A Case Study

Diabetes Mellitus Type II

“The Weakest Link”

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I. Health history

 

    A. Demographic profile

        

        Name: R.G

        Gender: Male

        Age: 41 years old

        Birth date: September 23, 1967

        Birth place: Pasig , Metro Manila

        Marital status: Married

        Nationality: Filipino

        Religion: Born Again- Christian

        Address: Brgy. Pantihan 3, Maragondon, Cavite

        Educational background: High school graduate

        Occupation: Factory worker in Monterey

        Usual source of medical care: Doctor/Healthcare Professional

   

    B. Source and reliability of information

 

        The patient R.G is the primary source of information. He is conscious and

coherent, able to speak Tagalog fluently. His wife is also considered as source of

information regarding patient status and condition.

 

    C. Reasons for seeking care or chief complaint (Top 3)

 

        1st – Loss of his weight

        2nd – Insufficient sleep at night

        3rd – Scaly of skin

 

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    D. History of present illness

 

Patient R.G was handled during our duty at Brgy. Pantihan 3,

Maragondon,,Cavite with the chief complaint of insufficient sleep at night, loss of his

weight and scaly of skin. The laboratory test and special treatment for the patient are

not applicable because this case is base on community setting.

E. PAST MEDICAL HISTORY OR PAST HEALTH

Pediatric/childhood

-Incomplete immunization- (-) serious illness on this stage

Injuries or accidents

-1992, right leg accident due to mishandling of machine

Serious or chronic illness

-December 2003, Diabetes Mellitus diagnosed clinically

-2x FBS result 300mg/dl

-2006 Pulmonary Tuberculosis, diagnosed clinically

-Chest X-ray and sputum AFB examination

-2007 Urinary Tract Infections

-Urinalysis (pyuria)

Hospitalization

-1992, Water Rose General Hospital

Admitting diagnosis: Right leg machine accident

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-December 2003, Rizal Medical Center, Pasig City, Metro Manila

Admitting diagnosis: Diabetes Mellitus Type 2

Operation

-not applicable

Obstetric History

-not applicable

Immunizations

-incomplete immunization (unrecalled)

Allergies

-No known allergies to food and medication

Medication

-Metformin 500mg/tab

1 tab TID p.c.

-Gliclezide 80mg/tab

1 tab OD a.c.

-Vitamin B Complex tablet

1 tab OD

-Alaxan 500mg/tab (Paracetamol + Ibuprofen)

1 tab PRN for fever and pain

Last Examination Date

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-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila

F. FAMILY HISTORY

LEGEND:

Female

Male

Patient

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(+) DM

83 y/o(+) CVA

55 y/o(+) HPN

41 y/o(+) DM

39 y/o 37

y/o

38 y/o

37y/o

11 y/o

13y/o

2 y/o

9 y/o16 y/o

15 y/o

Deceased

G. SOCIO-ECONOMIC STATUS

Mr. R.G. lives in their own house at Pantihan 3, Maragondon, Cavite. His wife is

selling and making barbeque sticks as the source of their income while his 16 years old

son works as a vendor in a wet market at Dasmarinas, Cavite as additional source of

income. They also received financial support from their relatives in Pasig. They can be

measured up as to poor class family. The patient is occasionally drinker of alcohol and

cigarette smoking.

H. DEVELOPMENTAL HISTORY

Generativity vs Stagnation

Maturity (35-45 yrs old)

A person may experience midlife crisis between the ages of 35-45 years old, the

“deadline decade”. This occurs when the individual recognizes that he has reached the

halfway mark of life and according to Erik Erikson, the developmental task of the

middle-aged adult is Generativity vs. Stagnation.

As to our patient, who belongs to a middle age group and is suffering from a life-

threatening condition, he had experienced this developmental crisis, which led him to be

non-productive.

Being non-productive led him to be stagnant after the occurrence and diagnosis of

his disease which made him to be dependent with his family, he can’t attend, function

and be able to accomplish his responsibilities as a father, a husband and as part of the

community.

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I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

Subjective Objective

General

“Ito nangangayat na dahil sa

sakit ko” as verbalized by the

patient.

