Introduction Overview of the Case Diabetes is a disease in which the body does not produce or properly use insulin.

Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles. There are 18.2 million people in the United States, or 6.3% of the population, who have diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2 million people (or nearly one-third) are unaware that they have the disease. The primary goals of treatment for patients with diabetes include controlling blood glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for diabetic patients must assist them to develop self-care management skills. I chose the case for my case study. I have taken care of him for 2 consecutive days. Lets find out more about Diabetes Mellitus! My patient specifically has Type 2 (NonInsulin Dependent Diabetes Mellitus) I hope you will learn many things through my case study. Objective of the Study

This study is directed towards understanding the condition of the chosen client as a part of the students learning about the abnormalities related to the resistant to the effects of insulin and glucose. Moreover, this study will also enhance students knowledge on this particular case and perform nursing interventions efficiently according to identified priority problems that weve observed during my two days exposure in caring the client. Lastly, this case study will supplement the students learning to value what was really the essence of performing a holistic care towards the client from the time she was admitted, up to the time that she will be discharged from the hospital.

Scope and Limitation of the Study The extent of study includes only to the information being gathered from the patient and the patients personal chart. It also deals with the several factors observed during our assessment with the client. The information gathered was based on the manifestations and complaints of the patient observed and the exact answers of the patients significant others. Interventions were rendered gradually depending on the objective assessment weve had gathered during our two days (16 hours) of clinical duty. The limitation of the study includes the place of interaction itself which was in Sabal General Hospital Incorporation, General Ward. The study was completed altogether by both research and actual hands-on exposure and interaction with the client during the two days (16 hours) of clinical duty, last April 24 to 25, 2010.

Health History Profile of Patient Name Age Address Birth date Occupation store Birthplace Sex Religion Nationality Allergies : : : : : Cagayan de Oro City Female Roman Catholic Filipino April 23, 2010 9:18 am : : : : : : : 37.9oC 80 bpm 20cpm 180/100 mmHg 61 kg 158 cm : Civil Status : : : : : Mrs. X 41 years old Married July 2, 1948 managing a small business sari-sari

Corrales Ext., Brgy. 21 Cagayan de Oro City

No known food and drug allergies

Date Admitted : Time Admitted :

Baseline Vital Signs upon Admission Temperature Heart Rate Respiratory Rate Blood Pressure Weight Height Chief Complaint extremities Diagnosis Physician : Diabetes Mellitus type 2 : Dr. Daitia

Weak of upper and lower

Family and Personal health history Patient Mrs. X was the third child of Mr. & Mrs .B . She was being delivered through normal spontaneous vaginal delivery (NSVD) on a health center and a fully immunized individual. She had no known food and drug allergies. During the process of interaction the patient opened up that this kind of disease run in the family, in both in the maternal and paternal side. History of Present Illness Before the patient was admitted at Sabal hospital, patient Mr. X was admitted at Northern Mindanao Medical Center due to lightheadedness and body weakness. She was advised by the physician to take rest at their home. She was diagnosed to have a Diabetes Millitus and advised to have good diet. A few days prior to admission, patient Mrs. X suffered lightheadedness, headache and body weakness and took her maintenance medicines, Metformen and Captopril but no relief. A day prior to admission she had experienced weakness of upper and lower extremities and prompted admission at Sabal Hospital Incorporation. Chief Complaint Patient Mrs. X 41 years old Filipino patient and a Roman Catholic, who was currently residing at Corrales Ext., Brgy. 21 Cagayan de Oro City, Misamis Oriental was brought to Sabal Hospital at station 2, last April 23 2010 at 9:18 oclock in the morning due to weakness of upper and lower extremities.

