Dm Ni Case With Patho

8/3/2019 Dm Ni Case With Patho

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1

A Case Presentation

On

DIABETES MELLITUS

In partial fulfilment for the Requirements

in Related Learning Experience III

Presented to:

Mrs. Rubilyn Bulquerin - Sumaylo, R.N.

Mrs. Nadia Bisnar, R.N.

Ms. Maureen N. Patricio, R.N.

Presented by:

Celestial, Charmie Lou D.

Contreras, Patricia Janelle A.

Deocampo, Melode Jean A.

Fonte, Ann Marie Zol H.

Horneja, Mary Georgette Gay M.

Langurayan, Deo Ray C.Lauron, Jasmin Joyce A.

Sarbues, Arvin C.

Toledo, Maria Evette M.

Trinidad, Gladys Mae D.

Verjes, Kathleen Jade S

BSN B 2013



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TABLE OF CONTENTS

Page

I. Acknowledgment-------------------------------------------3

II. Introduction-------------------------------------------------4

III. Objectives---------------------------------------------------- 5

IV. Textbook Discussion---------------------------------------6-7

V. Anatomy and Physiology---------------------------------8-9

VI. Vital Information-------------------------------------------10

a. Clinical Assessment----------------------------------------11

b. Present Health Status-------------------------------------11

c. Past Health Problem/ Status----------------------------11

d. Family Genogram---------------------------------------- 12

e. Patterns of Functioning-----------------------------------13

VII. Brief Social, Cultural, and Religious Background --14

a. Educational Background--------------------------------- 14

b. Occupational Background------------------------------- 14

c. Religious Practice------------------------------------------ 14

d. Economic Status--------------------------------------------14

VIII. Clinical Inspection------------------------------------------14

a. Vital Signs---------------------------------------------------- 14

b. BMI-------------------------------------------------------------14

c. Physical Assessment---------------------------------------15-16

d. General Appraisal------------------------------------------16

IX. Laboratory and Diagnostic Reports-------------------17-20

X. Pathophysiology-------------------------------------------21

XI. Medical Management------------------------------------22-43

XII. Concept Map ---------------------------------------------- 44-45

XIII. Nursing Management -----------------------------------46-55

XIV. Discharge Planning--------------------------------------- 56-57

XV. Our Journey-------------------------------------------------58

XVI. References-------------------------------------------------- 59



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Acknowledgment

People may come and go, but there are people who left footprints in our hearts. They are the

people who are nevertheless worth our heartfelt gratitude.

First and foremost, we would like to thank our dear God, the Father, for our lives most

especially and to every day he had given us. We would also to thank Him also for giving us these

people who had been there for our group throughout this exposure.

Next in line, are our beloved parents. They are to support us in our every decision in life, in

guiding us towards life and they are also there to support us in our financial needs. They strive hard

to give us a good life, good education and a brighter future.

To our smart, jolly and charming Clinical Instructor, Miss Rubilyn Bulquerin- Sumaylo,

R.N. with the support and guidance of our former Clinical Instructors Mrs. Nadia Bisnar, and Ms.

Maureen Patricio We are thankful that we have you. Thank you for being our second mother in the

clinical area and for providing us the knowledge that we all need. You are always there to guide us

in the different procedures we did and you are always there to shower us with knowledge in every

case that we handled. We really did enjoy and learned at the same time in our exposure under your

care.

To both our advisers, Mrs. Shiela Ritas- Soluta and Miss Jemmillee Ellen Olilang, thank

you for your unending support and inspiring advices. We are lucky to have you both as our adviser.

Thank You for the patience.

The group would also like to express our sincerest gratitude to all the staff nurses of Saint

Joseph Ward who unselfishly shared their knowledge and skills while we are on duty as student

nurses. We learned so much from you.

Thank you very much!



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I. IntroductionHave you heard about the sweetest temptation? Yes. The sweetest temptation you never

resisted. The one you would trade yourlife for to twist your fate. This disease is sweetly killing us,

sweetly consuming every part of you. Inch by inch its sweetly eating you. Have you ever heard of

this sweet cry? The cry of being sweetly diagnosed by diabetes. How about the mourn of an

amputed leg to its master? Then the master is crippled forever. Have you seen the tears of an eye to

its last sight? Or a man struggling for his sweet life? Is it worth one more cup? Is it worth one more

slice? Life is sweet but diabetes is the price!

Do you know that in the year 2010…

Under 20 years of age

186,300 or 0.22% of all people in this age group have diabetes

About 1 in every 400 to 600 children and adolescents has type 1 diabetes

About 2 million adolescents aged 12 to 19 have pre-diabetes

Age 20 years or older

23.5 million or 10.7% of all people in this age group have diabetes

Age 60 years or older 12.2 million, or 23.1% of all people in this age group have diabetes

Men

12.0 million, or 11.2% of all men aged 20 years or older have diabetes

Women

11.5 million, or 10.2% of all women aged 20 years or older have diabetes.

I would like to ask all of you, would you rather live your life in every piece of it, enjoying those

sweetest food that you could ever tasted? Or suffer by the sweet revenge of diabetes?



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II. OBJECTIVESA. General Objective

After the discussion of this case, the students will be able to deal and care for patients

with Diabetes Mellitus integrally by applying their knowledge, skills, and positive attitudesbased on what they have learned out of the discussion.

B. Specific Objectives

At the end of the case discussion, it is expected that the students will be able to:

Skills

1. Deal patient with Diabetes Mellitus.

2. Provide proper care according to the problem manifested by the patient.3. Conduct physical assessment and organize data efficiently.

4. Formulate and apply nursing care plans utilizing the nursing process.

5. Learn new clinical skills as well as sharpen our current clinical skills required in themanagement of the patient with Diabetes Mellitus.

Knowledge

1. Define Diabetes Mellitus.

2. Trace the pathophysiology of the disease.

3. Have an overview about the disease, including its causes and complications.

4. Determine the signs and symptoms and the possible symptomatic treatment of each.

5. Review the anatomy and physiology of the organ affected.

6. Identify and enumerate the management needed for Diabetes Mellitus and its relatedcomplications.

7. Formulate nursing care plans that will aid in the improvement of patient’s condition.

Attitudes1. Develop a positive attitude in caring the patient with Diabetes Mellitus throughout the

nursing Process.2. Establish rapport with the patient and folks.

3. Develop respect and trust.

4. Develop our sense of unselfish love and empathy in rendering nursing care to our patient sothat we may be able to serve future clients with higher level of holistic understanding aswell as individualized care.



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TEXTBOOK DISCUSSION Every time we eat sugary or starchy food, the amount of glucose available to the body rockets. Yet

the levels of glucose in the bloodstream are maintained within narrow limits by two key hormones – insulin and glucagon – working to prevent hyperglycemia or hypoglycemia.

What is Diabetes?Diabetes mellitus arises when insufficient insulin is produced, or when the available insulin does

not function correctly. Without insulin, the amount of glucose in the bloodstream is abnormally

high, causing unquenchable thirst and frequent urination. The body's inability to store or use

glucose causes hunger and weight loss.

There are two main types of diabetes. Insulin-dependent diabetes – type 1 diabetes – occurs when

there is a severe lack of insulin due to the destruction of most or all of the beta cells in the islets of Langerhans. This type of diabetes develops rapidly, usually appearing before the age of 35, and

most often between the ages of 10 and 16. Regular insulin injections are required to survive.