Weight: 35 kg. (July 10, 2009)

87 kg. (December 2003)

(+) wt. loss 48kg.

(+) numbness at times(lower

extremities)

(+)excessive sweats, axilla

(+)weakness

(-)malaise

(-)chills

(-)fever

BP- 130/80 Temp. – 36.5 °C

Integument

Skin:

“Hindi makati sa binti, pero ang

braso, nangangati” as verbalized

by the patient.

(+)itchiness (upper extremities)

(+)scaly skin

(-)history of skin disease

Hair:

“Dati malago ang buhok ko” as

verbalized by the patient.

Thinning of hair, evenly distributed

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(+)itchy scalp (scratching)

(+)Oily hair

Nails:

“Ito matigas na ang kuko ko

kumpara dati” as verbalized by

the patient.

(+)clubbing of nails (long nails)

(+)Yellowish nail beds

Amount of sun exposure: Exposure to sunlight every morning

Head:

“Sumasakit ang ulo ko na parang

tinutusok” as verbalized by the

patient.

(+)frequent headache

(+)dizziness

(-) lumps

Eyes:

“Malabo na ang paningin ko” as

verbalized by the patient.

(+)blurry vision

(+)PERRLA

(+)Anicteric sclera

(+)Pale conjunctiva

(+)itchiness

(-)discharge

Ears:

“Malinaw pa naman ang

pandinig ko, pero may sumasakit

minsan” as verbalized by the

patient.

Both ears hears well when the examiner

is 3 feet away

(-)cerumen

(-)discharge

Mouth and Throat:

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“Medyo hirap akong lumunok”

as verbalized by the patient.

(+)difficulty in swallowing

(+)lesions on tongue

(+)dental carries

(+)hoarseness of voice

Pink tonsils

(-)bleeding gums

(+) gag reflex

Neck:

“Wala naming problema sa leeg

ko” as verbalized by the patient.

(-)stiffness

(-)pain

(+)palpable bilateral lymphs

Breasts and Axillae:

“Pawisin ang kilikili ko” as

verbalized by the patient.

(+)excessive sweating, axilla

(-)lump

(-)pain

(-)rash

(-)nipple discharge

Respiratory:

“Medyo nahihirapan akong

huminga” as verbalized by the

patient.

RR – 28 bpm

(+)difficulty of breathing

(+)barrel chest

Productive cough

History of lung disease: pneumonia,

PTB, 2006

Last chest x-ray: 2007

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Cardiovascular

Central:

“Paminsan- minsan sumasakit

ang dibdib ko” as verbalized by

the patient.

(+)chest pain

(+)dyspnea on exertion (bed to chair)

(+)nocturia

Peripheral:

(+)coldness(general)

(+)pallor in hands

(+)clubbing of nails

(+)tingling (sole of feet)

(-)numbness

(-)varicose veins

(-)ulcers

0-1 second, capillary refill

Gastrointestinal:

“Eto madalas magan ako

kumain” as verbalized by the

patient.

(+)good appetite

Food intake tolerated

(+)minimal dysphagia

(-)hematemesis

Frequency of BM: 3x a week

Characteristic of stool: yellowish-

brown in color, formed in consistency

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(+)constipation (arch and formed stool)

(-)hemorrhoids

Urinary:

“Ihi ako ng ihi” as verbalized by

the patient.

(+)polyuria

(+)dysuria

(+)nocturia

Dark Yellow in color

History of urinary disease: UTI(2006)

Genitalia:

Refused

Musculoskeletal:

“Kumikirot ang kasukasuan at

buto-buto ko” as verbalized by

the patient.

(+)minimal pain, knee area and ankle

(+)pain, calf area

(+)lower back pain, radiating

(+)weakness, leg muscles

Neurologic:

“Alam ko pa naman ang mga

sinasabi ko ngayon” as

verbalized by the patient.

(-)history of seizure, stroke, fainting

Mental:

(-)nervousness

(+)depression

Self-pity and crying

Motor function:

(-)tremors

(-)paralysis

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Sensory function:

Oriented to time, person and place

Hematologic:

“Pagkakaalam ko,wala naman

akong sakit sa dugo” as

verbalized by the patient.