Developmental data The middle years from 40 to 65, have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or are moving away from home. Thus partners generally have more time for and with each other and time to pursue interests that they may have deferred for years. A number of changes take place during the middle years. At 40, most adults can function as effectively as they did in their 20s. However during ages 40 to 65 many physical changes take place. SIGMUND FREUDS FIVE STAGES OF PSYCHOSEXUAL DEVELOPMENT Genital Stage (12 years and above) Based on the age bracket presented by Sigmund Freud on his psychosexual theory, my patient belongs on this stage wherein we had observed that energy is directed already toward full sexual maturity and function and development of skills needed to cope with the environment. This implies the encouragement of separation already from the parents, achievement of independence, and decision making by her self. We were able to observe these implications to our patient making us to decide also that patient Mrs.X really belongs to the genital stage of psychosexual development. 5

ERIK ERIKSONS STAGES OF PSYCHOSOCIAL DEVELOPMENT Adulthood (25 65 years of age - Generativity versus Stagnation My patient belongs to an adulthood level since her age fits within the age bracket set by Erik Erikson on his psychosocial theory. On this stage the indicators of positive resolution are creativity, productivity, and concern for others; wherein I am able to observe this in my client. The negative resolutions are characterized as self-indulgence, selfconcern, and lack of interests and commitments. Erik Erikson views the developmental choice of the middle aged adult as generativity versus stagnation. Generativity is defined as the concern for establishing and guiding the next generation. In other words, the concern about providing for the welfare of humankind is equal to the concern of providing for self. People in their 20s and 30s tend to be self and family- centered. In middle age, the self seems more altruistic, and concepts of service to others and love and compassion gain prominence. These concepts motivate charitable and altruistic actions, such as church work, social work and political work, community fund-raising drives, and cultural endeavors. Marriage partners have more time for companionship and recreation, thus marriage can be more satisfying in the middle years of life. Partners have time to work together in volunteer activities, and time for one partner to go out for lunch and for the other to go camping or fishing. Generative middle-aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors. JEAN PIAGETS STAGES OF COGNITIVE DEVELOPMENT Formal Operational Thought Stage (12 years old and above) Patient Mrs. X was on the stage of Formal Operational Thought stage due to the fact that she was already 61 years old, and above 12

years old is being considered to have already a formal operational thought, according to Piaget. On this stage, the middle-aged adults cognitive and intellectual abilities change very little. Cognitive processes include reaction time, memory, perception, learning, problem solving and creativity. Reaction time during the middle years stays much the same or diminishes during the later part of the middle years. Memory and problem solving are maintained through middle adulthood. Learning continues and can be enhanced by increased motivation at this time in life. Middle-aged adults are able to carry out all the strategies described in Piagets phase of formal operations. Some may use post formal operations strategies to assist them in understanding the contraindications that exist in both personal and physical aspects of reality. The experiences of the professional, social, and personal life of middle-aged persons will be reflected in their cognitive performance. Thus approaches to problems solving and task completion will vary considerably in a middle aged group. The middle aged adult can reflect on the past and current experience and can imagine, anticipate, plan and hope. LAWRENCE KOHLBERGS STAGES OF MORAL DEVELOPMENT Middle Age (40 to 65 years old) Post conventional Level (Level 5: Social Contract Legalistic Orientation) Patient Mrs. X belongs to Post Conventional Level on Moral development since her age is within the age bracket. On this stage the person lives autonomously and defines moral values and principles that are distinct from personal identification with group values. She lives according to principles that are universally agreed on and that the person considers appropriate for life. On this stage also the social rules are not the sole basis for decisions and behavior because the person

