blinks involuntarily and bilaterally up to 20 times per minute

Normal

Eyelashes

Inspection

Normal

Eyelids Ability and frequency of blinking

Inspection

Normal

Normal

Symmetry

Conjunctiva Sclera Cornea Pupils

Inspection Inspection Inspection Inspection

Iris Inspection Ears Ear canal Inspection opening

Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge or inflammation Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Oval, symmetric and without discharge

the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge or inflammation Canal walls pink Client normally hears words in soft voice Smooth, symmetric with same color as the face Oval, symmetric and without discharge

Normal

Normal Normal Normal Normal Normal Normal

Normal Normal

Hearing Acuity

Inspection

Nose Shape, size Inspection and skin color

Normal

Nares

Inspection

Normal

Mouth Pharynx Lips Buccal mucosa

and Inspection Inspection Pink, moist symmetric Glistening pink soft moist Pink, moist symmetric Glistening pink soft moist Normal Normal

Gums

Inspection

Tongue

Inspection

Teeth

Inspection

Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny 32 teeth Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Clear breath sounds

Neck Symmetry of neck muscles Inspection

Neck ROM Thorax Lungs Breath sounds Symmetry and

Inspection

Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, yellow colored teeth, 8 teeth Uses prosthesis Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Clear breath sounds

Normal

Normal

Due aging

to

Normal

Normal

Auscultation Inspection

Normal

Spinal Inspection alignment Integrity of Inspection the skin Tenderness Palpation Upper Extremity Skin Color Inspection

Chest Chest Normal symmetric symmetric Spine vertically Spine vertically Normal aligned aligned Skin intact Skin intact Normal No tenderness No tenderness Normal

Light brown, tanned skin (vary according to race)

Tanned skin

Normal

Size ROM

Inspection Equal size Inspection Full mobility of each joint movement is deliberate, accurate, smooth and coordinated

Equal size Full mobility of each joint movement is deliberate, accurate, smooth and coordinated

Normal Normal

Lower Extremity Skin Color Inspection Light brown, tanned skin (vary according to race) Equal size ROM Inspection Full mobility of each joint movement is deliberate, accurate, smooth, and coordinated Neurological system Level of Inspection consciousnes s Fully conscious, respond to questions quickly, perceptive of events Makes eye contact with examiner, hyperactive expresses Full mobility of each joint movement is deliberate, accurate, smooth, and coordinated Fully conscious, respond to questions quickly perceptive of events Makes eye contact with examiner, hyperactive expresses Tanned skin Normal

Size

Inspection

With nonpitting edema on both extremities

Due to fluid volume excess Normal

Normal

Behavior and Inspection appearance

Normal

feelings with response to the situation

feelings with response to the situation

DRUG STUDY

CEFTRIAXONE Classification: antibiotic Indication: treatment of systemic infections caused by susceptible strains of microorganisms Actions: third generation cephalosporins that inhibits cell-wall synthesis, promoting osmotic instability, usually bacteridal Contraindication: Use cautiously in patients hypersensitive to penicillin because of possibility Adverse Reactions: fever, headache, dizziness Nursing Responsibilities: Check if the patient has allergy to the drug by doing skin test Observe ten rights in giving medications Note further reactions after administration

FUROSEMIDE Classification: fluids and electrolyte balance Indications: excretion of excess fluids in the body Actions: a potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle. Contraindications: hypersensitive to drugs and in those with anuria. Adverse Reactions: headache, dizziness, nocturia Nursing Responsibilities: Monitor weight, blood pressure, and pulse rate routinely in long term use and during rapid diuresis.

Monitor fluid intake and output Watch for signs of hypokalemia, such as muscle weakness and cramps

FERROUS SULFATE Classification: hematologic Drugs Indications: iron deficiency Actions: Provides elemental iron, an essential component in the formation of hemoglobin Contraindications: Peptic ulceration, in those receiving repeated blood transfusion Adverse Reactions: Nausea, epigastric pain, vomiting, constipation, black stools, diarrhea, anorexia Nursing Responsibilities: Monitor hgb level, hct and reticulocyte count during therapy.