(-)bruises

(+)palpable lymph nodes

(+)bleeding tendency of skin (scaly

skin)

(-)history of Blood Transfusion

Endocrine:

“Sa pamilya naming may

Diabetes, kaya ako merong

Diabetes” as verbalized by the

patient.

(+)DM, type II

(+)polydypsia

(+)polyuria

(+)polyphagia

(+)weight loss

(+)change in skin texture, scaly skin

(+)excessive sweating, axilla

(-)nervousness

(-)tremors

Cranial Nerves Assessment

I. Olfactory Nerve - Normal

II. Optic Nerve - Blurry vision

III. Oculomotor - Normal

IV. Trochlear - Normal

V. Abducens - Normal

VI. Trigeminal - Normal

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VII. Facial - Normal

VIII. Acoustic - Normal

IX. Glossopharyngeal - Normal

X. Vagus - Normal

XI. Spinal Accessory - Normal

XII. Hypoglossal - Normal

J. FUNCTIONAL ASSESSMENT

I. Health Perception/Health Management Pattern

Mr. R.G. is a 41 yrs old, male and seriously ill person. Once he felt something wrong

about his condition, he seeks for medical advice. Occasionally, he also had colds in the past. Last

December 2003, after a consultation from a physician and with accompanying lab result of blood

sugar level (2x done, result is increased 300mg/dl) he was diagnosed of DM type 2. The client

believes that he acquired his illness from his grandfather who also had Diabetes Mellitus.

According to Mr. R.G., eating nutritious food, exercise and religiously taking of prescribed

medication or what nurse’s and Doctor’s advise/suggest will keep him healthy. Due to financial

incapacity, this regimen was not taken into consideration.

II. Self Esteem, Self Concept/Self Perception Pattern

Before he was diagnosed with DM type 2, Mr. R.G. is a responsible husband and father

to his wife and kids. He was able to provide the needs of his family. The client possessed a jolly

and fun loving type of personality.

Since his illness started, most of the time, he felt self-pity and worthless. He is always

irritable and angry when he thinks that he was ignored. Because of his condition he became more

depress and the only thing that gave him hope and strength is through prayer.

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III. Activity-Exercise Pattern

Perceived ability for: (Refer to Functional Level Code)

Feeding Level II Grooming Level II

Bathing Level II General Mobility Level II

Toileting Level II Cooking Level IV

Bed Mobility Level II House Maintenance Level IV

Dressing Level II Shopping Level IV

Functional Level Code

Level 0 Full Self Care

Level I Requires Use of Equipment or Device

Level II Requires Assistance or Supervision from Another Person

Level III Requires Assistance or Supervision from Another Person and

device

Level IV Is Dependent and Does Not Participate

IV. Sleep/Rest Pattern

The patient had altered sleep pattern. Each day he only had a maximum of 2 hours of

sleep and despite of that he still fells god upon waking up. He said sometimes the pain he felt put

him into sleep.

V. Nutritional/ Elimination

The patient usually takes a glass of milk in his breakfast and he takes heavy meals more

frequently but after eating he usually felt stomach ache. He has supplements of vitamin B-

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complex. He typically drinks more than an 8 glasses of water per day. Patient stated that prior to

his illness he weighted 87kgs but at present he weighs 39kgs.

We noticed that the patient skin is scaly all over his body. He also have lesion in his

tongue and positive dental carries.

The patient usually had 3x bowel movement per week with a dark yellowish brown color

stool, with hard formed in consistency. On the other hand he noted that he frequently void with

dark yellow in color urine and felt some discomfort when urinating.

During the day patient is experiencing excessive sweating in his armpit.

VI. Sexually- Reproductive Pattern

The patient is inactive in sexual intercourse due to present condition

VII. Interpersonal Relationship / Resources

Patient can speak and understand English and Tagalog. He can clearly express himself.

He has 6 children and they were close to each other.

Before patient is very active and usually socializes with his neighbors.

Patient R.G’s family was very supportive and understanding, now that he is battling with

his disease.

The patient is dependent due to his illness.

VIII. Coping and Stress Tolerance

Before when patient R.G is anxious he wants to be alone, when he is stressed, he prefers

to drink liquor and involved himself in gambling.