believes a higher moral principle applies such as equality, justice or due process. According to Kohlberg, the adult can move beyond the conventional level to the post conventional level. Kohlberg believes that extensive experience or personal moral choice and responsibility is required before people can reach the post conventional level. Kohlberg found out that few of his subjects achieved the highest level of moral reasoning. To move from stage 4, a law and order orientation, to stage 5, a social contract orientation, requires that the individual move to a stage in which rights of others takes precedence. People in stage 5 take steps to support anothers rights. ROBERT HAVIGHURSTS DEVELOPMENTAL TASKS THEORY Middle Age (25 to 65 years old) Patient Mrs. X belongs to this level of task development based on the theory anchored by Robert Havighurst. Each developmental task provides a framework that the nurse can use to evaluate a persons general accomplishments. A developmental task is a task which arises at or about a certain period in the life of an individual, successful achievement of which leads to happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks. Middle aged individual, just like patient Mrs. X, will possess the following developmental task: a. achieving adult civic and social responsibility b. establishing and maintaining an economic standard of living c. Assisting teenage children to become responsible and happy adults d. Developing adult leisure time activities e. Relating oneself to ones spouse as a person 8

f. Accepting and adjusting to the physiologic changes of middle age g. Adjusting to aging parents

Medical Management Medical Orders and Rationale DATE April 23, 2010 DOCTORS ORDER Pls. admit under the service of Dr. Daitia Secure consent Vital signs every 4 hours Start IVF with PNSS 1 liter at 20 gtts/min RATIONALE To closely monitor the patient For legal purposes To monitor patient status It is an efficient and effective method of supplying fluids into the intravascular fluid compartment and also replacing the electrolyte losses. It also provides a path for Laboratory: a. CBC b. Blood Chemistry c. Xray the medications to be given directly for the fast effect into the system. For diagnostic purposes: To check for occurrence of Medications: infection in the 9

a. Captopril

body, and provides valuable information regarding the health condition of the client. Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to

b. Citicoline

decreased blood pressure, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.kidney.

c. Clopidogril

Citicoline activates the biosynthesis of structural phospholipids in the

10

neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitters, including acetylcholine and dopamine. April 24, 2010 Monitor Monitor hours intake V/S every and 4 Citicoline has shown neuroprotective effects in situations of hypoxia and ischemia. Reduce atherosclerotic events in patients April 25, 2010 Refer accordingly Please inform the with atherosclerosis documented by recent stroke, MI, or peripheral arterial disease. Reduce atherosclerotic events in patients with acute coronary syndrome, including IVF to follow PNSS 1 liter at 20gtts/min those managed medically and those who are to be vention or coronary 11 attending physician output every shift

artery bypass graft. To monitor patient status To properly inform the physician for further management and evaluation of the disease condition For further care to the patient For Treatment of complicated Diabetes Mellitus. For further evaluation and comanagement of the clients condition . It is an efficient and effective method of supplying fluids into the intravascular fluid compartment and also replacing the electrolyte losses. It also provides a path for the medications to

12

be given directly for the fast effect into the system.

Laboratory Results April 24, 2010 Complete Blood Count

13

RESULTS White blood cell Red blood cell Platelet MCV MCH Differential Count Neutro phils 0.78% 7.52 4.63 X 106/ml3 236 X 103/ml3 81 fL 30 pg

NORMAL VALUES 3.8 10.8 X 103/ml3 3.69 5.13 X 106/ml3 150 400 X 103/ml3 80 - 100 fL 27 33 pg

INTERPRETATIO N Within normal limit Within normal limit Within normal limit Within normal limit Within normal limit

0.45 0.73 %

Bacterial infection, inflammation, stress, drug reaction Within normal limit Within normal limit Within normal limit

Monocyt es Eosinoph ils Basophil

0.07% 0.01% 0.0

0.00 0.10 % 0.00 0.05% 0.00 0.20%

January 3, 2010 Blood Chemistry RESULT Potassium Sodium 3.82 mmol/L 143.1 NORMAL VALUES 3.5 5.5 mEq/ L 135-148 mEq/ L INTERPRETATION Within normal limit Within normal limit

