Clinical Summary

Name: Manuel Galang Delos Santos Sex: Male Age: 68 years old Address: A-A 6-20 PArola Tondo Manila Date of Birth: May 9, 1943 Birth Place: Mindanao Civil Status: Married Religion: Roman Catholic Nationality: Filipino Date of Admission: September 5, 2011 Ward and Room: Medicine Ward and Rm. 621 Admitting Diagnosis: Diabetes Mellitus Type II

A. Personal Data
Patient is Mr. Manuel Galang Delos Santos, a 48 years old male from A-A 6-20 Parola Tondo Manila. He is married, they have three childrens, and they are all Roman Catholic.

B. Chief Complain
The patient was admitted at Gat Andres Bonifacio Memorial Medical Center last September 5, 2011 due to the complaint of difficulty of breathing (DOB). He was attended at the Emergency Department and had taken a clinical history and physical assessment. He was transferred at the Medicine ward particularly in the isolation room of the hospital for further evaluation of the complaint. He was attended by Dr. Ancheta resident physician of the said hospital.

C. Past Medical History

The patient is known hypertensive, diabetic and asthmatic since he was a child it is triggered by dust, scented products and Strong odors from paints. Last attack of asthma he did not take any maintenance and medication. He has a history of asthma in her family. Whenever asthma attacks he uses inhaler if available. He does not have allergies to whatever kind of foods and medication as far as she kno

D. History of Present illness

The patient condition started about 2 months ago prior to consultation, as onset of cough, fatigue and difficulty of breathing.

One week prior to admission the patient experienced worsening of the condition, he had a Positive for Bipedal Edema with orthopnea gradually progressive. He also stabbing pain on his chest according to the assessment it is 8/10 and it radiates to his back. He just used inhaler and used of oxygen inhalation at home. On the day of September 05, 11 he was rushed into the hospital because of difficulty of breathing. Previously when he started experiencing these conditions, he immediately consults a doctor.

E.

Family History

Mother side = (+) Asthma (+) Hypertension Father side = (+) Hypertension (+) Diabetes Mellitus

F.

Social History

The Patient is a jeepney driver, he works hard for his children.

Nursing Care Plan

Assessmen t Subjective: hindi ko na magawa yung mga nagagaw a ko dati as reported by the patient. Objective: Generalize d weakness Polyphagi a Polyuria Polydypsia Restlessnes s Drowsy Lethargy Vital Signs: Bp;130/90 mmHg RR:25bpm Pr:95bpm Temp.:37.2 0C 3.Fear of breathlessness, pain, or falling may decrease Diagnosis Activity Intolerance related to poor glucose control as evidence by experienci ng shortness of breath when ambulating . Planning Short Term Intervention Rationale 1.Medications such as betablockers, lipidlowering agents, which can damage muscle, and some antihypertensi ves such as Clonedine and lowering the blood pressure to normal in the elderly can result in decreased functioning. Evaluation Short Term: After 8 hours of nursing intervention, goal met, as evidence by participating in physical activity with appropriate vitals changes. 1.Evaluate medication After 8 hours s the client of nursing is taking to intervention, see if they will be able could be to causing participate in activity physical intolerance activity with appropriate changes in heart rate, blood pressure, and respirations.

Long Term: After 3 days of nursing intervention, will be able to demonstrate increased tolerance to activity by discharge.

Long Term: After 3 days of nursing intervention goal met, as evidence by demonstrating increased tolerance to activity.

2.Assess nutritional needs associated with activity intolerance.

2.The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.

3.Provide emotional support and encourage ment to the client to gradually increase activity.

willingness to increase activity.

4.Monitor vital signs before and after any activity, noting any abnormal changes.

4.This can be caused by a temporary insufficiency of blood supply.

5.Assess for pain before activity.

5.Pain restricts the client from a achieving a maximal activity level and if often exacerbated by movement.

Assessment Subjective: palagi ako nagugutom kya palagi din ako kumakaen as verbalized by the patient. Objective: Generalized weakness Polyphagia Polyuria Polydypsia Restlessness Drowsy Lethargy Vital Signs: Bp;130/90mmH g RR:25bpm Pr:95bpm Temp.:37.20C

Diagnosis Nutritional Imbalance more than body requiremen t related to intake in excess of activity expenditur es as evidence by

Planning Long Term: After 3 days of nursing interventio n, will be able to have nutritional balance between needs and intake.