When he was diagnosed of DM Type 2 there have been many changes occurred that

made difficult for him to adjust. He cannot perform the usual activities that he had before. When

patient R.G is stressed, he prefers to cry until he falls asleep. When it comes to problem, he tried

to calm himself through prayers.

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IX. Values-Belief Pattern

Patient R.G is a Born Again Christian, before according to the client he always hears

mass every Sunday with his family.

Due to his illness he wasn’t able to go to mass. According to the patient there are many

practices affects his illness.

He wasn’t able to follow therapeutic regimen due to financial problem and a strong faith

to God helps him to get through all the suffering he has.

After what happened, patient R.G is still not seeking for medical assistance due to

financial problem. Religious effort is still a part of patient R.G.’s life.

X. Personal Habits

Before, patient R.G. used to maintain a good personal hygiene and had a diet without

restriction. He used to work as a factory worker 6 days per week and was able to help in doing

household chores when he got home. He had a good sleep pattern of almost 8 hours at night.

Every Sunday he goes to mass with his family and occasionally at his free time he drinks and

smoke with his friends.

At present, due to his illness, patient R.G wasn’t able to perform his usual routine. He had

to stopped from working in able to attend his health needs and become dependent to his family.

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XI. Concept Map

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1. Imbalanced nutrition: less than body requirements related to deficient insulin

4. Impaired skin integrity related to impaired metabolic state

2. Disturbed sleep pattern related to prolonged discomfort secondary to disease process

3. Activity intolerance related to generalized weakness

5. Risk for infection related to inadequate primary defense

Demographic Profile:Name: R.GGender: MaleAge: 41 years oldMarital status: MarriedReligion: Born Again-ChristianOccupation: Factory worker in MontereyEducational Background: High

II. PROBLEM LIST

1. Imbalanced Nutrition Less than body requirements

2. Disturbed Sleep Pattern

3. Impaired Skin Integrity

4. Activity Intolerance

5. Risk for Infection

III.

A.) ACTUAL OR ACTIVE PROBLEM

Problem No. Problem Date Identified Date Resolved Remarks

1

Imbalanced

Nutrition Less

than body

requirements

July 09, 2009 July 16, 2009 Client appetite was

increase.

2 Disturbed Sleep

Pattern

July 09, 2009 July 16, 2009 The client can sleep

now from 4-6 hours

unlike before.

3

Impaired Skin

Integrity

July 09, 2009 July 16, 2009 The wound is clean

and dry.

4

Activity

Intolerance

July 09, 2009 July 16, 2009 The client able to

perform some

minimal ADL

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B.) High Risk or Potential

Problem No. Problem Date Identified

1 Risk for infection July 09, 2009

IV. NURSING CARE PLAN ( At The Last Page)

V. ANATOMY AND PHYSIOLOGY

ENDOCRINE SYSTEM

Homeostasis depends on the precise regulation of the organ and organ systems of the body. The

nervous and endocrine system are two major systems responsible for that regulation. Together

they regulate and coordinate the activity of nearly all other body structures. When these system

fail to function properly, homeostasis is not maintained. Failure ofsome component of the

endocrine system to function can result in disease such as Diabetes Mellitus or Addison’s

disease.

The regulatory function of the nervous system and endocrine systems are similar in some

respects, but they differ in other important ways. The nervous system controls the activity of

tissues by sending action potentials along axons, which release chemical signals at their ends,

near the cell they control. The endocrine system releases chemical signals into the circulatory

sytem, whichh carries to all parts of the body. The cell that can detect those chemical signal

produce reponses.

The nervous system usually acts quickly and has short term effects, whereas the endocrine

system usually response more slowly and has longer-lasting effects. In general, each nervous

stimulus controls a specific tissue or organ, whereas each endocrine stimulus controls several

tissues or organ.

FUNCTIONS:

It regulates water balance by controlling the solute concentratiuon of the blood.

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It regulates uterine contractions during delivery of the newborn and stimulates milk

release from the breast in lactating females.

It regulates the growth of many tissues, such as bone and muslces, and the rate of the

metabolism of many tissues, which helps maintain a normal body temperature and

normal mental function. Maturation of tissues, which result in the development of adult

features and adult behavior, are also influence by the endocrine system.