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Calcium

---------

8.8- 10.2 mEq/ L

Drug Study Name of Drug Date Ordered Classification Dose/Frequency Route Mechanism of Action clopidogril April 23, 2010 Antiplatelet 75 mg P.O. O D Inhibits binding of ADP to its platelet receptor, which inhibits ADP-mediated activation and subsequent platelet aggregation. Because drugs acts by irreversibly modifying the platelet ADP receptor, platelet exposed to drug are affected for Specific Indication their lifetime. Reduce atherosclerotic events in patients with atherosclerosis documented by recent stroke, MI, or peripheral arterial disease. Reduce atherosclerotic events in patients with acute coronary syndrome, including those managed medically and those who are to be Contraindicatio n vention or coronary artery bypass graft. Contraindicated in patients hypersensitive to drug or any of its components, and in those with pathologic bleeding, such as Side Effects peptic ulcer or intracranial hemorrhage. depression, fatigue, headache, pain, chest pain, edema, hypertension, epistaxis, rhinitis, pain, constipation, diarrhea,dyspepsia, gastritis, Hemorrhage, ulcers, UTI, purpura, arthralgia, back pain. bronchitis, cough, dyspnea. Upper respirator tract infection, rash, pruritus

15

Nursing Precautions

Use cautiously in patients with hepatic impairment and in those at risk from increased bleeding from trauma, surgery or other conditions.

Name of Drug Date Ordered Classification Dose/Frequency Route Mechanism of Action

Captopril April 23, 2010 ACE inhibitor, Antihypertensive 25 mg PO bid Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. Treatment of hypertension Treatment of diabetic nephropathy Treatment of left ventricular dysfunction after MI Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter's syndrome; Raynaud's syndrome Contraindicated with allergy to captopril, history of angiodema, second or third trimester of pregnancy. Use cautiously with impaired renal function; CHF; salt or volume depletion, lactation. Tachycardia,angina pectoris, MI,CHF, hypotension in salt- or volume-depleted patientsRash,

Specific Indication

Contraindicatio n

Side Effects

16

pruritus,alopecia,Gastric irritation, ulcers, peptic ulcers, dysgeusia, anorexia, constipation Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, anemia, Nursing Precautions Other: Cough,malaise, dry mouth Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, dehydration); if light-headedness or dizziness occurs, consult your health care provider.

Name of Drug Date Ordered Classification Dose/Frequency Route Mechanism of Action

citicoline April 23, 2010 50 mg every 8 hours IVTT Competitively inhibits the action of histamine at the Histamine 2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin and pentagastrin Treatment of heartburn, acid indigestion, sour stomach Contraindicated with hepatic / renal impairment and gastric malignancy. Constipation, dizziness, tiredness, diarrhea a. Advise patient to avoid grapefruit juice and grapefruit products while using this drug b. Provide safety measures if dizziness and lightheadedness occur 17

Specific Indication Contraindicatio n Side Effects Nursing Precautions

Name of Drug Date Ordered Classification Dose/Frequency Route Mechanism of Action Specific Indication

Metformin April 23, 2010 Antidiabetic 500 mg 2 tablet, BID Decreases hepatic glucose production, decreases intestinal absorption of glucose, and increases peripheral uptake and utilization of glucose Improve glycemic control in clients with type 2 diabetes Extended-Release form used to treat type 2 diabetes as initial therapy Acute or chronic metabolic acidosis Abnormal hepatic function Dehydration and lactation - Hypoglycemia, diarrhea, N&V, asthenia, flatulence, headache, abdominal pain/discomfort > Metformin should be promptly withheld in the presence of any condition associated with hypoexmia, dehydration, or sepsis. >hepatic disease >Lactic acidosis

Contraindicatio n Side Effects Nursing Precautions

Pathophysiology with Anatomy and Physiology Definition:

Results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. Precipitating factors: 1. frequent or chronic infections 2. eating too much sweets 3. development of glucose intolerance during drug therapy 4. delivery of over 9 lbs infants Predisposing factors: Family History Obesity Age above 40

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5. diet 6. sedentary lifestyle

