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I. BIOGRAPHIC DATA

Name: Mrs. X

Age: 44 years old

Address: #03 Masaya Street, Pulong Kendi I, Sta. Ana, Taguig City

Marital Status: Married

Chief Complaint: Increased thirst, Polyphagia, Polyuria, Restlessness,

Gender: Female

Religious Affiliation: Roman Catholic

Occupation: Labandera Laundry Woman/Housewife

II. NURSING HISTORY

A. Past Health History

According to Mrs. X, her last check up to the doctor in the Taguig General Hospital was last year of 2006 and its almost 2

years ago. The result of her examination was, she has high blood sugar. She also had check up about the tenderness of herbreast and the presence of discharge and the doctor recommended her to take Cloxacillin.

B. History of Present Illness

C. Family Health History


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According to Mrs. X, her auntie in the mother side has diabetes mellitus. She also has hypertension because her blood pressurewas 180/110.

III. Patterns of Functioning

A. Psychological health

1. Coping Pattern

The client said that she easily loose temper and gets irritated especially when her husband got drunk. She

further added that she always makes herself busy by watching TV and play tong its to cope with stress.

Interpretation:

Analysis:2. Interaction Pattern

The client said that her relationship with her siblings is mutual that they are like brothers and sisters. When

asked about her relationship with her husband, she verbalized that, lagi kaming nag aaway at nagbabangayan kasi

palagi syang lasing. Siya lang talaga problema ko.

Interpretation:

Analysis:

3. Cognitive Pattern

The client is elementary graduate. She is able to read and write and understand what we tell to her. She is able to

speak out her problems to us.

Interpretation:

Analysis:


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4. Self-Concept

The client verbalized, Nagagawa ko parin mga trabaho ko at mga gusto kong gawin tulad ng paglalaba

dalawang beses sa isang linggo. As we observed, she is energetic and emotionally competent when we

conducted our interview.

Interpretation:

Analysis:

5. Emotional Pattern

She expressed her feelings, she was crying and overwhelmed during our assessment and interview as we

conducted our health teachings

Interpretation:

Analysis:

6. Sexuality

She is not sexually active due to her work and relationship with her husband.

Interpretation:

Analysis:

7. Family Coping Pattern

The client stated that theyre having a small conversation within their vicinity when they have problems within

their family.

Interpretation:

Analysis:

B. Socio-cultural


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1. Cultural Patterns

2. Significant Relationships

3. Recreation Patterns

4. Environment

5. Economic

C. Spiritual Patterns

1. Religious Beliefs and Practices

2 Values and Valuing

IV. ACTIVITIES OF DAILY LIVING

ADL Before

Hospitalization

During Hospitalization Interpretation/

Analysis1. Nutrition

2. Elimination

3. Exercise

4. Hygiene

5. Substance use

6. Sleep and rest Any illness that causes pain, physical

discomfort, or mood problems, such as


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anxiety or depression, can result in sleep

problems. Sleep disorders are conditions

that if untreated generally cause disturbed

night time sleep that result in one of the

three problems: insomnia, abnormal

movements or sensation during sleep or

when awakening at night(Aldrich and

Naylor, 2000)

Fundamentals of Nursing Potter &Perry

6th edition 2005, pp.1202-1203

7. Sexual

activity

V. PHYSICAL ASSESSMENT

ASSESSMENT NORMS AND

STANDARDS

ACTUAL FINDINGS ANALYSIS

General Appearance

1. Posture/Gait Relaxed, Erect

Posture, Coordinated

Movement

Slouch Slouch is the hanging down of thehead; a drooping posture

; a limpappearance. The commonmanifestations of bad posture areswayback (a large curve in the back)and slouching, where everythingmoves forward and rolls in.
http://en.wiktionary.org/wiki/headhttp://en.wiktionary.org/wiki/posturehttp://en.wiktionary.org/wiki/limphttp://en.wiktionary.org/wiki/headhttp://en.wiktionary.org/wiki/posturehttp://en.wiktionary.org/wiki/limp