Intervention 1.Obtain accurate history of weight changes. 2.Record accurate food hstory, including daily intake.

Rationale 1. Increases awareness of activities and foods that contribute to excessive intake 2. Increases awareness of activities and foods that contribute to excessive intake. 3. Goal setting provides motivation , which is essential for a successful weight-loss program 4.. A combined plan of calorie reduction and exercise can enhance weight loss since

Evaluation Long Term: After 3 days of nursing intervention, goal met as manifested by understandin g of nutritional balance between needs and intake.

3. Encourage use of internal reward systems when goals are accomplishe d. 4. Set a realistic plan with Mr. galang to include reduced food intake And increased energy expenditure. 5. Encourage attendance at support groups for weight loss and/or Refer to a community weight control program.

exercise increases caloric utilization 5. Overweig ht people are often nutritionall y deprived. Intake must be reduced by 500 calories per day to obtain a onepound-per week Weight loss.

Assessment Subjective: nanghihina ako at walang gana kumaen as verbalized by the patient. Objective: Generalized weakness Polyphagia Polyuria Polydypsia Restlessness Drowsy Lethargy Vital Signs: Bp;130/90mmHg RR:25bpm Pr:95bpm Temp.:37.20C

Diagnosis Risk for Injury (hypoglycemia) related to effects of insulin as evidence by restlessness.

Planning Long Term: After 3 days of nursing intervention, will be able to understand whats the cause of his restlessness.

Intervention 1.Assess clients level of disorientation to determine specific requirements for safety. 2. Obtain a urine sample for laboratory analysis of substance con-tent.

Rationale 1.Knowledge of clients level of functioning is necessary to formulate appropriate plan of care. 2. Subjective history is often not accurate. Knowledge of substance ingestion is important for accurate assessment of client condition. 3. Excessive stimuli increase client agitation 4. Client safety is a nursing priority.

Evaluation Long Term: After 3 days of nursing intervention, goal, met as evidence by understanding the cause of his restlessness.

3. Place client in quiet room.

4. Institute necessary safety precautions as follows: Observe client behaviors frequently; assign staff on one-toone basis if condition is warranted; accompany and assist client when

ambulating; use wheelchair for transporting client long distances. Be sure that side rails are up when client is in bed. 5. Ensure that smoking materials and other potentially harmful objects are stored away from clients access. 6. Monitor clients vital signs every 15 minutes initially and less frequently as acute symptoms subside. 5. Client may harm self or others in disoriented, confused state.

6. Vital signs provide the most reliable information about client condition and need for medication during acute detoxification period.

Gordons
Before Hospitalization Health Perception/Management He always consult a doctor whenever he feels sick During Hospitalization He realized the good effect of always consulting a doctor. Analysis and Interpretation Normal concern regarding on his body strength and capabilities. Decreased due to patients condition.

Nutritional-Metabolic Pattern

He usually eats 45 times a day. He loves to eat food with high cholesterol .And usually drinks 6-7 glass of water a day.

He only eats 3-4 times a day; eating food with high cholesterol was minimized. And water demand was increased due to his present condition, usually 8-10 glass a day.

Elimination Pattern

He usually urinates 4-5 times a day and defecates at least once a day.

He urinates 5-6 times a day and defecates once a day.

Patient number of void decreases due to lessen amount of oral intake Patient activity is altered because of being bedridden

Activity-Exercise pattern

Sleep-Rest Pattern

Since his a jeepney driver he just seat for a longer period of time and not practicing any form of exercise. He usually sleeps 2-4 hours a day.

He just spends his time talking to his wife during hospitalization.

He now has 6-7 hours of sleep a day and can sleep very well.

Interrupted sleep during hospitalization because of environmental factors and hospital procedure Normal cognitive patterns

Cognitive-Perceptual Pattern

He was very active, alert and responsive. Can understand and

He was not that active, alert and responsive and slightly understands

speaks well.

what others telling him.

Self Perception/Concept

He takes a bath every day, always well-groomed.He has a high selfesteem

He just takes sponge bath, slightly wellgroomed. Still has high self-esteem.