Insulin resistance Exhaustion of beta cells insulin production/ decrease secretion of insulin Absorption of glucose by the cell Cell starvation Stimulation of hunger mechanism via hypothalamus Hunger POLYPHAGIA (FBS 140 mg/dL) Nerve Demyelinization Impaired pain sensation NON-HEALING ULCERS F & E imbalance Number of solute relative to water Sodium ions lost POLYDIPSIA Diffuse glomerular sclerosis POLYURIA

Insufficient production of insulin (either absolutely or relative to the body's needs), production of defective insulin (which is uncommon), or the inability of cells to use insulin properly and efficiently leads to hyperglycemia and diabetes. This latter condition affects mostly the cells of muscle and fat tissues, and results in a condition known as "insulin resistance." This is the primary problem in type 2 diabetes. The absolute lack of insulin, usually secondary to a destructive process affecting the insulin producing beta cells in the pancreas, is the main disorder in type 1 diabetes. In type 2 diabetes, there also is a steady decline of beta cells that adds to the process of elevated blood sugars. Essentially, if someone is resistant to insulin, the body can, to some degree, increase production of insulin and overcome the level of resistance. After time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops. Glucose is a simple sugar found in food. Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. Carbohydrates are broken down in thesmall intestine and the glucose in digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the cells in the body where it is utilized. However, glucose cannot enter the cells alone and needs insulin to aid in its transport into the cells. Without insulin, the cells become starved of glucose energy despite the presence of abundant glucose in the bloodstream. In certain types of diabetes, the cells' inability

19

to utilize glucose gives rise to the ironic situation of "starvation in the midst of plenty". The abundant, unutilized glucose is wastefully excreted in the urine. Insulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. (The pancreas is a deep-seated organ in the abdomen located behind the stomach.) In addition to helping glucose enter the cells, insulin is also important in tightly regulating the level of glucose in the blood. After a meal, the blood glucose level rises. In response to the increased glucose level, the pancreas normally releases more insulin into the bloodstream to help glucose enter the cells and lower blood glucose levels after a meal. When the blood glucose levels are lowered, the insulin release from the pancreas is turned down. It is important to note that even in the fasting state there is a low steady release of insulin than fluctuates a bit and helps to maintain a steady blood sugar level during fasting. In normal individuals, such a regulatory system helps to keep blood glucose levels in a tightly controlled range. As outlined above, in patients with diabetes, the insulin is either absent, relatively insufficient for the body's needs, or not used properly by the body. All of these factors cause elevated levels of blood glucose (hyperglycemia).

Nursing Assessment (System Review and Nursing Assessment II)

Name: Patient Aya Date: December 29, 2009 Vital Signs: Pulse: 105 bpm RR: 24 cpm 37.5 C Height: 158 cm Weight: 64 kgs
EENT: [ ] impaired vision [ ] blind

Temp:

20

[ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, throat For abnormality [x] no problem RESPIRATORY [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ]cough[ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ]dyspnea [ ] orthopenea [ ] labored [ ]wheezing [ ] pain [ ] cyanotic Assess resp.rate, rhythm, depth, pattern Breath sounds, comfort [x] no problem CARDIOVASCULAR [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate, rhythm, pulse, circulation, fluid retention, comfort [x] no GENITO URINARY AND GYNE [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia GASTRO INTESTINAL TRACT [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain Assess abdomen, bowel habits, swallowing, Bowel sound, comfort [x] no problem NEURO [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethartic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech [x] no problem MUSCULOSKELETAL and SKIN [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [x] poor turgor [ ] cool [ ] deformity [] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist Assess mobility, motion, galt, alignment, joint function/ Skin color, texture, turgor, integrity [x] no problem

Dizziness

Hypertensive BP = 180/100 mmHg

NURSING ASSESSMENT ll SUBJECTIVE

COMMUNICATION: [ ] hearing loss wala may [ ] visual changes mata, [x] denied by the pt Comments: problema sakoa as verbalized

