Ateneo de Zamboanga University

College of Nursing

A PATIENT WITH DIABETIC KETOACIDOSIS

Obsiana, Eric Jones E.

Padaca, Niño Matrix L.
Pison, Adcel John S.
Rasonable, Alodia J.
Robinson, Ruth Margaret G.
Salvador, Orlando C.
Sayson, Lyka Rendzel M.
Soon, Fatima Zaffrata S.
Sulaiman Princess Nika N.

S.Y. 2023 - 2024

1st Semester
I. INTRODUCTION

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of

diabetes. DKA mainly occurs in patients with type 1 diabetes, but it is not uncommon in

some patients with type 2 diabetes (Hamdy, 2021). Diabetic ketoacidosis is less common to

patients diagnosed with type 2 diabetes mellitus, but it may occur in unusual physiologic

stress situations. According to Brutsaert (2022), Ketosis-prone type 2 diabetes is a variant of

type 2 diabetes, which sometimes occurs in obese patients. Patients with ketosis-prone

diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell

function with hyperglycemia, and are therefore more likely to develop DKA when significant

hyperglycemia occurs.

Insulin plays a vital role in helping sugar, a major source of energy for muscles and

other tissues, enter the cells of the body. The body cannot use sugar to make the energy that

the body needs without having enough insulin which leads to buildup of acids through the

bloodstream which is what we call ketones. Ketones build up in the blood and eventually spill

over into the urine. (Mayo Clinic, 2022). When left untreated, this build up can lead to

Diabetic Ketoacidosis, learning its warning signs and seeking immediate emergency care is a

must for this type of condition.

In the scenario, the loss of consciousness and difficulty of breathing (Kussmaul

breathing) that the patient experienced prior to admission are signs and symptoms of diabetic

ketoacidosis. The clinical presentation of DKA usually includes manifestations of

hyperglycemia such as increased urination, increased thirst, weakness and weight loss. In

severe cases, manifestations of acidosis such as lethargy, stupor, loss of consciousness and

respiratory compromise may appear. (Umpierrez & Freire, 2002). Physical examination

should include assessment of mental status, volume status and a focused systematic
examination. Patients usually present with signs of volume depletion such as tachycardia,

hypotension, decreased skin turgor and dry oral mucosa. Temperature can be normal or even

low in the presence of infection, mainly because of peripheral vasodilation. Other physical

signs may include Kussmaul respirations (rapid and deep breathing) with acetone (fruity)

breath odor, alteration in mental status, shock and coma. (Kitabchi et al., 2009). Along with

being diagnosed of diabetic ketoacidosis, the patient is also having comorbidities such as

hypertensive urgency and community acquired pneumonia at moderate risk. Diabetes is a

chronic condition with a range of symptoms to manage. It can also weaken your immune

system and leave you at greater risk of serious infections such as pneumonia. High blood

sugar levels caused by diabetes can also make it harder for your body to fight pneumonia

once it develops. This can lead to more severe cases of pneumonia and increased

complications, including organ damage, respiratory failure, and even death. (Srakocic, 2022).

In patients having hypertensive urgency might not necessarily cause diabetic ketoacidosis

but, it could increase someone developing diabetes when they have high blood pressure. High

blood glucose levels can cause widespread damage to tissues and organs, including those that

play a key role in maintaining healthy blood pressure. For example, damage to the blood

vessels and kidneys can cause blood pressure to rise. (Barhum & Sisson, 2023).

Early identification of factors can contribute to preventing harm and protect patients

from any associated complications. Studying complex competencies such as Diabetic

Ketoacidosis is not easy, considering DKA is very threatening to patients, fast and precise

action becomes very important. Knowledge and skills to combine, including leadership,

communication, teaching, and research, are urgently needed in the practice to improve patient

care so that learning using a simulation approach is essential. (Scientific Research, 2018).

Proper management of DKA requires hospitalization for aggressive intravenous fluids,

insulin therapy, electrolyte replacement as well as identification and treatment of the

underlying precipitating event along with frequent monitoring of patient's clinical and

laboratory states. (Eledrisi & Elzouki, 2020). Improvement in outcomes may include quicker

resolution of DKA and increased adherence to fluid resuscitation and electrolyte replacement

guidelines, decreased hospital admissions and length of stay, and cost savings. (Kreider,

2018).

A. SIGNIFICANCE OF THE STUDY

This study can contribute to the following:

1. Nursing Education

The study can contribute to a thorough understanding on the care given to patient with

diabetic ketoacidosis especially the early recognition to factors and physiologic stress

that could contribute to preventing harm and protect patient from associated

complications as well the proper education given to patient on the management of

diabetic ketoacidosis. While diabetic ketoacidosis continues to be a priority cause for

hospital admission, infections and nonadherence to insulin therapy remains as its

common causes. Prevention of DKA through structured educational programs and

identification of risk factors for recurrence should be part of the patient’s care plan.

(Eledrisi & Elzouki, 2020).

2. Nursing Practice

This study is also to contribute to health care providers about diabetic

ketoacidosis and providing holistic care considering not only physical but also

emotional and psychosocial needs of the patient. It is important for Nurses to know

the common clinical manifestations of DKA so they can anticipate and assist with
 preventing complications and to evaluate the effectiveness of medical treatment

(Schmitz, 2000). Given that evidence suggests that DKA onset and recurrence may be

largely related to education deficits and psychosocial considerations, Nursing

Practitioners are well prepared to assess and intervene for high-risk patients. Nurse

practitioners should assess patients with diabetes for need for educational coaching,

self-management skill level, self-efficacy, emotional status, and social support.

(Kreider, 2018).

3. Nursing Research

It is well known how the healthcare environment changes as time passes, but it

doesn’t change the fact that as health care workers or as nurses, our one and only goal

is to provide the best patient care and improve it. As researchers make discoveries, the

practice of nursing continues to change (Why Do Nurses Need Research, 2017). Thus,

this study could contribute to research in terms of the knowledge and decision-making

in care for patients with diabetic ketoacidosis and maybe future research, knowing

how high-risk of condition it is, would help discover for a more specialized care that

would also contribute an improved nursing care to decreasing hospital admission and

much more improved teaching on self-management of the patient. Every nurse can

benefit from knowing why nursing research is important, how research is conducted

and how research informs patient care. Bachelor of Science in Nursing (BSN)

programs teach nurses to appreciate and use research in their everyday careers,

compare findings and read published research (Why Do Nurses Need Research,

2017).
B. OBJECTIVES

General Objectives

Acquisition and application of knowledge, skills and attitude through

utilization of nursing process and performance of professional management and

leadership skills in the care of sick adults, clients with life-threatening conditions,

acutely-ill/ multi-organ problems, high acuity and emergency situations towards

health promotion, disease prevention, restorance, maintenance and rehabilitation.

Specific Objectives

● Determine the patient's problem using the Nursing Health History and Gordon’s 11

health patterns accurately;

● Assess early detection of patient’s problem (Diabetic Ketoacidosis) by determining

the factors that lead patient to be diagnosed with this problem correctly;

● Conduct a physical assessment following the Bates’ Cephalocaudal Assessment tool

thoroughly;

● Determine the result of the diagnostic test with its laboratory result by interpreting if it

is under normal or abnormal findings comprehensively,

● Discuss the importance of the test by determining the clinical significance

appropriately;

● Acquire knowledge on the administered medication as ordered guided with the

provided drug study comprehensively;

● Formulate a nursing care plan appropriate to the patient’s condition constructively;

● Conduct a health teaching to patient and significant other in line with nursing care

given thoroughly;

● Evaluate the clinical performance rendered based on the effectiveness of the

interventions given for a goal met in the patient's health outcomes honestly.
C. ANATOMY AND PHYSIOLOGY

Figure 1. Endocrine System

The endocrine system is a major controlling system of the body. Through hormones,

it stimulates such long-term processes as growth and development, metabolism, reproduction,

and body defense. Compared to other organs of the body, the organs of the endocrine system

are small and unimpressive. The endocrine system also lacks the structural or anatomical

continuity typical of most organ systems. Instead, bits and pieces of endocrine tissue are

tucked away in widely separated regions of the body. However, functionally the endocrine

organs are impressive, and when their role in maintaining body homeostasis is considered,

they are true giants. (Elaine, 2015).

Endocrine system is a series of glands which includes Adrenal glands, Thyroid gland,

Pituitary gland, Parathyroid gland, and Pancreas that secrete hormones that the body uses for

a wide range of functions, including regulating blood pressure. The liver plays a key role in

diabetic ketoacidosis, it occurs when the body isn't producing enough insulin to let blood

sugar enter the cells for energy utilization. Instead, the liver converts fat into ketone-

producing acids through a process called lipolysis. When ketones are created excessively

quickly, they might accumulate in the body at dangerous levels.

 Figure 2. The pancreas

The pancreas is located behind the stomach in the upper left abdomen. It is

surrounded by other organs including the small intestine, liver, and spleen. It plays an

essential role in converting the food we eat into fuel for the body's cells. The pancreas has

two main functions: an exocrine function that helps in digestion and an endocrine function

that regulates blood sugar.