Non-insulin-dependent diabetes – type 2 diabetes – occurs when the body does not produce enoughinsulin, and the insulin that is produced becomes less effective. This type of diabetes usually

appears in people over the age of 40, and tends to have a more gradual onset. In most cases, glucose

levels in the blood can be controlled by diet, or diet and tablets, although sometimes insulin

injections may be needed. About 90 per cent of diabetics are non-insulin dependent.

What causes diabetes?In type 1 diabetes, the insulin-producing beta cells are destroyed by an autoimmune process,whereby the body's immune system – its defence mechanism against disease – for some reason

recognises the cells as being 'foreign' rather than 'self', and therefore attacks them.

In susceptible individuals, this autoimmune process is thought to be influenced by environmental

factors – which are as yet unknown. Such susceptibility is genetically determined – two genes havebeen identified that appear to put an individual at risk, but there are certain to be more genes

involved.

Type 2 diabetes is thought to be due both to defects in the islet beta cells, so that less glucose is

produced, and to an impairment of insulin's ability to stimulate the uptake of glucose in muscles and

other tissues. The cause of this insulin resistance has not yet been fully established, but may involvedefects in the action of insulin after it has bound to the insulin receptor on the surface of cells.

There is a genetic influence, as type 2 diabetes tends to run in families even more strongly than type

1 diabetes, and several genes are likely to be involved. But increasing age, obesity and a sedentary

lifestyle also increase the risk of type 2 diabetes.

Type 2 diabetes is a progressive disease. This progression is characterized by continuing decline in

beta-cell mass and function added to worsening insulin resistance. This means that most patients

require intensified therapy over time to maintain glycemic control.

In type 2 diabetes, either the pancreas does not make enough insulin and/or the body does notuse it properly. No one knows the exact cause of type 2 diabetes, but it's more likely to occur in

people who:

are over 40 years of age

are overweight

have a family history of diabetes

developed gestational diabetes during a pregnancy



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have given birth to a baby that is more than 4 kg (9 lbs) have high blood pressure

have high cholesterol

have IGT or impaired fasting glucose

are of Aboriginal, Hispanic, Asian, South Asian, or South African descent

Signs and Symptoms

Type 2 diabetes symptoms may develop very slowly. In fact, you can have type 2 diabetes for years

and not even know it. Look for:

Increased thirst and frequent urination. As excess sugar builds up in your bloodstream,

fluid is pulled from the tissues. This may leave you thirsty. As a result, you may drink —

and urinate — more than usual.

Increased hunger. Without enough insulin to move sugar into your cells, your muscles and

organs become depleted of energy. This triggers intense hunger.

Weight loss. Despite eating more than usual to relieve hunger, you may lose weight.Without the ability to metabolize glucose, the body uses alternative fuels stored in muscle

and fat. Calories are lost as excess glucose is released in the urine.

Fatigue. If your cells are deprived of sugar, you may become tired and irritable.

Blurred vision. If your blood sugar is too high, fluid may be pulled from the lenses of your

eyes. This may affect your ability to focus clearly.

Slow-healing sores or frequent infections. Type 2 diabetes affects your ability to heal and

resist infections.

Areas of darkened skin. Some people with type 2 diabetes have patches of dark, velvety

skin in the folds and creases of their bodies — usually in the armpits. This condition, called

acanthosis nigricans, may be a sign of insulin resistance. Decreased sensation or numbness in the hands and feet

Dry, itchy skin

Frequent bladder and vaginal infections

Frequent need to urinate

Increased thirst and hunger

Male impotence (erectile dysfunction)

Tiredness

According to the Book Manifested by the patient

Polyuria

Polydipsia

Polyphagia

Weight loss

Dry skin

Sores that are slow to heal

Frequent infections

Tingling or numbness of extremities

Dehydration

Sudden vision changeDry, itchy skin/ itchiness in the genitalia

Tiredness/ fatigue

Areas of darkened skin

Male impotence (erectile dysfunction)



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III. ANATOMY AND PHYSIOLOGY

Pancreas- A fish-shaped spongy pinkish white glandular organ about 6 inches (15 cm) long that

stretches across the back of the abdomen, behind the stomach. It is the second largest gland that is

connected to the digestive tract, after the liver. The pancreas lies in the epigastrium and

lef thypochondrium areas of the abdomen

It is composed of the following parts:

The head lies within the concavity of the duodenum.

The uncinate process emerges from the lower part of head, and lies deep to superior mesenteric

vessels.

The neck is the constricted part between the head and the body.

The body lies behind the stomach. The tail is the left end of the pancreas. It lies in contact with the spleen and runs in the

lienorenal ligament.

The pancreas is one of the few organs that has both an exocrine and an endocrine function.

Exocrine glands are glands that secrete their products into ducts (duct glands). Endocrine glands are

glands that secrete their product directly into the blood rather than through a duct.

The pancreas is an important organ for digestion and the control of circulating levels of glucose.

The functions of the pancreas are the following:

-Completes the job of breaking down protein, carbohydrates, and fats using digestive juices

of pancreas combined with juices from the intestines.

http://www.newworldencyclopedia.org/entry/Gastrointestinal_tract

http://www.newworldencyclopedia.org/entry/Liver

http://en.wikipedia.org/wiki/Epigastrium

http://en.wikipedia.org/wiki/Hypochondrium

http://en.wikipedia.org/wiki/Duodenum

http://en.wikipedia.org/wiki/Stomach

http://en.wikipedia.org/wiki/Spleen

http://en.wikipedia.org/wiki/Lienorenal_ligament

http://www.newworldencyclopedia.org/entry/Glucose

http://www.newworldencyclopedia.org/entry/Glucose

http://en.wikipedia.org/wiki/Lienorenal_ligament

http://en.wikipedia.org/wiki/Spleen

http://en.wikipedia.org/wiki/Stomach

http://en.wikipedia.org/wiki/Duodenum

http://en.wikipedia.org/wiki/Hypochondrium

http://en.wikipedia.org/wiki/Epigastrium

http://www.newworldencyclopedia.org/entry/Liver

http://www.newworldencyclopedia.org/entry/Gastrointestinal_tract



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-Secretes hormones that affects the level of sugar in the blood.

-Produces chemicals that neutralize stomach acids that pass from the stomach into the small

intestines by using substances in pancreatic juice.

-Contains Islets of Langerhans, which are tiny groups of specialized cells that are scattered

throughout the organ.

These cells secrete:

Glucagon- raises the level of glucose (sugar) in the blood

Insulin-stimlates cells to use glucose

Somatostatin- may regulate the secretion of glucagons and insulin.



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IV. Vital InformationName A.M.

Age 61years old

Sex Female

Address Capricho 1 , Roxas City, Capiz

Civil Status Single

Religion Roman Catholic

Occupation Government Employee (Commission on Audit )

Diet Low salt, Low Fat, Diabetic Diet

Date and Time Admitted August 7,2011 @ 1:30pm

Ward/ Room Saint Joseph Ward/ Room 315

Chief Complaint Abscess at left subcostal margin

Admitting Diagnosis Draining Abscess at left Subcostal Margin;

Hypertension; DiabetesMellitus Type 2

Final Diagnosis Abscess at Left subcostal area S/P: I & D,Hypertension Stage 1, Diabetes Mellitus Type 2

– Insulin requiring, Mixed Dyslipidemia

Attending Physicians Dr.R.H, Dr.C N, Dr. A.B., Dr. N.C.



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V. CLINICAL ASSESSMENT

A. PRESENT MEDICAL HISTORY

One week prior to admission, she noticed swelling with erythema on the left subcostal area

accompanied with foul smelling and yellowish to greenish with blood streaks discharges. It was

also accompanied with pain but no consultation was done. She did not take any medication.

Two days prior to admission, she had fever and chills. She took Biogesic once and ciprofloxacin

two times a day. Fever and chills were relief. She also applied hot compress on the area but no

relief of signs and symptoms so she decided to seek medical attention and was advised for an

admission.

B. PAST HEALTH HISTORY

In 1992 she was diagnosed with Diabetes Mellitus Type 2.

In July 2009, she was admitted in St. Anthony College Hospital because of Urinary Tract Infection

under the service of Dr. C.N. She started her insulin injections Humulin N 25 ―U‖ pre-breakfast and

20 ―U‖ pre-supper. She was also given with Metformin 500mg two times a day before lunch andbefore supper and Janumet 50/120 once a day before lunch.

In December 2010, she was again admitted with the same complaints under the same doctor.

She did not undergo any surgical procedure in the past. She has no known allergies to both foods

and medications.



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FAMILY GENOGRAM



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PATTERNS OF FUNCTIONING

Patterns of Functioning Home Hospital

Breathing Patterns Respiratory rate ranges from

20-24 breaths per minute.Circulation Blood pressure ranges from

130/80 to 150/100mmHg.

Cardiac rate of 84 to 88 beats

per minute.

Sleeping Patterns Usually sleeps at 11 o’clock in

the evening and wakes up at 4

to 5 o’clock in the morning.

Sleeps at 10 o’clock in the

evening and wakes up at 5 to 6

o’clock in the morning. Sleeps

at intervals during daytime.

Drinking Drinks 8 to 10 glasses of water

everyday. Seldom drinks sodas

and juices. If ever, she only

drinks coke zero.

Drinks 10 to 12 glasses of

water.

Eating Eats the three regular meals

with snacks in between

everyday.

Eats three regular meals but not

allowed to eat between 1 to 5

o’clock in the afternoon.

Hygiene Takes a bath regularly and

brushes her teeth two to three

times a day.

Tepid sponge bath and mouth

care were provided by her

significant others.

Elimination Urinates 5 to 10 times a day

depending upon her fluid

intake.Defecates 1 to 2 times a day,

one in the morning and one

before going to bed, depending

upon her food intake.

Urinates 10 to 12 times a day

depending upon her fluid

intake.Defecates every morning.

Recreation and Exercise Does not involve herself in any

physical exercises. For her, her

exercise is when she do the

marketing every Saturdays and

Sundays. Plays mah-jong

during her leisure time.

Dos not exercise and watches

television when she is awake.



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VI. BRIEF SOCIAL, CULTURAL, AND

RELIGIOUS BACKGROUND

Educational Background

She finished her Bachelor of Science in Commerce at Colegio De la Purisima Concepcion.

Occupational Background

She works as a government employee in Commission on Audit at the Capiz Provincial

Capitol.

Religious Practices

She is a devoted Roman Catholic. She goes to church everyday to attend the holy mass. She

occasionally receives the Holy Communion because she does not go to confession regularly.Prays the Holy Rosary every night.

Economic Status

The family belongs to the middle class. They all have college degrees and have their

permanent jobs.

VII. CLINICAL INSPECTIONA. VITAL SIGNS

Upon Admission

( August 7, 2011)

During Care

( August 10,2011 @ 4pm)

Temp. 36.7 ˚C 36.2˚C

RR 24 breaths per minute 20 breaths per minuteCR 88 beats per minute 84 beats per minute

PR 85 beats per minute 82 beats per minute

BP 150/ 90 mmHg 140/100 mmHg

B. BMI- 36.42 (Obese )

HEIGHT- 63 inches

WEIGHT- 205.03 lbs

Formula:

Weight in pounds X 705

(Height in inches) ²



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C. PHYSICAL ASSESSMENT

General Assessment

Conscious, oriented, lying in a supine position to hospital bed with an IVF#2 PNSS

IL x KVO at her left metacarpal vein.

Skin

Fair complexion, normal turgor, cool to touch, and rough. Abscess in the left

subcostal margin noted about 2 inches in diameter. No signs of edema and lesions in other

parts of the body.

Hair

Hair is black with some gray and white due to aging. Hair loss noted specifically at

the posterior part of the head. No lice and flakes noted but with foul smell.

Face

The face is wrinkled due to old age.

Head

Symmetrical and can move from side to side; scalp is smooth and no lumps or

lesions noted.

Mouth

Gums and buccal mucosa are pinkish, smooth and moist. No presence of lesions

found. Tongue has white spots and can move from side to side when instructed. Tonsils are

not inflamed. Lips are moist and pinkish. Missing premolars, first and second molars on

both the maxillary and mandibular teeth noted. Cavities noted and her mouth has an

offensive odor or halitosis.

Eyes

Pupils are equally round reactive to light and accommodation; pupils constrict 2mm,

and pinkish conjunctiva. No noted lesions and unusual discharges. Wears eyeglasses.

Ears

Symmetrical. Has good hearing capacity. No presence of lesions and discharges.

Nails

Fingernails and toenails are pinkish and cool to touch. Not well trimmed and

presence of dirt noted. Capillary refill is less than three seconds.

Nose

Nasal mucosa is pinkish, no noted polyps or discharges. No signs of flaring, lesionsand swelling.



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Neck

Symmetrical, proportional to head and shoulders. Carotid artery is palpable. The

thyroid gland was not visible upon inspection. The gland ascends normally during

swallowing.

Upper Extremities

Upper extremities were very flabby due to accumulated fat tissues. Dark skinpigmentation on her elbows.

Chest

Abscess in the left subcostal margin approximately 3 cm in diameter noted with

soaked dressing with offensive odor .

Axilla

Axillae were dry and has slightly offensive odour. Presence of fatty tissues in the

area. With palpable lymph nodes on her left axilla.

Respiratory System

Respiration rate ranges from 20- 24 breaths per minute. Does not use accessory

muscle in breathing.

Cardiovascular System

Heart rate ranges from 84- 88beats per minute. Blood pressure ranges from 130/80 to

150/100mmHg.

Gastrointestinal System The bowel sounds were present during auscultation. Does not complain of pain

during palpation.

Genitourinary System

Urine output is adequate every hour (between 100- 150 cc per hour). Discretely scratches

her genital area during observation.

Musculoskeletal System

Moves slowly from side to side due to her weight and probably due to pain from her

surgical incision. No presence of contractures or fractures.

D. General Appraisal

1. Speech – Speaks in a small, soft voice, and utters comprehensible words. No slurring of

speech noted.2. Language – She speaks Hiligaynon, Filipino, and English.

3. Hearing – Has a good sense of hearing and answers accordingly to questions when asked.

Reacts to noises inside the room

4. Mental Status – She is coherent and oriented with person, time and place.



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VIII. LABORATORY

AND

DIAGNOSTIC DATA



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Date/ Type / Purpose of

Examination

Results Normal Values Significance

08/07/11

HematologyTo check the blood component for any abnormality

To check the volume of RBC’s in the blood.

WBC

Indicates the possiblepresence of severity of

infection or inflammatory

response.