OBJECTIVE
[ ] glasses [ ] language [ ] contact lens [ ] hearing aide R L Pupil size: 3 mm Speech Difficulties: None Reaction: Pupils Equally Round Reactive to Light and Accommodation(PERRLA)

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OXYGENATION: [ ] dyspnea man koy [ ] smoking history gapanigarilyo None [ ] cough the patient. [ ] sputum [x] denied CIRCULATION: [x] chest pain Magsakit [ ] leg pain usahay pag [ ] numbness of extremities akong BP, [ ] denied the

Comments: wala ubo, di pud ko as verbalized by

Respiration: irregular

[x] regular

[]

Describe: Client had regular breathing pattern during admission. R. Symmetrical to the left. L Symmetrical to the right

Comments: akong dughan maghuna-huna ko nga taas ang as verbalized by Patient.

Heart Rhythm [x] regular [] irregular Ankle edema : None Heart : regular Carotid Radial Dorsal Pedis Femoral R___+ 105 bpm+______ +__________+_____ L___ + 105 bpm+______ +__________+_____ Comments: All pulse sites were palpable during physical assessment. [ ] Dentures Full [] [] [x] None Partial [] [] With [] []

NUTRITION Diet: Soft Diet []N []V Comments: Wala man koy character problema sa pagkaon. [ ] recent change di man ko kasukaon pud, [ ] weight, appetite as verbalized by the patient [ ] swallowin g difficulty [ ] denied ( x) no problem ELIMINATION: Usual bowel pattern [ ] urinary frequency once a day. 5 - 6X a day (oliguria) [ ] constipation [ ] urgency remedies [ ] dysurria None [] hematuria Date of last BM [ ] incontinence December 30, 2009 [ ] polyturia [ ] diarrhea [ ] foly in place Character None [ ] denied

Patent Upper Lower

Comments: Bowel Normoactive sound was normoactive distention Yes [x] No

Bowel Sounds:

Abdominal Present [ ]

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MGT. OF HEALTH & ILLNESS [ ] alcohol [ ] denied (amount, frequency) Dili man ko gainom [x]SBE last pap smear: unrecalled LMP : Menopause (Unrecalled) SUBJECTIVE SKIN INTEGRITY: [ ] dry Comments: wala man koy katul-katol [ ] itching As verbalized by the pt. [ ] others [ ] denied

Briefly describe the patients ability to follow treatments (diet, medication, etc.) for chronic health problems (if present) Patient took all the prescribed medications as prescribed by the doctor. OBJECTIVE [ ] dry [ ] cold [ ] pale [ ] flushed [ ] warm [ ] moist [ ] cyanotic *rashes, ulcers, decubitus (describe size, location, drainage) Patient skin was not pale and cold clammy to touched.

ACTIVITY/SAFETY: LOC and Orientation: The patient was [ ] convulsion Comments: conscious and aware of time, place people [x] dizziness gakalipong man and date. ko, [ ] Gait [ ] Walker [ ] Care [] [ ] limited motion as verbalized by the Other patient [ ] Steady [ ] Unsteady of joints Sensory and motor losses in face or limitation of ability extremities to : Sensory and motor sensitivity was still [ ] ambulate observed [ ] bathe self [ ] ROM limitations: no limited range of [ ] other motion [ ] Denied COMFORT/SLEEP/AWAKE [ ] facial grimaces [ ] pain Comments: wala [ ] guarding man [ ] other signs of pain: irritable (location, frequency koy [ ] side rail release from signed (60+years): poblema sa not applicable remedies) akong tulog as [ ] nocturia verbalized by [ ] sleep difficulties the pt. [x] denied COPING: Observed non-verbal behavior: none Occupation: business woman Person (Phone Number):Not given Members of the household: 4 Most Supportive Person: Husband (SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) 64 kilograms Weight Daily 180/100 mmHg BP q Shift N/A Neuro vs N/A CVP/SG. Reading N/A PT/OT N/A Irradiation (/) Urine Test N/A 24 Hour Urine Collection