It regulaytes sodium, potassium and calcium concentrations in the blood.

It regulates the heart rate and blood pressure and helps prepare the body for physical

activity.

It regulates blood glucoce levels and other nutrient levels in the blood

It helps control the production and function of immune cells.

It controls the development and the function of the reproductive systems in males and

females.

Pancreas

an elongated gland extending from the duodenum to the spleen; consist of a head, body,

and the tail. There is an exocrine portion, which secretes digestive enzymes that are

carried by the pancreatic duct to the duodenum, and pancreatic islet, which secrete insulin

and glucagon.

The endocrine part of the pancreas consists of pancreatic islets (small islands; islet of

Langerhans) dispersed among the exocrine portion of the pancreas. The islets secrete two

hormones –insulin and glucagon—which function to help regulate blood nutrient levels,

especially blood glucose.

Alpha cells of the pancreatic islets secrete glucagon.

Beta cells of the pancreatic islet secrete insulin.

It is very important to maintain blood glucose levels within a normal range of values. A

decline in the blood glucose levels within a normal range causes the nervous system to

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malfunction because glucose is the nervous system’s main source of energy. When blood

glucose decreases, other tissues to provide an alternative energy source break fats and

proteins rapidly. As fats are broken down, the liver to acidic ketones, which are release

into the circulatory system, converts some of the fatty acids. When blood glucose level

are very low, the break down of fats can cause the release of enough fatty acid and

ketones to cause the pH of the fluids to decrease below normal, a condition called

acidosis. The amino acids of proteins are broken down and used to synthesize glucose by

the liver.

If blood glucose levels are too high, the kidneys produce large volumes of urine

containing substantial amounts of glucose because of the rapid loss of water in the form

of urine, dehydration result.

Insulin is released from the beta cells primarily response to the elevated blood glucose

levels and increased parasympathetic stimulation that is associated with digestion of a

meal. Increase blood levels of certain amino acids also stimulates insulin secretion.

Decreased result from decreasing blood glucose levels and from stimulation by the

sympathetic 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 cell.

The major target tissues for insulin are the liver, adipose tissue, muscles, and the area of

the hypothalamus that controls appetite, called satiety center (fulfillment of hunger).

Insulin binds to membrane-bound receptor and, either directly or indirectly, increases the

rate of glucose and amino acid uptake in these tissues. Glucose is converted to glycogen

or fat, and the amino acids used to synthesize protein.

Glucagon is released from the alpha cell when blood glucose level is low. Glucagon

binds to membrane-bound receptors primarily in the liver and caused the conversion of

glycogen storage in the liver to glucose. The glucose is then released into the blood to

increase blood glucose level. After a meal, when blood glucose levels are elevated a

glucagon secretion is reduced.

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Insulin and glucagon function together to regulate blood glucose levels. When blood

glucose 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 increase. Other hormones, such as epinephrine, cortisol, and growth

hormones, also function to maintain blood levels of nutrients. When blood glucose level

decrease, these hormones are secreted at a greater rate. Epinephrine and cortisol caused

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.

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VI. PATHOPHYSIOLOGY

Diabetes Mellitus Type 2 is referred to as non-insulin dependent diabetes mellitus

(NIDDM), or adult onset diabetes mellitus (AODM).In case our patient we classified the risk

factor into two categories the modifiable and non-modifiable. Under modifiable is the diet

because diet high in cholesterol increases number of adipose tissue and this tissue are resistant to

insulin therefore glucose uptake by cell is poor and the stress because stress stimulates secretion

of epinephrine, norepinephrine and glucocorticoids and this neurotransmitters increases glucose

level. In the non-modifiable factor hereditary because it can be transfer from parents to offspring.