12.2 x10ˆ9/L

(Increased)

4.5-11x10ˆ9/L Infection

Platelet

Used to assess the ability of

the bone marrow to produceplatelets and to identify the

destruction or loss of platelets in the circulation.

516 x10ˆ9/L

(Increased)

150-450x10ˆ9/L Infection

WBC Deferential Count:Used to assess the ability of the body to respond to and eliminate infection. It also detects the

severity of the infection, allergic reactions, and parasitic infection and identifies various stages of

leukemia.

Lymphocytes 0.07

(Decreased)

0.25 -0.40 Infection

Segmenters 0.82

(Increased)

0.45-0.65 infection

08/07/11

Hemoglobin A₁C- A Glycosylated

Hemoglobin

determination is used to

measure a patient’sdiabetic control over a

period of weeks or

months. The maximumperiod for evaluation of

control is the life span of

the red blod cells (120days)

9.2 %

(Increased)

4.5-6.8 % Poorly controlled

Diabetes Mellitus

Glucose- Used to Measure the

Blood Glucose Level

7.72 mmol/L

(Inreased)

4.1-5.9 mmol/L Diabetes Mellitus

08/07/11

URINALYSIS

- Is a physical, chemical & microscopic analysis of the urine

Useful for diagnosing renal disease or Urinary Tract infections and for detecting metabolic disease notrelated to kidneys.

Transparency Turbid Clear to slightly

hazy

Presence of bacteria

in the urine

WBC/hpf Numerous to count 0-5 infection

Bacteria moderate None infection



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8/7/2011

RADIOGRAPHY

CHEST AP- It helps to assess Pulmonary Status and detect Pneumonia, Atelectasis, Pneumothorax, Pulmonary

Bullae, and Tumors.

It helps to determine correct placement of Pulmonary artery catheter, Endotracheal tube, or ChestTube.

Impression:

- Pulmonary congestion

- Atheromatous and tortuous aorta

- Cardiomegaly borderline

8/8/11

Wound discharge gram

stain

- Determine whether awound is infected, and

to identify the bacteria

causing the infection,- method of

differentiating bacteria

of one species into two

large groups (Gram-

positive and Gram-negative)

- Stained smear shows

many gram(+)Cocci insingles in pairs and in

chain; occasional gram

(-) bacilli in singlesPuscells 18-30 / OIF

No growth Bacterial infection

08/10/11

Bacteriology- Is the study of Bacteria. It comprises the identification, classification and characterization of

bacterial species.

Nature of specimen: wound discharge

Organ identified: modified growth of Sphingomonas paucimobilis

Sensitive to: Resistant to:

Amo/ penicillin

Amox/clav

Piperacillin/tazobactamTicarcillin

Ticar/clav

Cefuroxime

MeropenemImipenem

Cortrimoxazole

Netilmicin

Ciprofloxacin

Cefuxitin

Cefepime

TobramycinAmikacin

Getamicin

Ceftazidine

08/11/11

BacteriologyIs the study of Bacteria. It comprises the identification, classification and characterization of bacterial

species.

Specimen: Urine

Organism identified: very light growth of Escherichia coli.

Colony CT: <10,000 CFV’s/ mL Sensitive to: Resistant to:

- Amo/penicillin; tobramycin

- Amox/clav;amikacin

- Piperacillin/tazobactam; gentamicin

- Ticarcillin; netilmicin

- Cotrimoxazole

- Moxifloxacin

- ciprofloxacin



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- Ticar/clav.; ampicillin-sulbactam

- Cefoxitin; ceftriaxone

- Cefepime;cefixime

- Cefuroxime

- Meropenem

Capillary Blood Glucose Monitoring-

Carried out to assess and manage patients with Diabetes mellitus. Provides current data that areused to determine the next dose of insulin or to monitor the patient’s response to diabeticmedications.

-

08/08/11 CBG results Normal Values

- 12:00 pm

- 5:30 am

- 11:30am

- 5:30 pm

- 192mg/dl

- 160mg/dl

- 170 mg/dl

- 193 mg/dl 60-110mg/dl

08/09/11

- 5:30 am

- 5:20pm- 11:30 pm

- 188 mg/dl

- 201mg/dl- 166mg/dl

08/10/11

- 4:00 am

- 8:00 am

- 122mg/dl

- 141mg/dl



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IX. PATHOPHYSIOLOGY

Precipitating Factors:

*Sedentary lifestyle *Frequent infections

Too much sweets intake

Predisposing Factors:

*Family history of DM *Race/ ethnicity

*Age (30 and above ) *Obesity

*Sex

Beta cell exhaustion

Decreased insulin production

Elevated blood glucose levels.

Increased osmolarity

Chronic elevation in blood glucose

Production of glucose from protein and fats

Increased glucagon production

Wasting of lean body mass

Glycoprotein cell wall deposits

Small vessel disease Accelerated atherosclerosis

CAD, HPN, LDL Delayed wound healing,infectiion

Numbness and tingling sensation,wasting of intrinsic muscle, foot

ulceration, dry skin, impotence,

Fatigue, weight

loss

Polydipsia, polyphagia,

polyuria, weight loss

Diabetic neuropathy, diabetic

retinopathy, diabetic nephropathy

Impaired immune function

End- stage renal failure

Other systemic complications which may

eventually lead into DEATH



22

X.



23

MEDICAL

MANAGEMENT

Generic

Name/Brand

Name,

Dose, Route,

Frequency

Action Mechanism of

Action

Indications Contraindications

SideEffects

Adverse Effects Nursing

Responsibilities



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Humulin N

28‖u‖ SQ pre

breakfast

26 ―u‖ SQ pre

supper

Antidiabetic,hormone

Insulin is ahormone

secreted bybeta cells of

the pancreasthat, by

receptor-mediated

effects,promotes the

storage of the

body fuels,

facilitating thetransport of

metabolites&ions

(potassium)through cell

membranes &stimulating

the synthesisof glycogen

from glucose,of fats from

lipids, &

proteins fromamino acids.

- Treatment of type 2

diabetesmellitus that

cannot becontrolled by

diet or oraldrugs.

Contraindicated topatient with

hypoglycemia, IVadministration,

Hyperglycemic coma

Rash, redness,swelling,

itching.

Decline inpulmonary function,

angioedema

1. Alternate injection

sites regularly to

prevent breakdown

at injection sites2. Ensure uniform

dispersion of insulin suspensions

by rolling the vialgently between;

hands, avoidvigorous shaking.

3. Store drug in the

refrigerator or in a

cool place out of direct sunlight; do

not freeze insulin.4. Monitor urine or

blood levels forglucose and

ketones.5. Report fever, sore

throat, andvomiting,

hypoglycemic orhyperglycemic

reactions, rash.

Prior to:

Wash hands

thoroughly

Ask the patient’sname

Always observe

aseptic technique

During:



25

Explain the

procedure to the

patient/SO

Explain what is thegeneral action of

the drug to thebody

After:

Record the drug

after itsadministration

(charting) Observe

the patient for

possible untowardreaction.

Janumet 50/ 120

OD pre lunch

Antidiabetic Exactmechanism is

notunderstood;

Adjunct todiet to lower

blood glucosewith type 2

Contraindicated withallergy to metformin.

Nausea,vomiting,

diarrhea,allergic skin

Lactic acidosis 1. Give drugbefore lunch.