Patient family was dependent on him.

Role-Relationship Pattern

He was the father and living with family happily.

He cant do the thing he used to do at home, his wife was very loving and caring, his sons and daughters visited him often due to his work.

Patient family was dependent on him.

Sexuality-Reproductive Pattern Coping-Stress Tolerance

Not Applicable

Not Applicable

Not Applicable

Whenever he feels stressed or has a problem, he just wrote all his feeling in a piece of paper then crampled and throws it, to relieve stress. The client goes to church every Sunday with his family & always prays.

Whenever he feels stressed or has a problem, he just wrote all his feeling in a piece of paper then crampled and throws it, to relieve stress.

Patients display normal psychosocial, psychosexual and cognitive development. Emotional stability

Value-Belief Pattern

He cant go to church but he still prays & has strong faith in God.

Patient has strong religious belief.

ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The bodys primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

PATHOPHYSIOLOGY

PHYSICAL ASSESMENT
Normal Findings Level of consciousness Conscious and coherent Responsive Skull Generally round, with prominences in the frontal and occipital area. (Normocephalic). No tenderness noted upon palpation. Scalp Can be moist or oily. Head (Skull, Scalp, Hair) No scars noted. Free from lice, nits and dandruff. No lesions should be noted. No tenderness nor masses on palpation. Hair Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin, coarse or smooth. Neither brittle nor dry. Eyebrows Symmetrical and in line with each other. Eyes Maybe black, brown or blond depending on race. Evenly distributed. Eyes Evenly placed and inline with Her eyes are symmetrical, black in color, almond shape. Pupils constrict when diverted to light and dilates when she gazes afar. Conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink. Normal Actual Findings The client is conscious and coherent; responsive The clients head has a round skull contour. The hair is thick, brown (on dye), and fine which is evenly distributed. The scalp is smooth and firm. No lesions noted. ANALYSIS Normal Normal

each other. Non-protruding. Equal palpebral fissure. Eyelashes Evenly distributed. The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye. Skin is same in color as in the complexion. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. Ears The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process. The ear canal has normally some cerumen of inspection. No discharges or lesions noted at the ear canal. On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color Nose - Symmetric and straight Nose - No discharge or flaring - Uniform color External nose is symmetric and straight. Cilia present upon inspection. Nasal septum is not deviated. Both nostrils are patent as each nostril is being occluded. No discharge, tenderness and lesions noted. The sinuses are Normal Ears are symmetrical with no discharge. The clients auricles have the same color as the facial skin. It is mobile, firm, and not tender. The pinna recoils often as it is folded. Moderate loud voice is needed when talking with the client. Most of the geriatric client has problem with their hearing. Thus, moderate loud voice is needed when talking with her.

- Not tender and no lesions - Patent nares - Mucosa is pink - Clear, watery discharge - Nasal septum intact and in midline Facial Sinuses - Not tender Teeth and Gums - 32 adult teeth - Smooth, white, shiny tooth enamel - Pink gums (bluish or dark patches in dark-skinned clients) - Moist, firm texture to gums - Smooth, intact dentures Tongue/Floor of the Mouth - Central position Mouth - Pink color (some brown on borders for dark-skinned clients); moist; slightly rough; thin whitish coating - Moves freely; no tenderness - No prominent veins and palpable nodules Uvula - Midline Oropharynx and Tonsils - Pink and smooth posterior wall - No discharge Neck 1.The neck is straight.

well outlined illumination.

after

trans

Has dentition. Oral mucosa and gingival are pink in color, moist, and there were no lesions or inflammation noted. Tongue is pinkish with thin whitish coating and free of swelling and lesions.

Normal

The clients head is coordinated with smooth

Normal

2.No visible mass or lumps. 3. Symmetrical 4.No jugular venous distension (suggestive of cardiac congestion) 5. The trachea is palpable. It is positioned in the line and straight. Lymph nodes 1.May not be palpable. Maybe normally palpable in thin clients. 2. Non tender if palpable. 3. Firm with smooth rounded surface. 4. Slightly movable. 5. The thyroid is initially observed by standing in front of the client and asking the client to swallow. Thyroid 1. Normally the thyroid is non palpable. 2. Isthmus maybe visible in a thin neck. Posterior Thorax - Chest symmetric - Spine vertically aligned - Skin intact; uniform temperature Thorax and Lungs - Chest wall intact; no tenderness; no masses - Full and symmetric chest expansion (3-5cm gap) - Bilateral symmetry of vocal fremitus

movements and no discomfort. The neck supports the head properly. No presence of abnormal swelling or masses. Lymph nodes are palpable. No nodules are palpable.

