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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. The client weight before is 56 kg.
And recently her weight now is 47 kg. So she loses almost 9 kg.

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 mmHg. The client verbalized
GENOGRAM

Pastora,
UNKNOWN
70

nakulam

Pelicin, 60 Linda, 59 Sefa Martinez, Uncle


68 Kering, 57
DM, HD
HPN

Andronico, Ma. Louisa


55 Remillo, 44

HPN DM, HPN

Ariel, 26 Arnel, 24
Andy, 28 Ailen, 22
III. Patterns of Functioning
A. Psychological health
1. Coping Pattern
The client said that she easily loose temper and gets stressed and 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. Sometimes after lunch in the afternoon, she
takes a nap by 2 pm.
Interpretation: The client experience stress with regards to her husband. Based on the interview the client experience stress
because her husband got always drunk that made to loose her temper but she is able to cope with it by making herself busy in washing
clothes. Stress may affect the health and the attitude of a person.

Analysis: Every individual needs a source of recreation to alleviate stress. Sleep and rest are good ways to release pressure. It’s
advised that all angers are negative elements are released so that it could not lead to heart or back problems. (Psychiatric Health
Nursing by Beck. p.87)

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: The client has harmonious relationship with her sons and daughters but with her husband they always have a
conflict and arguments.
Analysis:
The affective and coping function of the family involves providing emotional comfort to family members. It also helps
members to establish an identity and maintain that identity in times of stress.
Illness may precipitate a health crisis in a family.
Fundamentals of Nursing by Taylor, pp.29-30

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:

The client is able to read and write. She sees herself as a strong person. She is expressive whenever she has problems she was able to
speak it out to her siblings.

Analysis:

Cognitive refers to the manner in which people learn to think reason and use language. It involves a person’s intelligence,
perceptual ability, and ability to process information. Changes the nervous may also affect perceptual capacity.

(Fundamentals of Nursing: Barbara Kozier, et al page 359 and 409)


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.” She sees herself as a brave person to face and solve all the problems in her life. Because of her work sometimes she doesn’t
think her health status.
Interpretation:
The client is energetic and emotionally competent when we conducted our interview.
Analysis:

Self-concept involves all of the self-perceptions, that is, appearance, values, and beliefs, which influence behavior.
Self-concept is a complex idea that influences how one thinks, and acts; how one sees and treats other person; choices they
make, ability to give and receive love; ability to take actions and to change things. Factors that affect self-concept are:
development, family and culture, stressors, resources, history of success and failure and lastly illness.

(Fundamentals of Nursing: Barbara Kozier, et al page 957,961 and 962)

5. Emotional Pattern
She expressed her feelings, she was crying and overwhelmed during our assessment and interview as we conducted our health
teachings.
Interpretation:
The client has appreciated the health teachings of the nursing students about different interventions that may
help her control and prevent her previous illness.
Analysis:
6. Sexuality
According to her, she is sexually active. They make love with her husband every twice a month only because of their work and
sometimes they’re both busy and tired. She verbalized, “pag di mo naman pinagbigyan baka pag hinalaan ka naman na sa iba mo
binibigay”. They use withdrawal method for she is capable of bearing child but before she used pills but her husband opposed her to
use pills, intrauterine device, etc for their contraceptives.
Interpretation: Our client has a knowledge about contraceptives.
Analysis: Characteristics of Sexual Health

Knowledge about sexuality and sexual behavior

Ability to express one’s full sexual potential, excluding all forms of sexual coercion, exploitation, and abuse

Ability to make autonomous decisions about one’s sexual life within a context of personal and social ethics

Experience of sexual pleasure as a source of physical, psychologic, cognitive, and spiritual well-being

Capability to express sexuality through communication, touch, emotional expression, and love

Right to make free and responsible reproductive choices

Ability to access sexual health care for the prevention and treatment of all sexual concerns, problems, and disorders

(Fundamentals of Nursing: Concepts, Process and Practice; 7th Edition; Kozier, Erb, Berman, Snyder; Page 973)
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:

The fact that the client’s family is approachable; they can easily discuss any situation regarding their family problem.
They are giving suggestions to every problem for it to easily resolve.