2. Monitor urineand serum



26

possibly

increasesperipheral

utilization of glucose,

decreaseshepatic

glucoseproduction, &

altersintestinal

absorption of glucose.

diabetes

mellitus.

As part of

combinationtherapy with a

sulfonylureaor insulin

when eitherdrug alone

cannot controlglucose levels

in patientswith type 2

diabetesmellitus.

reactions. glucose level to

determineeffectiveness of

drug.3. Report fever,

sore throat,unusual

bleeding orbruising, rash,

dark urine,light-colored

stools,hypoglycemic

orhyperglycemic

reactions.4. Encourage

patient not tostop taking this

drug withoutconsulting

healthcareprovider.

Prior to:

Wash hands

thoroughly


Always observe

aseptic techniqueDuring:

Explain the

procedure to the

patient/SO



27

Explain what is the

general action of the drug to the

bodyAfter:

Record the drugafter its

administration(charting) Observe

the patient forpossible untoward

reaction.

Metformin 500mg

1tab BID A.C.

lunch, supper.

Antidiabetic Exactmechanism is

not understood;possiblyincreases

Adjunct to diet

to lower blood

glucose withtype 2 diabetesmellitus in

Contraindicated withallergy to metformin; heart

failure, diabetescomplicated by fever,severe infections, severe

nausea,vomiting

diarrhea,flatulence.

Hypoglycemia,

Anorexia, lactic

acidosis.

1. Instruct patient toswallow drug whole,

do not cut, chew or

crush.2. Encourage the

patient to do not



28

peripheral

utilization of glucose,

decreaseshepatic glucoseproduction, andalters intestinalabsorption of

glucose.

patients 10 yr

and older, ERin patients 17

yr and older.

trauma, major surgery. discontinue this

medication withoutconsulting health

care provider.3. Monitor blood or

urine for glucose andketones.

4. Report severe fever,

sore throat, unusualbleeding or bruising,rash, dark urine.

Prior to: Wash hands

thoroughly

Ask the patient’sname Always observe

aseptic technique

During:

Explain theprocedure to thepatient/SO

Explain what is the

general action of the

drug to the bodyAfter:

Record the drug afterits administration(charting) Observethe patient forpossible untoward

reaction.

Piperacilin +tazobactam

(Tazocin)

Antiibiotic Bactericidalinhibits

synthesis of

cell wall of sensitive

Severeinfections

caused by

sensitiveorganisms

Contraindicated withallergies to penicilins,

cephalosporins or other

allergens.

Sore mouth,nausea,

vomiting,

diarrhea, rash,fever.

Seizuresthrombocytopenia,

leucopenia,

nephritis.

1. Monitor serumelectrolytes and

Cardiac

status(B/P,CR andcardiac output).



29

2.25gms. IVTT

Q8h ANST

organisms,

causing celldeath.

(streptococci).

Prophylaxisof rheumatic

fever &chorea.

2. Inform patient that

she may experiencethese side effects:

Nausea, vomiting,diarrhea, mouth

sores, pain atinjection sites.

3. Report difficulty of breathing rashes,

sever diarrhea,severe pain at

injection site,mouth sores,

unusual bleeding orbruising.

4. Check IV sitescarfully for signs of

thrombosis or localdrug reaction.

Prior to:

Wash hands

thoroughly

Ask the patient’s

name

Always observe

aseptic technique

During:

Explain theprocedure to the

patient/SO

Explain what is thegeneral action of the drug to the

body

After:



30

Record the drug


(charting) Observethe patients for

possible untowardreaction.

Coamoxiclav

(Augmentin )

1gm/tab. 1 tab.

Antibiotic Inhibitstranspepti-dase ,

preventingcross-linking

skin at skinstructureinfections, &

urinary tractinfections

Hypersensitivity todrug or anypenicillin.

Phenylketonuria(some products)

nausea,vomiting,diarrhea,

abdominalpain,

seizures, intestinalnephritis.

1. Give w/ or withoutfood.

2. Monitor patient

carefully for sign &symptoms of



31

BID of bacterial

cell wall &leading to cell

death.Addition of

clavulanate (abeta-lactam)

increasesdrug’s

resistance tobeta-

lactamase ( anenzyme

produced bybacteria that

mayinactivate

amoxicillin).

(UTI’s)

caused bysusceptible

strains of gram (-) &

gram (+)organisms.

Histoy of cholestatic

jaundice or hepatic

dysfunction

associated with thisdrug.

wheezing,

rash.

hypersensitivity

reaction.3. Check patients

temp. & watch forother signs &

symptoms of superinfection,

especially oral orrectal candidiasis.

4. Instruct patient toimmediately report

signs & symptoms

of hypersensitivity

reaction, such asrash, fever or chills.

Prior to:

Wash handsthoroughly

Ask the patient’s

name

Always observeaseptic technique

During:

Explain the

procedure to the

patient/SO


the drug to the

bodyAfter:

Record the drug

after its

administration



32

(charting) Observe

the patient for

possible untoward

reaction.

Clindamycin

300mg IVTTANST Q6hrs

antibiotic Inhibits

proteinsynthesis insusceptible

bacteria,causing cell

Treatment of

septicemiacaused bystaphylococci,

streptococci;acute

Contraindicated with

allergy toclindamycin.

Headache,

dryness,urinaryfrequency,

nausea,vomiting.

Hypotension,

cardiac arrest,

severe colitis,

thrombophle-bitis.

1. Storereconstitutedproduct at room

temperature.2. Do not



33

death. hematogenous

osteomyelitis;adjunct to

surgicaltreatment of

chronic boneand joint

infections dueto susceptible

organisms.

refrigerate

reconstitutedsolution.

Remember thatreconstituted

solution isstable for too

weeks at roomtemperature.

3. Do notadminister

1,200mg I asingle 1hr

infusion.4. Do not mix

with calciumgluconate,ampi

cillin,phenytoin, barituates,

amiphylline anmagnesium

sulphate.

Prior to:

Wash hands

thoroughly


Always observe

aseptic techniqueDuring:

Explain the

procedure to the

patient/SO



34

Explain what is the

general action of the drug to the

bodyAfter:

Record the drugafter its



reaction.

Algesia1tab Q6h x 2days

Analgesic Binds to mu-opioidreceptors &

inhibits thereuptake of

Relief of moderate tomoderately

severe pain.

Contraindicated withallergy to tramadolor opioids or acute

intoxication withalcohol, opioids, or

Dizziness,headache,confusion,

sweating, rash,nausea,

Hypotension,seizures.

1. Inform patientthat she mayexperience

these sideeffects:



35

norepinephrin

e & serotonin;causes many

effects similarto the opioids-

dizziness,somnolence,

nausea,constipation-

but does nothave the

respiratory

depressant

effects.

psychoactive drugs. vomiting, dry

mouth.

Dizziness,

sedation,drowsiness,

impaired visualacuity.

2. Report severenausea,

dizziness,severe

constipation.3. Obtain history

of hypersensitivity

to tramadolbefore starting

drug therapy.4. Control

environmentalfactors like

temperature andlighting if

sweating or

CNS effects

occur.

Prior to:


Ask the patient’s

name


During:

Explain the

procedure to the



36

patient/SO

Explain what is the

general action of

the drug to thebody

After:

Record the drug


(charting) Observethe patients for

possible untoward

reaction.