She has a slight deviation of respiratory rate of 22 breaths per minute. Breath sounds are clear on both lungs upon auscultation. Excursion shows a 3-cm gap during inspiration. No signs of swelling or masses noted.

Normal; slight deviation in respiratory rate (22bpm) may be possibly caused by her present condition.

Anterior Thorax - Quiet, rhythmic, and effortless respirations - Full symmetric excursion - Bronchial and tubular breath sounds upon auscultation on trachea - Neck veins JVD at 45 - Carotid arteries: - Palpation (Amplitude and contour) upstroke and amplitude are bilateral - Auscultaion no bruits - Precordium - Inspection no lifts or heaves - PMI not visible Heart - Palpation no parasternal impulses and no thrills -PMI palpable in 5th ICS, MCL, equal size - Auscultation: - S1 heard best at apex, nl intensity - S2 heart best at base, nl splitting, A2 > P2 - Extra sounds no S3, S4 - No murmurs Pulsation in apical pulse is visible. No lifts and heaves noted. Cardiac rate is 76 bpm. Blood pressure is 130/80 mmHg. Reported chest pain frequently. Common sign of HCVD CASHD is chest pain. Slight increased blood pressure of 130/80 mmHg is still manageable. Normal cardiac rate.

- Rounded shape, slightly unequal in size Breast - Same skin color as abdomen - Skin smooth and intact

The clients breast is rounded in shape, slightly unequal in size, and generally symmetric. The skin color of the breast was the same color as of the abdomen. The breast nipples are erect and not

Normal

Areola - Round/oval or bilaterally the same - Color varies (pink to dark brown) Nipples - Round, everted, and equal in size - Discharge for lactating mother Axilla - No tenderness, masses, or nodules Inspection - Unblemished skin - Uniform color - Flat, rounded (convex), or scaphoid (concave) - Symmetric contour Abdomen - Symmetric movements caused by respiration - No visible vascular pattern Auscultation - Audible bowel sounds Palpation - No tenderness; relaxed abdomen with smooth, consistent tension

inverted. No tenderness noted.

The abdomen is uniform in color. Its rounded and has a symmetric contour. No tenderness was palpated

Normal

- No edema Upper Extremities - Skin texture resilient and moist - Capillary refill test: immediate return of color (2-3 sec)

The client has a brownish complexion. A capillary refill of 3 seconds was noted. No lesions and scars noted. Able to extend arms in front or push them out to the side.

Normal

- Limbs not tender - Symmetric in size - No edema - Skin texture resilient and moist Lower Extremities - Capillary refill test: immediate return of color (2-3 sec) - Limbs not tender - Symmetric in size - Conscious and coherent - Able to respond to reflex tests Neurologic Assessment - Able to distinguish different sensory functions. The patient is conscious and responsive upon interaction. But sometimes, she cannot directly and clearly answer all questions rendered. Reflexes such as Blinking reflex and deep tendon reflex are present. She was able to distinguish touch, pain, hot, and cold. With bipedal edema, dry skin and with some lesions and bruises on legs. With color deviation, darker brown complexion compared to upper extremities. Edema on the lower extremities may indicate increased fluid retention on the body. Color deviation (darker) may indicate altered circulation of blood/oxygen throughout the body. Due to old age and present condition, her ability to answer clearly and directly is altered.

ISMN

Nitrate Vasodilator

60mg tab/ OD

Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption.

CNS: headache CV: tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension, angina, rebound hypertension, atrial fibrillation GI: nausea, vomiting, abdominal pain, incontinence GU: dysuria, urinary frequency

Give sublingual preparations under the tongue or in the buccal pouch; discourage patient from swallowing. Give oral preparation on empty stomach, 1 hour before or 2 hours after meals; take with meals if severe, uncontrolled headache occurs Assess for history of allergy to captopril and history of angioedema. Use cautiously in patients with CHF, impaired renal function, salt or fluid volume depletion, or in pregnant or lactating women. Administer 1 hr before or Or 2 hrs.