In the case of our his father has a diabetes also. And the age with strong heritability patterns

which present as type 2 diabetes early in life, usually before 30 years in the case of our patient he

was diagnosed at the age of 37 years old. In type 2 diabetes, can still produce insulin, but do so

relatively inadequately for their body's needs, beta cells are primary affected and there is a poor

production of insulin. Insulin is also the principal control signal for conversion of glucose to

glycogen for internal storage in liver and muscle cells. Lowered glucose levels result both in the

reduced release of insulin from the beta cells and in the reverse conversion of glycogen to

glucose when glucose levels fall. If the insulin is deficient the intracellur and the intravascular

space are affected. In the intracellular space there is a failure of glucose to enter in the

intracellular space because there is a lack of insulin and insulin acts as the key to be able the

glucose to enter in the cell. And when this happened the glucose supposed to be absorb by the

cells are staying in the blood and this term is hyperglycemia. If cell was not able to absorb the

sugar their will be intracellular and extracellular dehydration and body will compensate and the

person will have the urge to drink more water it is term polydipsia. Also if cell has no glucose

intake their will be cellular starvation and the person will have the urge to eat and eat and it is

termed polyphagia.

In the intravascular area if the insulin is insufficient and glucose are not absorb by the cell the

glucose is staying in the blood stream and the glucose level in the blood will increase as the

sugar in blood increase the blood circulation will become viscose. Prolonged high blood glucose

level leads to sluggish circulation and when the glucose concentration in the blood is raised

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beyond its renal threshold, reabsorption of glucose in the proximal renal tubuli is incomplete, and

part of the glucose remains in the urine (glycosuria). This increases the osmotic pressure of the

urine and inhibits reabsorption of water by the kidney, resulting in increased urine production

(polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water

held in body cells and other body compartments, causing dehydration and increased thirst. In a

sluggish circulation due to high blood content in blood the oxygen supply in the peripheral site is

insufficient and when this happened there is a proliferation of microorganism in the case of our

patient his wound doesn’t easily heal due to poor oxygen delivery and microorganism take place

and multiply.

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Pathophysiology

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Poor production of Beta cells

Polyphagia

Modifiable Diet

Stress

Non-modifiable Hereditary

Age

Insulin Deficiency

Intracellular: failure of glucose to enter in ICS

Intravascular: increase glucose in blood

Hypergylcemia

ECF/ICF dehydration

Systemic blood Viscosity

Cell Starvation

Sluggish circulation

Polydipsia

Increase Osmotic pressure in renal

tubules

Poor oxygen delivery to peripheral area

Proliferation of microorganism

Polyuria

VII. MEDICAL MANAGEMENT

A. Pharmacotherapeutics/Medicines

GN (BN)Classification stock

Indication (Client specific)

Dosage and Frequency

Nursing Responsibilities And Implications(Pre,Intra,Post)

Generic Name: MetforminBrand Name: FormetClassification: Anti-diabetic agent

Indication: Treatment for NIDDM

(Type II) not responding to dietary modification

Dosage and Frequency: 500mg/tab TID 1 tab TID

Pre: Check for allergies Ask for history of heart

disease (for dose adjustment)

Intra: Take with meal Tell patient not to

crush, chew or break (may cause too much of drug to be released at one time)

Post: Test blood (to assure

that Metformin is helping the patient’s condition)

Advice patient to avoid drinking alcohol (may decrease blood sugar and increase risk of lactic acidosis)

Generic Name: GliclazideBrand Name: Ritemed GliclazideClassification: antidiebetic agent

Indication: Type 2 diabetes not

controlled by diet alone

Dosage and frequency:

80 mg/tab1 tab OD

Pre: Check the patient for

allergiesIntra:

Take with meal Instruct the patient to

swallow the tablet whole, without breaking, crushing or chewing it, it may cause too much of drug to be released at one time

Post:

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Poor wound healing

Advice the patient not to drink alcohol because it may cause severe decrease of blood sugar

Generic Name: Vitamin B ComplexClassification: food supplement

Indication: Dietary supplement for

certain patient who do not receive a proper amount of vitamin from the diet

Dosage and frequency:1 tab OD

Pre: Ask patient if he is

taking any prescription or non prescription medicine, herbal preparation or dietary supplement

Ask the patient if he has allergies to medicines, foods or other substances (some meds may interact with vitamin B)

Intra: May be given with or

without food, if stomach upset occurs, take with food to reduce stomach irritation

Advise the patient to take it as soon as possible if he missed a dose

Tell the patient to skip missed dose if it is almost time for the next dose and go back to the regular dosing schedule