Cilostazol

(Pletaal)

100mg./tab. 1

Antiplatelet Reversiblyinhibitsplatelet

aggregationinduced by a

Reduction of symptoms of intermittent

claudicationallowing

Contraindicated withallergy to cilostazol,heart failure of any

severity (decreasedsurvival rates have

Dizziness,headache,diarrhea,

nausea, cough,back pain.

Heart failure,rhinitis.

1. Take drug onan emptystomach at least

30min. beforeor 2hrs. After



37

tab BID variety of

stimuliincluding

ADP,thrombin,

collagen,shear stress,

epinephrine,& arachidonic

acid byinhibiting

cAMPphosphodieste

rase III;produces

vasculardilation in

vascular bedswith a

specificity forfemoral beds;

seems to haveno effect on

renal arteries.

increased

walkingdistance

occurred), active

bleeding hemostaticdisorders.

breakfast &

dinner.2. Encourage

patient not todrink grapefruit

juice whiletaking this drug

3. Report fever,chills, sore

throat,palpitations,

chest pain,edema or

swelling,difficulty of

breathing, andfatigue.

Prior to:


Ask the patient’s

name


During:

Explain theprocedure to thepatient/SO

Explain what is the

general action of the drug to thebody

After:

Record the drug



38

after its



reaction.

Losartan K

(lifezar) 100mg½ tab OD ACbreakfast

Antihypertensive

ARB

Selectively blocks

the binding of angiotensin II tospecific tissue

receptors found inthe vascular

Treatment of hypertension,alone or in

combination withother

Contraindicated withhypersensitivity tolosartan, use cautiously

with hepatic or renalimpairment,

Headache,dizziness,insomnia,

abdominalpain.

Hypotension,

urticaria, pruritus,

alopecia.

1. Give this drugwithout regards tomeals.

2. Encourge patientnot to stop taking



39

smooth muscle

and adrenalgland; this action

blocks thevasoconstriction

effect of therenin-angiotensin

system as well asthe release of

aldosteroneleading to

decreased BP.

antihypertensives.

Treatment of

diabeticnephropathy with

an elevated serumcreatinine and

protein-urea inpatients with type

2 diabetes.

hypovolemia. this drug without

consulting her

health care

provider.3. Monitor patient

closely in anysituation that may

lead to a decreasein BP .

4. Report fever, chills,and dizziness.

Prior to: Wash hands

thoroughly

Ask the patient’s

name

Always observe

aseptic technique

During:

Explain the

procedure to thepatient/SO

Explain what is the

general action of the drug to thebody

After: Record the drug

after its

administration

(charting) Observe



40

the patient for

possible untoward

reaction.

Sodium Citrate(Ural)1 sachet in ½

glass of H2OTID

Urinary alkaliniser Increases theexcretion of free base in

the urine.

Treatment of UTI,symptomatic

relief of dysuria.

Contraindicatedtobpatient withallergy to coponents

of preparations; lowserum chloride,

Weakness,nausea,irritability.

GI rupture, systemic

alkalosis, tissue

necrosis.

1. Give drug with orwithout food.

2. Dissolve 1 Sachetin Cold water



41

hypocalcemia

Use cautiously withimpaired renal

function, HeartFailure, sodium

retaining states.

3. Do not give within1-2 hours of other

oral drugs to reducerisks of drug

interactions.Prior to:


Ask the patient’s

name


During: Explain the



the drug to thebody

After:

Record the drug


(charting) Observe

the patient forpossible untowardreaction.

Orovas 2omg1tab HS

Antihyperlipi-demic

InhibitsHMG-CoAreductase, the

enzyme thatcatalyzes the

Adjunct todiet in thetreatment of

elevatedcholesterol

Liver disease orunexplainedpersistent rise of

serumtransaminases.

Abdominaldiscomfort,headache,

dyspepsia, dizziness, muscle

Fatigue, rash,

myopathy,

asthenia,myalgia,

pancreatitis

1. Give drug beforebedtime.

2. Encourage patient

not to drink grapefruit juices



42

first step in

thecholesterol

synthesispathway,

resulting in adecrease in

serumcholesterol,

serum LDLs,and either an

increase or nochange in

serum HDLs.

and LDL

cholesterolwith primary

hypercholesterolemia in

thoseunresponsive

to dietaryrestriction of

saturated fatand

cholesteroland other non-

pharmacologic measures.

Pregnancy &

lactation.

cramps,

vomiting.

while taking this

drug.

3. Encourage patient

to have a periodicblood tests.

4. Inform patient thatshe may experience

these side effets:nausea,headache,

muscle and jointaches and pain.

Prior to:


Ask the patient’s

name


During:

Explain the

procedure to the

patient/SO

Explain what is the

general action of

the drug to thebody.

After: Record the drug

after its

administration

(charting) Observe



43

the patient for

possible untoward

reaction.

Vigor ACE 1tabOD after lunch

Vitamins andMinerals

Vigor-ACEprovides thesynergistic

actions of protective

Nutritionalsupplement tosupport active

functioning inadults & to

No knowncontraindications

nausea,increasedsalivation,

diarrhea, nausea

Hepatitis, anorexia,

pharyngitis, urinary

tract infection.

1. Administer drugafter meals to

reduce GIdisturbance.



44

biologic

antioxidants:Vitamins C and

E, and selenium.Vitamin E

protects the cellmembranes

against damageby preventing the

formation of lipidhydroperoxides.

Vitamin C andthe selenium-

containingenzyme,

glutathioneperoxidase,

inactivate theseoxidizing agents,

thus maintainingthe integrity and

stability of thecell membrane

structures.

help restore

vitality inaging &

convalescingpatients.

2. Stress importance

the Vitaminsupplement

3. Teach patient abouthealthy dietary

habits. Prior to:


Ask the patient’s

name


During: Explain the



the drug to thebody

After:

Record the drug


(charting) Observe

the patients for possible untowardreaction.



45

XI. Concept Map



46

Chief ComplaintAbscess at left subcostal margin

DiagnosisAbscess at Left subcostal area S/P: I

& D, Hypertension Stage 1, DiabetesMellitus Type 2 – Insulin requiring,

Mixed Dyslipidemia

DIAGNOSIS

Infection related to invasion of pathogens.

OBJECTIVE

Abscess at left subcostal marginapproximately 3cm in diameter, withexudative drainage and foul odor.

Erythema and warm skin around the

abscessLaboratory results:

Urinalysis (8-7-11)Transparency-turbidWBC/hpf- numerous to countBacteria- moderate

Hematology:

WBC – 12.2 x10ˆ9/L Platelet - 516 x10ˆ9/L Segmenters - 0.82Lymphocytes-0.07

Bacteriology

Specimen:

Wound discharge – moderategrowth of Sphingomonas

paucimobilisUrine - very light growth of

Escherichia coli

DIAGNOSIS :

Imbalanced nutrition; more than body requirementsrelated to excessive food intake

SUBJECTIVE:

― Namian gid ako magkinaon pirme kagdamu guid ko pakan-on labi na guid kung mag

kuyam-kuyam‖.

OBJECTIVE

Accumulated fatty tissues on triceps, abdomen,buttocks, back, and other parts of the body.

