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I.

BIOGRAPHIC DATA

Name: Mrs. X

Age: 44 years old

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

Marital Status: Married

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

Gender: Female

Religious Affiliation: Roman Catholic

Occupation: “Labandera” Laundry Woman/Housewife

II. NURSING HISTORY

A. Past Health History


According to Mrs. X, her last check up to the doctor in the Taguig General Hospital was last year of 2006 and it’s almost 2
years ago. The result of her examination was, she has high blood sugar. She also had check up about the tenderness of her
breast and the presence of discharge and the doctor recommended her to take Cloxacillin.

B. History of Present Illness

C. Family Health History


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

III. Patterns of Functioning


A. Psychological health
1. Coping Pattern
The client said that she easily loose temper and gets irritated especially when her husband got drunk. She
further added that she always makes herself busy by watching TV and play tong – its to cope with stress.
Interpretation:
Analysis:
2. Interaction Pattern
The client said that her relationship with her siblings is mutual that they are like brothers and sisters. When
asked about her relationship with her husband, she verbalized that, “ lagi kaming nag aaway at nagbabangayan kasi
palagi syang lasing. Siya lang talaga problema ko.”
Interpretation:
Analysis:
3. Cognitive Pattern
The client is elementary graduate. She is able to read and write and understand what we tell to her. She is able to
speak out her problems to us.
Interpretation:
Analysis:
4. Self-Concept
The client verbalized, “Nagagawa ko parin mga trabaho ko at mga gusto kong gawin tulad ng paglalaba
dalawang beses sa isang linggo.” As we observed, she is energetic and emotionally competent when we
conducted our interview.
Interpretation:
Analysis:
5. Emotional Pattern
She expressed her feelings, she was crying and overwhelmed during our assessment and interview as we
conducted our health teachings
Interpretation:
Analysis:

6. Sexuality
She is not sexually active due to her work and relationship with her husband.
Interpretation:
Analysis:
7. Family Coping Pattern
The client stated that they’re having a small conversation within their vicinity when they have problems within
their family.
Interpretation:
Analysis:
B. Socio-cultural
1. Cultural Patterns
2. Significant Relationships
3. Recreation Patterns
4. Environment
5. Economic
C. Spiritual Patterns
1. Religious Beliefs and Practices
2 Values and Valuing

IV. ACTIVITIES OF DAILY LIVING


ADL Before During Hospitalization Interpretation/
Hospitalization Analysis
1. Nutrition

2. Elimination

3. Exercise

4. Hygiene
5. Substance use
6. Sleep and rest Any illness that causes pain, physical
discomfort, or mood problems, such as
anxiety or depression, can result in sleep
problems. Sleep disorders are conditions
that if untreated generally cause disturbed
night time sleep that result in one of the
three problems: insomnia, abnormal
movements or sensation during sleep or
when awakening at night(Aldrich and
Naylor, 2000)
Fundamentals of Nursing Potter &Perry
6th edition 2005, pp.1202-1203
7. Sexual
activity

V. PHYSICAL ASSESSMENT
ASSESSMENT NORMS AND ACTUAL FINDINGS ANALYSIS
STANDARDS

General Appearance

1. Posture/Gait Relaxed, Erect Slouch Slouch is the hanging down of the


Posture, Coordinated head; a drooping posture; a limp
Movement appearance. The common
manifestations of bad posture are
swayback (a large curve in the back)
and slouching, where everything
moves forward and rolls in.
2. Skin Colour

3. Personal Neat and Clean Looks Neat and Clean Normal


Hygiene/Grooming

4. Nutritional Status
5. Age appropriateness
6. Verbal Behavior
7. Non-verbal Behavior
Measurements

1. Temperature 59 cpm

2. Pulse Rate 24 bpm

180/110 mmHg
3. Respiratory rate

4. Blood Pressure
47 kg

5. Weight 145.5cm/4 ft 7 inches

6. Height 22.38

7. BMI

Body Part (Technique Used)


VI. Course in the Ward

Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation and


Analysis
November 30, 2008 Benedict’s Test (-) Blue or no change in (+4)Orange Deviated to normal
color because the Benedict
(+) bluish green solution turned into
(++) yellowish green color orange which
(+++) yellow indicated that her urine
(++++) orange or brick has presence of sugar.
red

Heat and Acetic acid (-) no turbidity Faint turbidity/Cloudy The normal result in
Test (+) faint turbidity acetic acid test is no
(++) moderate turbidity turbidity or no
(+++) heavy turbidity coagulation of albumin
(++++)solid(opaque) but the result shows that
her urine has (+)positive
1 or faint turbidity which
indicates a slight
presence of albumin or
protein in her urine.
VII. Medications, IV Infusions, Blood Transfusions, Treatments Given

Generic/Trade Dosage/Frequency Classification Indication Contraindication Side-Effects Nsg.


Name Responsibility

VIII. Pathophysiology of Diabetes Mellitus

IX. Ecologic Model


A. Hypothesis

1. Type 2 Diabetes Mellitus is due to the client’s sedentary lifestyle.


2. Type 2 Diabetes Mellitus can be attributed to the client’s familial history of DM.
3. Obesity can also be attributed to the development of Type 2 Diabetes Mellitus.

B. Predisposing Factors

1. Host

a. Age- 44 years old


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

c. Heredity- familial history of Diabetes Mellitus

2. Environment

a. Socio-economic- housewife

C. Model

D. Analysis

Diabetes Mellitus is not a single disease. It is genetically and clinically heterogeneous group of metabolic
disorders characterized by glucose intolerance with hyperglycemia present at time of diagnosis.
Specific cause depends in the type of diabetes; however, it is easier to think of diabetes as an interaction
between two factors: Genetic Predisposition (diabetogenic genes) and Environment/Lifestyle (obesity, poor nutrition,
lack of exercise). (Public Health Nursing in the Philippines, 2007, p.195)

E. Conclusion and Recommendation

Modernization of life has dramatically increased the prevalence of Diabetes Mellitus. Most people with Type 2
Diabetes Mellitus are older and near overweight. There is also a strong susceptibility to clients whose family has
genetic predisposition of DM. Lifestyle also plays an important role in the development of the disease.

In the Philippines, increasing life expectancy, urbanization and lifestyle modification have brought about great
change on the health status of the country. Globalization and social change has influenced the spread of non-
communicable or lifestyle/degenerative diseases by escalating exposure to risk.

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

• Maintain body weight and prevent obesity through proper nutrition and physical activity/ exercise.
• Eat more dietary fiber, reduce salt and fat intake, avoid simple sugars like cakes and pastries, and avoid junk
foods.
• Promote regular physical activity and exercise to enhance insulin action in the body.

The fact that lifestyle plays an important role in the development of Type 2 Diabetes Mellitus has led to increased
stress on prevention. Diet and exercise can significantly delay the onset of the disease.
X. Prioritized List of Nursing Problems
Date Nursing Problems Identified Cues Justification

XI. Nursing Care Plan

Nursing Problem Analysis Goal/Objectives Nursing Rationale Evaluation


Interventions
Cues: Scientific SMART Supplemental: Effectiveness:
Subjective: Implication: Developmental: Efficiency:
Objective: Immediate Cause: Facilitative: Adequacy:
Intermediate Cause: Appropriateness:
Root Cause: Acceptability: