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. ADL

ACTIVITIES OF DAILY LIVING Before Hospitalization
1. Nutrition 2. Elimination

During Hospitalization

Interpretation/ Analysis

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 STANDARDS ACTUAL FINDINGS ANALYSIS

General Appearance 1. Posture/Gait Relaxed, Erect Posture, Coordinated Movement Slouch Slouch is the hanging down of the head; a drooping posture; a limp 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. 3.

Skin Colour Personal Hygiene/Grooming Neat and Clean Looks Neat and Clean Normal

4. Nutritional Status 5. Age appropriateness 6. Verbal Behavior 7. Non-verbal Behavior Measurements 1. Temperature 59 cpm 24 bpm 180/110 mmHg 3. 4. 5. 6. 7. Respiratory rate Blood Pressure Weight Height BMI 47 kg 145.5cm/4 ft 7 inches 22.38

2. Pulse Rate

Body Part (Technique Used)

VI.

Course in the Ward

Laboratory and Diagnostic Examination Results Date
November 30, 2008

Procedure
Benedict’s Test

Norms

Result

Interpretation Analysis
Deviated to normal because the Benedict solution turned into color orange which

and

(-) Blue or no change in (+4)Orange color (+) bluish green (++) yellowish green (+++) yellow (++++) orange or brick red

indicated that her urine has presence of sugar.

Heat and Acetic acid Test

(-) no turbidity (+) faint turbidity (++) moderate turbidity (+++) heavy turbidity (++++)solid(opaque)

Faint turbidity/Cloudy

The normal result in acetic acid test is no turbidity or no coagulation of albumin 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 Name Dosage/Frequency Classification Indication Contraindication Side-Effects Nsg. Responsibility

VIII. Pathophysiology of Diabetes Mellitus IX. Ecologic Model

A. Hypothesis

1. Type 2 Diabetes Mellitus is due to the 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 noncommunicable 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.
Date

Prioritized List of Nursing Problems
Nursing Problems Identified Cues Justification

XI.

Nursing Care Plan
Analysis Scientific Implication: Immediate Cause: Intermediate Cause: Root Cause: Goal/Objectives SMART Nursing Interventions Supplemental: Developmental: Facilitative: Rationale Evaluation Effectiveness: Efficiency: Adequacy: Appropriateness: Acceptability:

Nursing Problem Cues: Subjective: Objective:

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