Height:63 inches Weight:205.03 lbs

BMI:36.42 (Obese ) Laboratory results:

CBG results:

08/09/11:

5:30 am - 188 mg/dl5:20pm - 201mg/dl11:30 pm - 166mg/dl

DIAGNOSIS:

Acute pain related to surgical incision

SUBJECTIVE:

― Masakit akon kilid sa maysamad dampit.‖

OBJECTIVE:

Grimacing face

Guarding/protecting incision site

BP – 140/100mmHg

Pain scale of 7 out of 10

S/P : Incision & Drainage

DIAGNOSIS:

Impaired skin integrity related toaccumulation of drainage secondary toabscess.

SUBJECTIVE:―Makatol ang akon samad pati sa palibot sini‖.

OBJECTIVE

Abscess at left subcostal marginapproximately 3cm in diameter, with

exudative drainage.

Erythema and warm skin around the

abscess Soaked dressing with foul odor.

Laboratory results:

Hematology:

WBC -12.2 x10ˆ9/L

CBG results:

08/09/11:5:30 am - 188 mg/dl5:20pm - 201mg/dl11:30 pm - 166mg/dl

DIAGNOSIS:

Risk for injury related to abnormal blood

profile. SUBJECTIVE:

― kung masamadan ko dugay gid mag ayo‖.

OBJECTIVE:

Laboratory results:

CBG results:

08/09/11:5:30 am - 188 mg/dl

5:20pm - 201mg/dl11:30 pm - 166mg/dl

Hematology:

WBC - 12.2 x10ˆ9/L

12

4

53



47

XII. Nursing Management

Assessment Diagnosis Planning Intervention Rationale Evaluation



48

Objective:

Abscess at left subcostal margin

approximately 3cm in diameter, with

exudative drainage and foul odor.

Erythema and warm skin around

the abscess

Laboratory results:

Urinalysis (8-7-11)

Transparency-turbid

WBC/hpf-

numerous to countBacteria- moderate

Hematology

WBC – 12.2 x10ˆ9/L Platelet - 516 x10ˆ9/L

Segmenters - 0.82

Lymphocytes-0.07

Bacteriology

Specimen:

Wound discharge – moderate

growth of Sphingomonas

paucimobilis

Urine - very light growth of Escherichia coli

Infection related toinvasion of pathogens.

At the end of thehospital stay, patient

will be free fromfurther infections asevidenced by timelywound healing and

normal urinalysisresults.

Independent:

Informed the

importance of proper

hand washing

Ensured steriletechnique duringdressing change.

Encouraged to increaseoral fluid intake.

Emphasized theimportance of

performing of good

personal hygiene daily

in the genital area.

Dependent:

Administered:

To reduce risk of

cross contamination.

Proper techniqueprevents crosscontamination andthe introduction of additional organism

into the wound.

Decreasessusceptibility to

infection. Increasedurinary flow

prevents stasis and

aids in maintainingurine pH- acidity,reducing bacteriagrowth and flushing

organisms out o the

system.

Good personalhygiene reduces

number of pathogens in the

body.

Goal partially met. As

evidenced by:

Absence of

necrotic cells and

pus in the wound.

With clean and

dry dressing.

Repeat urinalysis

revealed (8-10-11)

Transparency –

hazy

WBC – 5-10/hpf Bacteria – (-)



49

Piperacilin +

tazobactam (Tazocin) 2.25gms. Q8h ANST

Clindamycin 300mgIVTT ANST Q6hrs.

Vigor ACE 1 tab ODafter lunch

Incision and drainage

done by A.P. in the OR

Antibiotic treatment

is the primary

therapy and kills

susceptible bacteria.

Adequate nutritionenhances cellularhealing.

To remove necroticcells and pus whichwill facilitate inwound healing.

Subjective :

― Masakit akon kilid sa may

Acute pain related tosurgical incision

To alleviate pain fromthe pain scale of 7

down to 4 after 30

Independent:

Provided comfortmeasures like To promote

Goal met. As evidencedby reduction of pain

form the pain scale of 7



50

samad dampit.‖

Objective :

Grimacing face

Guarding/protecting incision site

BP – 140/100mmHg

Pain scale of 7 out of 10

S/P : Incision & Drainage

minutes of nursinginterventions.

repositioning andprovided quietenvironment.

Encouraged use of relaxation techniquessuch as deep breathingexercises.

Encouraged adequaterest periods.

Reminded to splintarea with pillow when

moving or coughing.

Dependent:Administered:

Algesia 120mg/tab 1

nonpharmacologicalpain management.

To distract attention,relieves muscle andemotional tension;enhances sense of control and mayimprove copingabilities.

To prevent fatigue.

Equalizes pressureon the woundminimizing pain.

To relieve pain.

down to 4, absence of grimacing face.



51

tab Q6hrs. x 2 days PO

Piperacilin +tazobactam

(Tazocin) 2.25gms. Q8h IVTT

ANST

Clindamycin 300mg

IVTT ANST Q6hrs.

To kill susceptible

bacteria thus help inminimizing pain.



52

Subjective :

“Makatol ang akon samad pati sa palibot sini‖.

Objective:

Abscess at left subcostal margin

approximately 3cm in diameter,

with exudative drainage.

Erythema and warm skin aroundthe abscess

Soaked dressing with foul odor.

Laboratory results:

Hematology:

WBC -12.2 x10ˆ9/L

CBG results:

08/09/11:

5:30 am - 188 mg/dl

5:20pm - 201mg/dl

11:30 pm - 166mg/dl

Impaired skin

integrity related to

accumulation of drainage secondary to

abscess.

At the end of theshift, will verbalize

decrease indiscomfort.

Independent:

Assisted in wounddressing.

Removed soiled/wet

linens promptly, andkept wound dressing

clean and dry.

Instructed client notto touch the affectedsite.

Encouraged earlyambulation/ Mobilization.

Repositioned client,involving her in theintervention.

To protect thewound and for

faster wound

healing.

Moisture

potentiates skinbreakdown

Preventscontamination

Promotescirculation and

reduces risksassociated with

immobility.

To enhanceunderstanding and

cooperation.

Goal met. Asevidenced by

verbalization of:―Nag hagan – hagan

na ang katol kag dawok na siya‖.



53

Dependent:

Administered:


Piperacilin +

tazobactam (Tazocin)

2.25gms. Q8h ANST

Clindamycin 300mg

IVTT ANST Q6hrs.

To aid inskin/tissue healing

and to maintain

general goodhealth

To kill susceptible

bacteria that aids inskin breakdown..



54

Subjective:

― Namian gid ako magkinaon pirme kagdamu guid ko pakan-on labi na guid kungmag kuyam-kuyam‖.

Objective:

Accumulated fatty tissues on

triceps, abdomen, buttocks, back,

and other parts of the body.

Height:63 inches

Weight:205.03 lbs

BMI:36.42 (Obese )

Laboratory results:

CBG results:

08/09/11:

5:30 am - 188 mg/dl

5:20pm - 201mg/dl

11:30 pm - 166mg/dl

Imbalanced nutrition;more than body

requirements relatedto excessive food

intake

At the end of the shift, willverbalize future plansto control food intake.

Independent:

Stressed need for

adequate fluid intakeand taking fluidsbetween meals ratherthan with meals.

Encouraged to eat

smart snacks like in

season fruit slicesinstead of soft drinks,chocolates and cake.

Emphasized theimportance of avoidfad diets.

Discussed need to give

self permission toinclude desired/craved

food items in dietaryplan.

To meet fluid

requirements andreduce possibility of early satietyresulting in feelingsof hunger.

To assist client in

finding healthy

options.