Analysis:

The effectiveness of the family communication determines the family’s ability to function as a cooperative, growth-
producing unit. Messages are constantly being communicated among family members, both verbally and nonverbally. The
information transmitted influences how members work together, fulfill their assigned roles in the family, incorporate family
values, and develop skills to function in the society. Intra family communication plays a significant role in the development of
self-esteem, which is necessary for the growth of personality.

(Fundamentals of Nursing: Barbara Kozier, et al page 193)

B. Socio-cultural
1. Cultural Patterns
Our client doesn’t use any herbal medicines because her family is not used to it. She doesn’t even try to use one.
Our client praised different saints like Saint Anne and Sto. Niño.
Analysis:
Health practices and beliefs are strongly influence by a person’s economic level, family and culture. Family
and culture to which a person belongs influence the person’s pattern of leaving and values about health and illness.
Fundamentals of Nursing by Taylor, page 66
2. Significant Relationships

3. Recreation Patterns
Our client spend her time watching television, playing cards with her friends and chatting with her friends
whenever she doesn’t have customers for her laundry.
4. Environment
Our client’s house is not well- ventilated, insufficient amount inside their house, insufficient space and presence
of health hazards specifically fall, fire and accidents hazards. There was also a presence of polluted river on the
back of their house. They also use NAWASA as their water supply. Sometimes she directly get her drinking
water in the faucet. There is also presence of livestock wastes coming from the animals such as chicken, duck
near their house.

Analysis:
The environment has many influences on health and illness. Housing, sanitation, climate and pollution of
air, food and water are elements in environmental dimension.
The environment of the community in which an individual lives and works might have both helpful and
harmful effects on health. The quality of air and water differ across communities. Large urban areas are often
affected by air pollution, whereas smaller communities may be at risk for water pollution from run-off of chemical
or livestock wastes.

Fundamentals of Nursing by Taylor, page 34


5. Economic
Our client’s family income is insufficient with her family needs. She verbalized, “anlalaki ng mga anak ko,
anlalakas pa nila kumain”. Her family doesn’t have any health insurance because they cannot afford to have
some. Her son was only an extra in the construction site.

Analysis:
Financial and insurance coverage affects an individual’s access to healthcare services within a community.
As private health insurance costs continue to escalate, fewer citizens have it. Many part-time and unskilled jobs
provide no insurance benefits at all, resulting in a substantial number of citizens who do not have any financial
assistance for healthcare screenings or care for illnesses.

C. Spiritual Patterns
1. Religious Beliefs and Practices
Everytime our client wakes up she usually pray rosary, for her prayers can help her to overcome her illness as well
as her problems. She worships different saints such as Saint Anne and Sto. Niño, she believes that she can conquer
her triumphs regarding health with their guidance.

Analysis:

Spiritual beliefs and practices are associated with all aspects of persons life including health and illness.

Certain practices generally associated with healthcare may have religious significance for a patient.

Fundamentals of Nursing by Taylor , pages 976 &979


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 Posture, Slouch Slouch is the hanging down of the head; a
Coordinated drooping posture; a limp appearance. The
Movement(Kozier 5th common manifestations of bad posture
ed.,p.473) are swayback (a large curve in the back)
and slouching, where everything moves
forward and rolls in.