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2. Skin Colour

3. Personal

Hygiene/Grooming

4. Nutritional Status

5. Age appropriateness

6. Verbal Behavior

7. Non-verbal Behavior

Neat and Clean Looks Neat and Clean Normal

Measurements

1. Temperature

2. Pulse Rate

3. Respiratory rate

4. Blood Pressure

5. Weight

6. Height

7. BMI

59 cpm

24 bpm

180/110 mmHg

47 kg

145.5cm/4 ft 7 inches

22.38

Body Part (Technique Used)


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VI. Course in the Ward

Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation and

AnalysisNovember 30, 2008 Benedicts Test

Heat and Acetic acid

Test

(-) Blue or no change in

color

(+) bluish green

(++) yellowish green

(+++) yellow

(++++) orange or brick

red

(-) no turbidity

(+) faint turbidity(++) moderate turbidity

(+++) heavy turbidity

(++++)solid(opaque)

(+4)Orange

Faint turbidity/Cloudy

Deviated to normal

because the Benedict

solution turned into

color orange which

indicated that her urine

has presence of sugar.

The normal result in

acetic acid test is noturbidity or no

coagulation of albumin

but the result shows that

her urine has (+)positive

1 or faint turbidity which


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indicates a slight

presence of albumin or

protein in her urine.

VII. Medications, IV Infusions, Blood Transfusions, Treatments Given

Generic/Trade

Name

Dosage/Frequency Classification Indication Contraindication Side-Effects Nsg.

Responsibility

VIII. Pathophysiology of Diabetes Mellitus

IX. Ecologic Model

A. Hypothesis

1. Type 2 Diabetes Mellitus is due to the clients sedentary lifestyle.2. Type 2 Diabetes Mellitus can be attributed to the clients familial history of DM.3. Obesity can also be attributed to the development of Type 2 Diabetes Mellitus.

B. Predisposing Factors

1. Host

a. Age- 44 years old


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b. Behavior- lack of physical activity (sedentary lifestyle), intake of foods high in salt and sugar, fatty foods

c. Heredity- familial history of Diabetes Mellitus

2. Environment

a. Socio-economic- housewife

C. Model

D. Analysis

Diabetes Mellitus is not a single disease. It is genetically and clinically heterogeneous group of metabolic

disorders characterized by glucose intolerance with hyperglycemia present at time of diagnosis.


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Specific cause depends in the type of diabetes; however, it is easier to think of diabetes as an interaction

between two factors: Genetic Predisposition (diabetogenic genes) and Environment/Lifestyle (obesity, poor nutrition,

lack of exercise). (Public Health Nursing in the Philippines, 2007, p.195)

E. Conclusion and Recommendation

Modernization of life has dramatically increased the prevalence of Diabetes Mellitus. Most people with Type 2

Diabetes Mellitus are older and near overweight. There is also a strong susceptibility to clients whose family has

genetic predisposition of DM. Lifestyle also plays an important role in the development of the disease.

In the Philippines, increasing life expectancy, urbanization and lifestyle modification have brought about great

change on the health status of the country. Globalization and social change has influenced the spread of non-

communicable or lifestyle/degenerative diseases by escalating exposure to risk.

The Department of Health suggests activities for prevention and control of Diabetes Mellitus.

Maintain body weight and prevent obesity through proper nutrition and physical activity/ exercise.

Eat more dietary fiber, reduce salt and fat intake, avoid simple sugars like cakes and pastries, and avoid junk

foods. Promote regular physical activity and exercise to enhance insulin action in the body.

The fact that lifestyle plays an important role in the development of Type 2 Diabetes Mellitus has led to increased

stress on prevention. Diet and exercise can significantly delay the onset of the disease.


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X. Prioritized List of Nursing Problems

Date Nursing Problems Identified Cues Justification

XI. Nursing Care Plan

Nursing Problem Analysis Goal/Objectives Nursing

Interventions

Rationale Evaluation

Cues:

Subjective:

Objective:

Scientific

Implication:

Immediate Cause:

Intermediate Cause:

Root Cause:

SMART Supplemental:

Developmental:

Facilitative:

Effectiveness:

Efficiency:

Adequacy:

Appropriateness:

Acceptability:

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