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Date Ordered

Diagnostic/ Lab exam

Date done

Date ordere d

I.V. fluids/blood

Date done

4-23-10 4-23-10

Blood Chemistry and CBC X-ray

4-24-10 4-2310 4-24-10

Pnss 1 liter at 20 gtts/min

4-23-10

Nursing Management Ideal Nursing Management Nursing Diagnosis: Activity Intolerance; Level I r/t difficulty walking secondary to body weakness Interventions Rationale 1. .establish rapport 1. To facilitate NPI. 2. place the client in a 2. To prevent backaches or muscle aches. permanent, physical or psychological. Assessment guides treatment. 4. Assess mobility. patient's level of 4. This aids in defining what patient is capable of, which is necessary before setting realistic goals. comfortable position of causes of fatigue or activity intolerance.

3. Determine patient's perception 3. These may be temporary or

5. Assess nutritional status. 6. Teach energy

5. Adequate energy reserves are required for activity.

conservation 6. These reduce oxygen 24

techniques

consumption, allowing more prolonged activity.

25

Nursing Diagnosis: Cardiac Output, risk for decreased Risk factors may include Reduced myocardial contractility. Interventions 1. Auscultate heart sounds, noting presence rate, of rhythm, extra Rationale Specific dysrhythmias are more clearly detected audibly than by palpation. Hearing extra heartbeats or dropped beats helps identify dysrhythmias in the unmonitored patient. 2. Palpate carotid, pedis), regularity, (full/thready), symmetry. 3. Provide environment. reasons activities phase. for during calm/quiet Review limitation of acute pulses femoral, noting (radial, dorsalis rate, and 2. Differences in equality, rate, and regularity of pulses are indicative of the effect of altered cardiac output on systemic/peripheral circulation. 3. Reduces stimulation and release of stress-related catecholamines, which can cause/aggravate dysrhythmias and vasoconstriction, increasing 4. Demonstrate/encourage use of stress management behaviors, e.g., relaxation techniques, imagery, breathing. 5. Drug Levels 5. Reveal therapeutic/toxic level of prescription medications or street drugs 26 that may affect/contribute to presence of dysrhythmias. guided slow/deep myocardial workload. 4. Promotes patient participation in exerting some sense of control in a stressful situation.

1.

heartbeats, dropped beats.

amplitude

Nursing Diagnosis: Ineffective tissue perfusion related to kidney obstruction / impairment of kidney functioning Interventions Rationale 1. Observe for skin changes 1. May indicate presence of dehydration. Continued losses without adequate replacement 2. Monitor patients neurologic status for changes in level of consciousness 3. Monitor for complaints of numbness, muscle cramps. may lead to hypovolemia. 2. Decreased perfusion may result in cerebral perfusion decreases resulting to lethargy, weakness. 3. May indicate impairment of neuromuscular activity, hypocalcemia, and potential to 4. Monitor intake and output of decreased cardiac perfusion and patient function. 4. Decreased in urinary outputs that do not respond to fluid challenges cause renal vasoconstriction and decreased perfusion from renin secretions.

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Actual Nursing Management S O A P I galisod man ko ug ginhawa, as verbalized by the patient. - Irritability as noted Ineffective breathing pattern related to hyperventilation At the end of 15 20 mins, the patient will be able to verbalize good ventilation at a tolerable level Interventions INDEPENDENT: 1. Elevate head of the bed and instruct to do deep breathing exercises. 2. Maintain calm attitude while dealing with client & significant others. 3. Assess color of the skin and oral mucosa including the tongue. 4. Encourage client to use relaxation technique like diversional activities 5. Teach client and significant others with the contributing factors of the condition. COLLABORATIVE: Provide oxygen inhalation as ordered. 4. Relaxation minimizes oxygen demand 5. It helps client to be aware of the condition at it reduces the risk for reoccurrence of ineffective breathing episodes. To increase oxygenation, improve ventilation, and 3. To determine cyanosis Rationale

1. Promotes ease of maximal inspiration, allowing optimal lung expansion 2. This will limit clients level of anxiety.

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reduce dyspnea. At the end of 15 30 mins, the patient had verbalized good ventilation at a tolerable level.