CALCIUM CARBONATE Classification:G.I Drugs Indications: Calcium supplement Actions: Reduces total acid load in GIT, elevates gastric ph to reduce pepsin activity, strengthens gastric mucosal barrier and increases esophageal sphincter tone. Contraindications: in patients with ventricular fibrillation or hypercalcemia Adverse Reactions: headache, irritability, weakness, rebound hyperacidity, nausea, constipation, flatulence Nursing Responsibilities: Monitor calcium level, especially in patients with mild renal impairment Watch for evidence of hypercalcemia

SODIUM BICARBONATE Classification: Drugs for fluid and electrolyte balance, Antacid Indications: Antacid Actions: Restores buffering capacity of the body and neutralizes excess acid Contraindications: contraindicated to patient with metabolic and respiratory alkalosis Adverse Reactions:nausea or vomiting, headache, sever mood changes, muscle pain, swelling of feet, ankles or legs decreased appetite, unusual tiredness, constipation Nursing Responsibilities:obtain blood pH, partial pressure of arterial oxygen, partial pressure of arterial carbon dioxide, and electrolytes level

ATORVASTATIN Classification:Antilipemics Indications: To reduce LDL cholesterol Actions: Inhibits biosynthesis HMG-CoA reductase, an early step in cholesterol

Contraindications: Contraindicated to patient hypersensitive to drugs and in those with active liver disease or unexplained persistent elevation of transaminase level Adverse Reactions: Headache, insomnia, peripheral edema Nursing Responsibilities: Before starting treatment, assess for underlying causes for hypercholesterolemia and obtain a baseline lipid profile. Watch for signs of myositis.

AMLODIPINE Classification:Antianginals

Indications: Hypertension Actions: Inhibits calcium ion influx across cardiac and smooth muscle cells, thus decreasing myocardial contractility and oxygen demand Contraindications: contraindicated to patients hypersensitive to drugs and with hypotension Adverse Reactions: Headache, somnolence, fatigue, dizziness Nursing Responsibilities: Monitor BP frequently during initiation of therapy. Because drug induced vasodilatation has a gradual onset, acute hypotension is rare.

LOSARTAN Classification: Indications: Hypertension Actions: Inhibits vasoconstrictive and aldosterone secreting action of angiotensin II by blocking angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells. Contraindications:Use cautiously in patient with impaired renal or hepatic functions Adverse Reactions: Dizziness, asthenia, fatigue, headache, insomnia Nursing Responsibilities: Monitor BP closely to evaluate effectiveness of therapy. Regularly assess the patient renal function.

CLINDAMYCIN Classification: Antibiotics Indications: Infection caused by staphylococci, streptococci and other sensitive aerobic and anaerobic organisms.

Actions: Inhibits bacterial protein synthesis by binding the 50S subunit of the ribosome Contraindications: Contraindicated to patient hypersensitive to drug or lincomycin. Adverse Reactions: Thrombophlebitis, nausea, vomiting. Abdominal pain, diarrhea Nursing Responsibilities: Obtain specimen for culture and sensitivity test before giving he first dose. Observe patient for signs of super infections. MEFENAMIC ACID Classification: Non-steroidal Anti-inflammatory drug Indications: short-term treatment of mild to moderate pain from various conditions Actions: inhibits the enzyme cyclooxygenase (COX)-1 and COX-2 and reduces the formation of prostaglandins and leukotrienes. It also acts as an antagonist at prostaglandin receptor sites. It has analgesic and antipyretic properties with minor anti-inflammatory activity. Contraindications: inflammatory bowel disease, peptic ulcer, neonates, coronary artery bypass graft surgery, severe renal impairment, severe heart failure Adverse Reactions: Upset stomach, nausea, heartburn, dizziness, drowsiness, diarrhea, and headache may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Nursing Responsibilities: 1. Assess patient for any allergic reaction to drug. 2. Instruct patient to take drug with food to avoid GI upset.

KALIUM DURULE Classification: Electrolytes and minerals Brand Name:KCl

Indication: Hypokalemia. As prophylaxis during treatment with diuretics Dosage: 1 tab BID Contra Indication: Renal insufficiency, hyperkalemia, untreated Addisons disease, stricture of the esophagus and or destructive changes in the alimentary tract. SP: Obstructive changes in the alignmentary tract, stricture of the esophagus. Heart/ Kidney disease. Pregnancy and lactation DI: K salts and K- sparing diuretics ,e.gspironolacture , amiloride , triamferene, tacrolimus. ACE inhibitors. Nursing Responsibilities:
1. Instruct patient to take drug with meals.

2. Instruct pt. to swallow the drug whole with glass of liquid, do not chew/crush. 3. Do not administer to a pt. in a supine position.

Discharge Teachings Medication a. Advice to strictly adhere to treatment regimen especially on supplements b. Always check the expiration of medicines before taking.

Environment a. Provide an environment conducive for patients recovery b. Maintain a clean and well ventilated environment to prevent spread of infection. Encourage the SO and the patient to clean environment specially their own backyard or place to allow good rest and stress free surroundings for the patient to regain strength and comfort. c. Patient/SO will provide clean environment which is free from infectious agents and to allow patient to rest with a clean surrounding.

Health Teaching A-dequate rest B-lood glucose monitoring C-omplications D-rugs-insulin, OHA type II DM E-xercises-walking is safe and beneficial. Teach that exercise can decrease blood glucose level Diabetics must first control the glucose level before initiating exercise programs. Offer extra food or calories before engaging in exercise. Offer snacks at the insulin treatment.

