TARLAC STATE UNIVERSITY COLEGE OF NURSING S.Y.

2008-2009

SUBMITTED BY:
RACHAEL ANN B. ESPINOSA BSN III-A GROUP A2 SUBMITTED TO: MS. MARIA TERESA MENDOZA CLINICAL INSTRUCTOR

PATIENT’S PROFILE NAME: Mr. M AGE: 54 YEARS OLD SEX: Male CIVIL STATUS: Married OCCUPATION: Jeepney Driver RELIGION: Roman Catholic POSITION IN THE FAMILY: Father ADDRESS: Gerona, Tarlac DATE OF BIRTH: July 16, 1953 NATIONALITY: Filipino HEIGHT: 5’4 WEIGHT: 76 kg DATE OF ADMISSION: July 10, 2008 CHIEF COMPLAIN: Non-healing wound on the ® foot DIAGNOSIS: Type II Diabetes Mellitus uncontrolled Diabetic foot ®

INTRODUCTION

The cause of the common form of type II diabetes mellitus is unknown. The genetic of type II are complex and not clearly defined. Autoimmune mechanisms are not involved. Individuals with maturity onset diabetes of youth (MODY), a subset o type II, are normal weight to underweight. MODY is thought to be auto somal dominant because it affects 50 % of first-degree relatives. Cellular resistance is a factor for 60% to 80% of individuals with type II DM. Insulin resistance is increase in obesity. Decrease beta cells responsiveness to the plasma glucose level is noted, along with abnormal glucagons secretion. Levels of insulin may increase to compensate or insulin resistance in peripheral tissues, but there is still a relative deficiency of insulin. Pancreatic changes in individuals with type II DM are non-specific and have been observed to a lesser degree in persons without DM. Liver changes are related to elevated serum lipid levels. Risk for developing diabetes after age 40 years old in general, incidence increases with the age into the 70’s. Diseases results from genetic susceptibility combined with environmental determinants and other risk factors. It is associated with long duration obesity. Islet cell antibodies are not present. Increased insulin resistance caused by altered cellular metabolism and an intracellular post receptor defect. Typically increased at time of diagnosis; may be normal or decreased. The goal of treatment is restoration of euglycemia and correction of related metabolic disorders. Dietary measures, including the restriction of the total caloric intake, are of primary importance in the overweight individual.

13 AREAS OF ASSESSMENT
1. SOCIAL STATUS

Mr. M is a 54 year old male born on July 16, 1953. He is presently residing at Gerona, Tarlac. He is third eldest son to a family of 11 members. He worked as a company driver of a Chinese businessman in Angeles City, Pampanga for more than 10 years. But he is now currently driving his own passenger jeepney. He is a high school under graduate. He lives with his wife and 3 children including his 2 sons-inlaw and 2 grandsons. He declares that his salary is just enough to sustain their daily needs. He interacts respectfully to others and is friendly. His family is a devout Catholic and they go to church together every Sunday. NORMS: Social functioning of an individual is to form relationships with others. Social support is a perception that one has an emotional and tangible resource to call on when needed; perceived social support is being followed by the family to express the love of the family, financial aspects is one of the normal constraints in the family. (Nursing Fundamentals by Daniels; An Introduction to Health and Physical Assessment in Nursing by D’Amico and Barbarito) ANALYSIS: The patient’s social status can be described as normal; he has support system (the family) which he can turn to when face with difficult periods particularly upon encountering emotional or coping crisis and has a strong foundation of emotional stability. He has also close family ties. He interacts well with others. He also communicates with his fellowman thus, he gain many friends. 2. MENTAL STATUS GENERAL APPEARANCE AND BEHAVIOUR: Mr. M was not well groomed during our first encounter. He looks restless, weak and lethargic. However, he appears to be responsive whenever someone is asking him. LEVEL OF CONSCIOUSNESS: As I talked to him, he is increased in level of alertness, conscious and coherent. He responded to some questions appropriately. ORIENTATION: Mr. M is aware of his present condition. He knows some of the reasons why he was admitted in the hospital. The patient is well oriented about the time, place, person, and date. And he is able to answer all questions asked. SPEECH:

Mr. M’s spoken words can be clearly understood. He can understand and able to speak Tagalog, Ilocano and a bit of Pampango. NORMS: Patients should be able to reason, to find meaning, and make judgment from information, to demonstrate rational thinking and perceive realistically. Appearance and behavior; posture must be relaxed. Patients should be dressed appropriately with the season, age, and gender. Grooming and hygiene should be proper and neat. Should typically able to state their name, location, the date, month, season, and time of the day. Ability to form words (articulation) should be understood and clear. (An Introduction to Health and Physical Assessment in Nursing by D’Amico and Barbarito; Physical Examination and Health Assessment by Carolyn Jarvis) ANALYSIS: His appearance, level of consciousness, behavior, speech, cognitive abilities, and memory does not show any significant deviations from an average person and thus, considerately shows no mental impairment. 3. EMOTIONAL STATUS Mr. M was relaxed and calm even though he doesn’t have enough sleep because of the interruptions o opening and closing the door of their ward. He also wanted to go home despite of his condition as much as possible because of thinking about the increasing bills and that they have no money to pay. NORMS: Normal copping pattern or emotions stability could include acceptance of the problem, adjustment to it, expressing of selfperception and self-control of emotions, probable temporary use o defense mechanism and support system (Fundamentals of Nursing by Kozier). Carrying out emotional feelings through words and facial expressions are normal signs of present physical condition (Nursing Fundamentals by Daniels) ANALYSIS: The patient manifests acceptance of health condition and felt support from his family and is capable of controlling his emotions. He also is experiencing anxiety because of the worrying on how to get the money in paying or his hospital bills. 4. SENSORY PERCEPTION SENSE OF LIGHT: Patient can open his eyes. Upon assessment, papillary reflex is done. Complaint of blurred vision and cannot read small letters at the distance of 3 feet. Blinking reflex was symmetrical and involuntary.

SENSE OF TASTE: can able to recognize different taste of food such as salty and sour foods. TACTILE SENSITIVITY: Patient was generally warm to touch upon assessment and he can perceive and able to distinguish hot and cold temperature. AUDITORY ACUITY TEST: Patient can hear the words I was talking to him a to a distance of 2 meters and he was able to hear me. SENSE OF SMELL: According to the patient, he can recognize good and bad odors. NORMS: Normal visual acuity of the person is 20/20. Visual acuity can be impaired by pathology affecting the optic nerve or neovascularization of the optic nerve with resultant bleeding and related to diabetes mellitus. The patient should be able to perceive light touch, superficial pain, and temperature accurately. Should be able to distinguish and identify the odor with each nostril. Normal sensation would be accurate perceptions of sweet, sour, salty, and bitter tastes. (Health and Assessment and Physical Examination, 3rd Edition by Estes) ANALYSIS: Systemic disease like diabetes mellitus damages the choroids and retina of the eye, causing visual acuity which is present in the patient. But the remaining sensory organs functions in normal state. 5. MOTOR STABILITY Mr. M has limited range o motion especially in the affected area. He cannot turn from side to side without assistance. But he can use his upper extremities in feeding his self. NORMS: Full range of motion on voluntary muscles should be performed without strain and there are no feelings of pain or tenderness. (Nurse’s Handbook of Health Assessment by Weber) ANALYSIS: The patient cannot perform activities that require full motion and he cannot ambulate normally because o his condition. He has limited movement.

Sign up to vote on this title
UsefulNot useful