Ing-ana man gyud na siya, masige na nuon na siya ug hunahuna sa kataas sa iyang blood pressure. Mahadlok siya basin unsa mahitabo sa iya kay taas iyang dugo, as verbalized by patients son. - T= 37.0C - BP = 180/100 Anxiety related to change in health status At the end of 30 mins., the patient will be able to demonstrate anxiety to a manageable level. Interventions Rationale 1. Monitor physical responses 1. To determine the anxiety such as pulse rate. 2. Provided comfort measures such as pursed lip breathing and back rubbing. 3. Instructed significant others not to tell the patient about her blood pressure and other anxiety provoking situations. 29 3. To prevent increase of anxiety level level, either mild, moderate and panic thus to provide the proper interventions needed. 2. To reduce anxiety or tension

O A P I

4. Encouraged client to acknowledge and express feelings such as fear. 5. Stayed with the client and maintaining a calm and confident manner. E 7. Reduces level of anxiety or the tension level of the client 5. This could lessen the anxiety level of the client.

At the end of 30 mins, the patient had already demonstrated anxiety to a manageable level.

Health Teachings MEDICATI ONS o The patient was advised to take all the medications as prescribed by the physician. a. Clopidogril 75 mg P.O. O D b. Captopril 25 mg PO bid c. Citicoline 50 mg every 8 hours IVTT d. Metformin 500 mg 2 tablet, BID The patient must report to the physician if experiencing any adverse effect of medication such as allergic reactions or rashes. Patient is encouraged to keep a list of the medication with him all times and should not use any other over the counter medications without consulting or EXERCISE TREATME prescription from the physician. o For most pt. WALKING is the safe and beneficial for the exercise. o Diabetes must control 30 the glucose level before

NT CHECK UP DIET

initiating any activities. o Advised patient to have follow-up check up to her Diabetes. o Plan for the caloric intake distributed as follows CHO 50-60%; Fats 20-30%; Protein 10-20%.

Referrals and Follow up Although our patient having Diabetes Millitus and can be prevented and treated, the patient was then instructed to religiously follow medication regimen as prescribed by the physician such as antiplatelet, antihypertensive, drugs to prevent complications and further damage. The patient was advised to have an appointment with a physician or a health care provider, 2 weeks after discharging or if there is any abnormalities observe by the client to check for any complications and to check the condition of the client. The significant others also was being instructed to guide the patient in taking her medications and to have regular check-up, especially in her blood pressure, to any near health centers on their community and also to visit her physician on the schedule given. Recommendations Prevention is always better than curing. As Ben Franklin said, An ounce of prevention is worth a pound of cure. Since the patient seek for medical attention, health care provider was given her the right care that she needs.

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Liceo de Cagayan University R.N. Pelaez Blvd. Carmen Cagayan de Oro City College of Nursing

In Partial Fulfillment of the Course of the NCM501204

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Related Learning Experience

Submitted to: Ms.Charito Gerong R.N MAN Clinical Instructor

Submitted by: Christina C. Flores May 21, 2010

TABLE OF CONTENTS Introduction Overview of the Case Objective of the Study Scope and Limitation of the Study Health History Profile of Patient Family and Personal health history History of Present Illness Chief Complaint Developmental data Medical Management

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Medical Orders and Rationale Laboratory Results Drug Study Pathophysiology with Anatomy and Physiology Nursing Assessment (System Review and Nursing Assessment II) Nursing Management Ideal Nursing Management Actual Nursing Management Health Teachings Referrals and Follow up Recommendations Bibliography

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