Remind patient not to take two doses at once

Generic Name: Iboprofen+ParacetamolBrand Name: AlaxanClassification: NSAID

Indication: Relief of mild to

moderately severe pain of musculoskeletal origin

Dosage and frequency: 500mg/tab

1 tab PRN

Pre: Check the patient for

allergiesIntra:

Take with food to lessen stomach upset

Post: Instruct patient not to

continue taking drug

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more than 10 days for pain or 3 days for fever

VIII. DISCHARGE HEALTH TEACHING PLANS

Content Strategy

1.Compliance Medication  Metformn(Formet) 

500mg/tab, 1tab TID, take

with meal. 

Gliclazide 

80mg/tab, 1tab OD

     

Vitamin B complex          

1tab OD, take with/ without

food.             

Ibuprofen+paracetamol          

500mg/tab, 1 tab PRN, take

with food.

Do not crush, chew or

break. Avoid drinking

alcohol.

Take with meal swallow

whole, without breaking,

chewing or crushing it (it

may cause too much of

drug to be released at one

time.                                   

Do not drink alcohol (it

may cause severe decrease

of blood sugar.

If missed a dose, take

as soon as possible skip-

missed dose if it is almost

time for the next dose and

go back to regular dosing

schedule.

Do not continue taking

drug more than 10 days for

pain or 3 days for fever.

2. Diet  Low carbohydrate diet   

High fiber diet   

Reduce intake of rice

Eat fruits and

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vegetables

Teach patient to read

labels of "health" foods

because they contain sugar

product such as honey,

brown sugar and corn

syrup.

3.Exercise  Light stretching

 

Chin to chest 

Head to shoulder

Flexing and extending

very slowly of upper and

lower extremities.            

Rotating of the extremities

at a very light and slow

motion.

Touch chin to the chest

slowly

Flex the head to the

right and to the left

shoulder at a very slow

movement.

Note: the exercise

should be done with

assistance of significant

others at a very slow

motion to avoid further

complication.

4. Activity/Lifestyle  Positive reinforcement  Give positive

reinforcement for self-care

behaviors.

Changes instruct family to

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assist in the situation of

the client.

Have a regular interaction

with patient to avoid low

self-esteem.

Social support is very

important to the client.

IX. SUMMARY OF CLIENT STATUS OR CONDITION AS OF LAST DAY OR

CONTACT

Date Problems encountered (actual and resolved)

July 9, 2009

Actual problems that are identified are and have been resolved last

July 16, 2009:

First is imbalanced nutrition: less than body requirements. As

evidence by verbalization of the client and based on the assessment

done that the client really loss weight. It should be the first priority, to

meet the metabolic needs of the body by intake of sufficient nutrients

and able to gain weight. Because of the necessary nursing interventions

that have been done the client’s appetite increased.

Second is disturbed sleep pattern. As evidence by verbalization of

the client “di ako masyado makatulog sa gabi, lagi akong pagising

gising”. And based on the assessment done that there are (+) sunken

eyeballs and weakness. It should be the second priority because the

client is experiencing a insufficient time or period of sleep. The

necessary nursing interventions should be done for the client to be able

to maintain a comfortable environment. After doing so, the client

verbalized improvement in sleep pattern and can sleep now from 4-8

30

hours.

Third is impaired skin integrity. As positively evidence by skin

disruption of skin surface and as verbalized by the client that “para na

nga akong isda na kinakaliskisan eh, naniniklap na yung balat ko”.

Necessary nursing interventions should be done; and after doing so the

client’s wound becomes dry and clean.

And Forth is activity intolerance. It should be identify for the

client to have sufficient energy to endure or complete required or

desired daily activities. The problem was evidence by verbalization of

the client that “di na ko makalabas ng bahay at di na rin ako makatayo

ng matagal” and positive immobility, weakness and weight loss based

on the assessment done. Because of the necessary nursing interventions

that have been formulated the client was able to perform some minimal

ADL.

July 9, 2009

There is a potential problem that had been identified during our

contact with the client and this is risk for infection due to the disruption

of the skin which is the primary defense. Necessary nursing

interventions should be done to prevent infection and complications.

 

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