Elimination of needed componentscan lead tometabolicimbalances.

Denying self by

excluding desired orfavourite foods

results in a sense of deprivation andfeelings of guilt/ failure whenindividual

―succumbs totemptation‖. Thesefeelings cansabotage weightloss.

Goal met. As evidencedby verbalization of:

―ma dieta na ko, maskimaka guwa na ko dirikay kabudlay gid kungdaku-dako ako ah‖.



55

Emphasized theimportance of avoidingtension at meal timesand not eating tooquickly.

Dependent:

Administered:


Reducing tensionprovides a morerelax eatingatmosphere andencourages moreleisurely eatingpatterns. This isimportant because aperiod of time isrequired for theappestat mechanism

to know the stomachis full.

Obese individualshave largefuelreerves but areoften deficient invitamins andminerals.



56

Subjective:

― kung masamadan ko dugay gid magayo‖.

Objective:

Laboratory results:

CBG results:08/09/11:

5:30 am - 188 mg/dl 5:20pm - 201mg/dl

11:30 pm - 166mg/dl

Hematology:

WBC -12.2 x10ˆ9/L

Risk for injury related

to abnormal bloodprofile.

At the end of the shiftwill verbalizeunderstanding of individual factors thatmay contribute to thepossibility of injury.

Independent:

Informed to use wellfitted shoes or slippers,and to cut nailsregularly takingprecautions not to

injure/ cut thesurrounding skin.

Instructed to maintaina safe environment in

their house by keeping

sharp objects in a safe

place.

Informed to avoid very

strenuous activities.

Dependent:

Humulin N 28‖u‖

SQ pre breakfast26 ―u‖ SQ pre supper

To avoid skinbreakdown

To promote safephysical

environment

and individualsafety.

Strenuous

exercise oractivities maylead to bruising

thus potentiates

easy skinbreakdown.

To help in

lowering blood

glucose.

Goal met. As evidenceby verbalization of ― Mahalong nagid ko samga ginaubra ko para

hindi ko masamarandali- dali‖.



57

XIII. DISCHARGE PLANNING

Medication Medications prescribed by the attending physician should be followed at the right time,

right dosage and inform patient a on the importance of continuing the medications.

Instruct patient to take the following drugs at home following the timing, and dosage.

Humulin N 28 ―U‖ before breakfast

Humulin N 24 ―U‖ before supper

Celostazol (Pletaal)10 mg two times a day

Losartan (Lifezar) 100 mg ½ tab before breakfast

Metformin 500 mg/tab 1 tab 2x a day after breakfast, after supper

Janumet 50/500 mg 1 tab after lunch

Simvastatin 20 mg/tab 1 tab at bedtime

Exercise and Activity Encourage patient to engage herself in performing daily exercises like walking briskly

early in the morning outside their house.

Light stretching

•lexing 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.

Treatment

Instruct to maintain a clean home environment conducive to rest and relaxation. Instruct her to take medications as indicated. Notify physician for any adverse reaction.

Instruct to seek medical assistance from a medical provider whenever she experiences

any signs and symptoms.



58

Health TeachingEmphasize the importance of clean environment for her fast recovery.

Encourage to strictly adhere to medical regimen to ensure good recovery from her

present condition.Instruct to avoid sharp objects or any activity that can cause cuts or any skin trauma.

Remind the importance of correct proper hand washing and to give extra attention to

her personal hygiene.

Out-patient Follow-upStress to follow the scheduled follow- up appointments by her attending physician in

order to assess her improvement and to modify treatment if ever.

Stress the importance and remind about follow-up check-ups on the 17th

and on the

19th

of August.

Diet Encourage to have a regular meal and serve nutritious foods like green leafy

vegetable, fruits, and fish.

Encourage to avoid junk food and sweet delicacies.

Encourage to follow the low salt, low fat, diabetic diet prescribed by her attending

physicians.

Encourage to eat high fiber foods.

Teach patient to read labels of "health" foods because they contain sugar product such

as honey, brown sugar and corn syrup.

SpiritualityEncourage to submit herself into a Confession and receive the Holy Communion when

attending mass.



59

XIV. Our Journey

Nursing encompasses an art, a humanistic orientation, a feeling for the value of the

individual and intuitive sense of ethics and of the appropriateness of action taken. Nurses

dispense comfort, compassion, and caring without even a prescription. There will always be

learning in everyday of our life and in every step we take, and as a student nurse learning is an

important factor in order to be competent and best health care provider.

Being student nurses is never easy, we all need to balance everything; studies, duties,

family, God and especially you need to give time to yourself. Sometimes, we almost want to give

up and stop, but we always come to realize that we should always keep on moving forward. Not

just because we need to but it is because we really want to. We’ve been through a lot of tough

times and our sacrifices are countless. But with our every downfall, we stand up and face every

new challenge that is waiting for us.

Our every experience in our duty days was priceless. The learning we have gained was

the most precious thing we have earned in our every duty days. We’ve experienced different

consequences in our duties, we’ve been exposed to different people and di fferent procedures. We

also got a chance to handle different cases in the ward and in every case, there is learning.

We’ve been to different wards, we’ve been under different Clinical Instructors, we’ve

been through different paths, but yet our group stands as one. We are different people who are

stuck in these group but yet strangers became friends, friends became family.

In our journey, the end is not the most important, it is the journey itself. And throughout

our journey we are happy to have each other as our team mates. And we are proud to say that we

played our game right and it is not winning we aim, but it is the learning.

This is not the end of our journey; this is just the part of it. So we choose to make it

meaningful, we choose to make it worth our sacrifices.



XV.References

Nurse’s Manual of Laboratory Tests and Diagnostic Procedures. Louise Malarkey, EllenMcMorrow. 1st Edition. WB Saunders Company. 1996.

Nursing Guide to Laboratory and Diagnostic Tests. Louise Malarkey. Elsevier, Inc. 2005

Laboratory and Diagnostic Tests Handbook. M. K. Gaedele. Addison- Wesley Publishing

Company, Inc.1996.

Pathophysiology Concepts of Altered Health States. Carol Watson-Porth. &th Edition.

Lipincott- Williams and Wilkins.

Straight A’s in Pathophysiology. Lippincott- Williams and Wilkins. 2006.

Textbook on Medical- Surgical Nursing. Suzanne C.Smeltzer. 11th

Edition. Lipincott-

Williams and Wilkins. 2008.

Nursing: Understanding Diseases. Lippincott- Williams and Wilkins. 2008.

Mosby’s Pocket Dictionary of Medicine, Nursing, and Health Professions. 5th

Edition.2006.

www.mims.com

MIMS Philippines. 125th Edition. 2010.

2010 Lippincott’s Nursing Drug Guide. Lipincott- Williams and Wilkins. 2010.

Essentials of Anatomy and Physiology. Stephens Seeley. McGraw- Hill Companies, Inc.

2007.

Fluids and electrolytes made Incredibly Easy. Lipincott- Williams and Wilkins. 2005.

Brunner and Suddarth’s Textbook of Medical- Surgical Nursing. Suzanne C. Smeltzer, etal.12th Edition. Lipincott- Williams and Wilkins. 2010.

www.wikipedia.com

Mims. Com – Philippines 119th Edtion. 2009

Nursing Care Plans ( Nursing Diagnosis and Intervention).6th

Editiion. Meg Gulanick.

M b El i 2007

http://www.mims.com/

http://www.mims.com/

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