Capt opril

Angiotensin converting enzyme (ACE) inhibitor

25mg/ tab/ OD

Blocks ACE from converting angiotensin I to angiotensin II leading to 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.

CV: Tachycardia Angina ,MI, CHF Raynaud's syndrome Hypotension in salt- or volumedepleted patients GI: Gastric irritation Aphthous ulcers Peptic ulcers Cholestatic Jaundice Hepatocellular injury, Anorexia Constipation GU: Proteinuria Renal insufficiency Renal failure Polyuria,oliguria Urinary frequency Hematologic: Neutropenia

Agranulocytosis Thrombocytopenia Hemolytic anemia Pancytopenia

before meals. Watch out for excessive perspiration, or diarrhea; may cause hypotension Assess location, duration and intensity of anginal pain Monitor BP and PR before and after administering the drug.

Trime tazidi ne

Vasodilator Anti-angina

35mg/1tab/ BID

Improves myocardial glucose utilization through inhibition of fatty acid metabolism

CNS: headache, vertigo GI: nausea, vomiting

Ome prazo le

Anti- Ulcer

20mg/tab/B ID

It inhibits transport of hydrogen ions into the gastric lumen. Omeprazole increases the gastric pH and reduces gastric acid formation.

Headache Diarrhea Abdominal pain Nausea Dizziness Asthenia (loss of strength) Vomiting Constipation Upper respiratory tract infection Back pain Rash Cough

Give before meals Do not crush or chew tablets, swallow whole Evaluate for therapeutic response like relief of Gastrointestin al symptoms Question if Gastrointestin al discomfort, nausea, and diarrhea occurs.

Metf ormin

Antidiabetic drug

500mg/tab/ OD

Metformin improves hyperglycemia primarily by suppressing glucose production by the liver (hepatic gluconeogenesis)

Lactic acidosis occurs rarely (0.03 cases/ 1,000 patients) but s a serious, often fatal (50%) complication. Characterized by increase in blood lactate levels (more than 5 mmol/L), decrease in blood pH, electrolyte disturbances. Symptoms include unexplained hyperventilation, myalgia, malaise, and somnolence. May advance to cardiovascular collapse (shock), acute CHF, acute MI, and prerenal azotemia.

Inform the patient of potential risks/advanta ges of therapy and of alternative modes of therapy. Monitor fasting blood glucose, hemoglobin a, and renal function. Monitor renal function test for evidence of early lactic acidosis. Be alert to conditions that alter glucose requirements: fever, increased activity or stress, surgical procedure.

Salbu tamo l Neb.

Bronchodila tor (therapeuti c); adrenergics (pharmacol ogic)

Neb./q6

It relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles. The relief from nasal congestion and

1. Nervousness 2. Restlessness 3. Tremor 4. Headache 5. Insomnia 6. Chest pain 7. Palpitations 8. Angina 9. Arrhythmias 10. Hypertension

sounds, PR and BP before drug administratio n and during peak of medication. fore

bronchospasm is made possible by the following mechanism that takes place when Salbutamol is administered.

11. Nausea and vomiting 12. Hyperglycemia 13. Hypokalemia

paradoxical spasm and withhold medication and notify physician if condition occurs. Administer PO medications with meals to minimize gastric irritation. release tablet should be swallowedwhole. It should not be crushed or chewed. administering medication through inhalation, allow at least 1 minute between inhalation of aerosol medication.

Laboratory
Diagnostic/ laboratory procedure Date ordered and date result/s in Indication or purposes Result Normal used values (units in the hospital) Significance and Interpretation Reports The result is within normal values.

Electrolytes
Na K Date ordered: 9/6/11 Date Received: 9/7/11

Tests that measure the concentration 134.6 of electrolytes 3.25 are needed for both the diagnosis and management of renal, endocrine, acid-base, water balance, and many other conditions. It is the area of pathology that is generally concerned with analysis of bodily fluids.