Varies from light deep


2. Skin Colour and brown; from ruddy pink
Not uniform in color ant dry skin
uniformity Normal
to light pink; Generally
uniform except areas
exposed to sun; areas of
lighter pigmentation) in
dark skin people(Kozier
5th ed.,p.475)
Looks Neat and Clean
3. Personal Neat and Clean
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

5. Weight 47 kg

6. Height 145.5cm/4 ft 7 inches

7. BMI 22.38

Body Part (Technique Used)

VI. Course in the Ward

Laboratory and Diagnostic Examination Results


Date Procedure Norms Result Interpretation and Analysis
November 30, Benedict’s Test (-) Blue or no change in (+4)Orange Deviated to normal because
2008 color the Benedict solution
(+) bluish green turned into color orange
(++) yellowish green which indicated that her
(+++) yellow urine has presence of sugar.
(++++) orange or brick
red
The normal result in acetic
Heat and Acetic acid Test (-) no turbidity Faint turbidity/Cloudy acid test is no turbidity or
(+) faint turbidity no coagulation of albumin
(++) moderate turbidity but the result shows that
(+++) heavy turbidity her urine has (+)positive 1
(++++)solid(opaque) or faint turbidity which
indicates a slight presence
of albumin or protein in her
urine.

VII. Medications, IV Infusions, Blood Transfusions, Treatments Given

Name of Drug Actions Therapeutic Effects Contraindications Administration Nursing


Responsibilities
Glibenclamide Glibenclamide exerts Hypoglycaemia; Severe or life- Glibenclamide:
Assess allergy history
pancreatic and cholestatic jaundice; threatening Should be taken with
®
Brands: DiaBeta , extrapancreatic agranulocytosis; hyperglycaemia, food. prior to beginning
Glucovance® , actions. It stimulates aplastic anaemia; severe liver or renal Glyburide: Should be
therapy. Assess
Glycron® , Glynase® , an increase in insulin haemolytic anaemia. failure, type 1 taken with food.
Micronase® release by the Blood dyscrasias diabetes, diabetic potential for
pancreatic β-cells. It (reversible), liver ketoacidosis with or Route: oral interactions with other
may also reduce dysfunction, without coma,
hepatic hypoglycaemia, GI patients with severe prescriptions, OTC
gluconeogenesis and symptoms, allergic skin infection or trauma. medications, or herbal
glycogenolysis. reactions.
Increased glucose products patient may
uptake in the liver be taking. Assess
and utilization in the
skeletal muscles. results of laboratory
Duration: 24 hr. tests, therapeutic
effectiveness, and
adverse response (eg,
hypoglycemia) at
regular intervals during
therapy. Teach patient
proper use (or refer
patient to diabetic
educator) for
instruction, possible
side
effects/appropriate
interventions, and
adverse symptoms to
report.

VIII.
IX. Pathophysiology of Diabetes Mellitus

X. 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 and laundry woman

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.

XI. Prioritized List of Nursing Problems


Date Nursing Problems Identified Cues Justification

XII. Nursing Care Plan


-Imbalanced nutrition: Less than body requirements related to inability to utilize nutrients to meet metabolic needs
evidenced by increased thirst.
-Deficient knowledge individual care needs related to misinterpretation evidenced by request information and statements of
concerns.
-Altered nutrition: Less than body requirements related to decreased number or function of pancreatic islet cells, r/t increase
blood glucose level by poor cell uptake, r/t glycosuria caused by exceeding renal tubular capacity limits
Defining Characteristics: Polydipsia, polyphagia, polyuria, weight loss
Diabetes Mellitus is a pancreatic disorder in which the beta cells of the islets of Langerhans do not secrete enough
insulin, if any. Insulin a hormone usually secreted after meals facilitates glycogen storage in the liver and transport
of glucose into muscle and fat cells and maintains blood glucose at normal levels. Inadequate insulin causes
hyperglycemia and glycosuria, which lead to fluid and electrolyte imbalance. Gluconeogenesis (use of protein and fat
stores) causes ketoacidosis, muscle wasting, and weight loss.
Nursing Care Plans, Nursing Diagnosis and Intervention (Gulanick, Klopp) pp.490
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:
CASE PRESENTATION

(Diabetes Mellitus)

Submitted by:
Lorca, Jamil
Magtibay, Jay-ar
Pajarillo, Cherry Lyn
Rico, Alyssa
BSN020- Group 79
Submitted to:
Mrs. Leni C. Domingo
(Clinical Instructor)