 Advice exercise same time every day, preferably when peak of glucose level. Regular exercise a. b. c. d. Maintain ideal body weight Maintain cardiovascular reserves Maintain normal blood sugar-total cholesterol, triglycerides Monitor fbs-increase 140 twice get possible dm

Inform the patient the importance of follow-up appointments

Promotion of health from illness. Healing process from treatment

Foot care o o o o o o Avoid walking barefoot Do not soak feet in cold water No to use alcohol Use lotion & moisturizer Instruct to inspect the shoes all the times Cut the nails straight across

Out Patient Referral preventions a. After Discharge, advised client to come back at April 27, 2011. Diet Plan for caloric intake distributed as follows: -CHO-50-60% -FATS-20-30% -PROTEINS-10-20%

Advice moderation in alcohol Excessive salt intake is to be avoided Artificial sweeteners are to be used in moderation. Meals should be evenly distributed throughout the day.

NURSING CARE PLAN

ASSESSMENT Subjective Data: Sumasakit sa may bandang pwet ko, as verbalized by the patient Objective Data: Facial grimace Guarding behavior (+)Irritability (+) restlessness Pain scale of 7/10 BP:140/100 DIAGNOSIS Alteration in comfort; Pain r/t traumatiz ed nerve endings secondary to tissue destructio n. PLANNING After 30 minutes of nursing management, the patient will manifest signs of relief like (-) irritability, facial grimace, restlessness and patients pain scale will decrease from 7/10 to 3/10 INTERVENTION Encouraged deep breathing exercises Placed the client in comfortable position (right side lying and semi fowler ) Provided relaxation exercises or techniques. EVALUATIO N After 30 To distract minutes of attention and reduce tension nursing managemen t, the To allocate patient pain and to manifested promote signs of comfort relief like (-) irritability, facial grimace, The goal of restlessness these and techniques is patients to reduce pain scale tension, decreased subsequently reducing pain. from 7/10 to 3/10 To promote nonpharmacol ogical pain management. To maintain acceptable level of pain RATIONALE

Provided back rubs

Administered analgesic as ordered

(Mefenamic acid 500mg /tab q 4 hours) ASSESSMENT Objective Data: Capillary refill time of 3 seconds Pale skin, conjunctiva and buccal mucosa Presence of edema Delayed wound healing Hgb = 87 mg/ dl Erythrocytes number concentratio n = 3.26 Pulse rate = 63bpm DIAGNOSIS Altered peripheral tissue perfusion related to decreased arterial blood flow PLANNING Within the shift the Patient will demonstrate increased tissue perfusion as manifested by strong peripheral pulses, vital signs within normal range, absence of edema and normal capillary refill time. INTERVENTION Positioned properly (moderate high back rest). RATIONALE EVALUATIO N

Performed passive range-ofmotion (ROM) exercises to unaffected extremity every 2 to 4 hours. Provided quiet and restful atmosphere Caution client to avoid activities that increase

Goal This promotes partially met. optimal lung After an 8 ventilation and hour perfusion. nursing Exercise intervention the patient prevents venous stasis. the demonstrat ed increased tissue perfusion as manifested by strong peripheral Conserves pulses, vital energy and signs within lowers tissue normal O2 demand range, (+) Conserves edema and a capillary energy and refill time of lowers tissue 1-2

cardiac workload Hooked to O2 as needed.

O2 demand This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues.

seconds.

Emphasized importance of taking prescribed medications

Strict adherence to medication regimen results to better health outcome

ASSESSMENT Subjective Data: Nurse pakitingin naman itong sugat ko,as verbalized by the patient Objective Data: Presence of a reddened pus-filled warm and tender lump on the upper left gluteal area

DIAGNOSIS Impaired skin integrity related to inflammato ry response secondary to infection/bo il.

PLANNING Within 8 hours of nursing interventio n the patient will be kept clean and free from any further infection.

INTERVENTION Encouraged verbalization of feelings

RATIONALE To establish rapport and acquire additional information Decreases pressure on edematous, poorly perfused tissues to reduce ischemia.

EVALUATION After an 8 hour of good nursing intervention the patient has been clean and is free from any further infection

Changed position frequently, move patient carefully

Recommend client to use lotion and moisturizer to help promote a soothing skin.

Emphasized proper hygiene like: Handwashing before and after touching the infected area

Lotions and ointments may be desired to relieve dry, cracked ski n

To prevent further infection

 Wound care done Keeping the skin clean Keeping the nails short Informed about the importance of taking antibiotics and other prescribed medications

To promote adherence to medication regimen for better health outcome