135-145 3.4-4.0

Clinical Chemistry
ALP (Alkaline Phosphates) ALT/SGPT Cholesterol Creatinine FBS (Glucose) Total Protein Albumin Globulin A/g Ratio Uric Acid (BUA)

Date ordered: 8/1/11

77.9 28.4 56.3 1.19 80.1

35-129 10-50 0-38 44-106 64-83

Date Received 8/2/11

Some of the result is below or above normal range which indicated that there is something wrong in the release or secretion of body fluids.

8.7 3.3 5.4 1.6 9.72 Date ordered: Urinalysis are performed for

4.11- 5.9 3.4-4.8 3.0-3.5 1.1-1.8 0.14-0.41

Urinalysis

Color

9/7/11 Date Received 9/7/11

several reasons: general evaluation of health diagnosis of metabolic or systemic diseases that affect kidney function Diagnosis of endocrine disorders. Twenty-fourhour urine studies are often ordered for these tests diagnosis of diseases or disorders of the kidneys or urinary tract monitoring of patients with diabetes testing for pregnancy screening for drug abuse

Orange

Pale yellow Straw to amber Clear to slightly hazy Acidic 1.016- 1.022 Normal Normal

Transparency

Hazy

Reaction Specific Gravity Albumin Sugar RBc Pus cells Squamous cells Bacteria

5.0 1.016

Positive Negative 0-1 1-3 Few Few Few

Negative Negative Glycosuria and Proteinuria due to increased glomerular permeability and presence of bacteria and pus cells for infection.

Negative Negative Negative

Hematology
Hemoglobin

Date ordered: 9/7/11 Date Received

It measures the total amount of hemoglobin

151g/ml

120-180 gm/l

The result is within normal values.

9/8/11

in the blood , to determine the oxygen carrying capacity of the blood.

Hematocrit

It measures .467 the percentage of RBCs in the total blood volume. It determines the number of circulating WBCs of the whole blood. 8.2

0.370-0.540

The result is within normal values.

Leukocyte

4.6-10.0

The result is within normal values.

Platelet count

271 To evaluate platelet production. to assist in the diagnosis of bleeding disorders and to monitor patients who are being treated for any disease involving bone marrow failure

150-450

The result is within normal values.

DISCHARGE PLANNING

Medicine: Ceftazidime 1g/IV/Q8 Aminoleban 1sachet/BID Kalium Duruyle 1tab/PO/TID Furosemide 40mg/IV/Q8 ISMN 60mg tab/PO/OD Captopril 25mg tab/ PO/OD Trimetazidine 35mg/tab/PO/BID Omeprazole 20mg/tab/PO/OD Metformin 500mg/tab/PO/OD Salbutamol neb Q6 Encouraged to take medications on time as prescribed by his physician. Report any adverse effect when taking the prescribed drug such as nausea and vomiting or skin allergies. Instruct not to take other medications without consulting with the physician to prevent any harmful drug-drug interactions.

Exercise: Encouraged patient to have adequate rest periods and sleep to promote faster recovery. Encourage client to do deep breathing exercise to promote circulation of blood and relaxations. Avoid lifting heavy objects. Advised client and family members to try to have or maintain safe, clean, comfortable and calm environment.

Treatment: Advised client or significant others to take in time prescribed medicines especially for high blood pressures.

Health Teaching: Encouraged to elevate the part where there is edema Teach the client to follow all the instructions including medications, diet regimen and dos and don'ts that was instructed to him by the physician. Teach the patient to ensure rest for himself as much as possible. Encouraged the patient to comply with the medication as ordered by his physician. Explain the importance of adhering to his treatment regimen.

Out- patient referral:

Inform the patient to have follow-up check-ups to prevent further complications and to update the medical team concerning the progress of the patients condition and to promote continuity of care. Encourage him to comply with all the modifications and instructions given to her. Advised significant others to immediately consult her physician if signs and symptoms of the diseases occurs or persist.

Diet: Emphasized limit fluid of intake. Keep on low fat, low sodium, full-diabetic diet. Encouraged to eat fruits and vegetables. Instructed to eat meals on time with proper diet.

SPIRITUAL Instruct client to attend mass every Sunday. Advised relatives or significant others to provide moral support and widen their understanding. Also tell them to pray for the client to help with the recovery.