Exocrine glands in the pancreas create digestive enzymes that are vital. These

enzymes break down proteins using trypsin and chymotrypsin, carbohydrates using amylase,

and lipids using lipase. Islet cells, or islets of Langerhans, make and release essential

hormones into the bloodstream as part of the pancreas' endocrine system. Insulin, which

lowers blood sugar, and glucagon, which increases blood sugar, are two of the main

pancreatic hormones.
 Figure 3. Respiratory System

The organs of the respiratory system include the nose, pharynx, larynx, trachea,

bronchi and their smaller branches, and the lungs, which contain the alveoli, or terminal air

sacs. Because gas exchanges with the blood happen only in the alveoli, the other respiratory

system structures are really just conducting passageways that allow air to reach the lungs.

However, these passageways have another, very important job. They purify, humidify, and

warm incoming air. Thus, the air finally reaching the lungs has many fewer irritants (such as

dust or bacteria) than when it entered the system, and it is warm and damp. (Elaine, 2015)

Cells in the body require oxygen to survive. Other gasses as well as oxygen are

present in the air we breathe. The primary function of the respiratory system is to introduce

fresh air into the body while expelling waste gases. After entering the lungs, oxygen travels

through the body's bloodstream. The waste gas carbon dioxide is exchanged for oxygen at

each cell in the human body. This waste gas is then transported by the bloodstream back to

the lungs, where it is expelled after being eliminated from the bloodstream. Gas exchange, a

crucial activity carried out automatically by the lungs and respiratory system, is a

fundamental function.

D. PATHOPHYSIOLOGY
 Figure 4. Physiologic process involved in Pathophysiology of Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) is a severe and life-threatening complication of

diabetes, with its pathophysiology occurring at the cellular level. DKA primarily afflicts

individuals with type 1 diabetes, but it can also affect some with type 2 diabetes. The disease

process begins with a significant deficiency of insulin, often absolute in type 1 diabetes and

relative in type 2 diabetes. This deficiency results in uncontrolled hyperglycemia, causing

blood sugar levels to soar, and glucose to remain outside the cells where it's needed for

energy.

In response to the insufficient glucose utilization, the body resorts to lipolysis,

breaking down stored fat to provide an alternate energy source. This process releases fatty

acids into the bloodstream. These fatty acids are then absorbed by the liver and converted into

ketone bodies, such as acetoacetate and beta-hydroxybutyrate, in a process known as

ketogenesis. The accumulation of ketone bodies in the bloodstream is a hallmark of DKA.

Ketones, being acidic compounds, lower the blood's pH, inducing a state of acidosis. Along

with acetoacetate and beta-hydroxybutyrate, the ketone bodies also include acetone, which

can cause the breath to have a distinct fruity odor. Metabolic acidosis ensues as the
accumulation of ketones causes the blood pH to become more acidic. Acidosis impairs

normal cellular function and can lead to severe complications.

Symptoms of DKA include polyuria (increased urination) and polydipsia (extreme

thirst) resulting from hyperglycemia, as well as fatigue, abdominal pain, fruity-smelling

breath, rapid and deep breathing (Kussmaul respirations), nausea, vomiting, and altered

mental status.

The causes of DKA primarily revolve around a lack of sufficient insulin. This can be

due to missed insulin doses, inadequate insulin dosage, infections or illnesses that increase

the body's demand for energy, high-stress situations or trauma, and other conditions that

elevate stress hormones. The interplay of insulin deficiency, hyperglycemia, lipolysis,

ketogenesis, and acidosis characterizes the complex pathophysiology of DKA, leading to the

clinical symptoms and complications associated with the condition. Early recognition and

prompt treatment are essential to prevent severe consequences.

Moreover, Pneumonia can develop as a complication to DKA. The following is the

pathophysiology of Pneumonia associated with DKA. First, stress and Infection: Pneumonia,

as a severe respiratory infection, induces stress on the body. Infections generally trigger a

stress response, releasing stress hormones like cortisol and adrenaline. These hormones

antagonize the effects of insulin, leading to increased blood glucose levels, especially in

individuals with diabetes. It can also be due to Insulin Resistance. Infections, including

pneumonia, can lead to insulin resistance, rendering insulin less effective. Even if a person

with diabetes continues to take their insulin as prescribed, it may not adequately control

blood glucose levels due to the counteraction of stress hormones. This results in uncontrolled

hyperglycemia, setting the stage for DKA.

Organs and Cellular Processes Affected by Diabetic Ketoacidosis:

DKA affects various organs and cellular processes:

1. Pancreas

The pancreas, responsible for insulin production, cannot secrete enough insulin to

control blood glucose levels during DKA.

2. Liver

The liver plays a significant role in DKA. In response to insulin deficiency, the liver

engages in excessive gluconeogenesis (glucose production) and releases stored

glucose, further elevating blood sugar levels.

3. Adipose Tissue (Fat Cells)

As insulin levels decrease, adipose tissue releases fatty acids through lipolysis. These

fatty acids are transported to the liver to produce ketone bodies.

4. Ketogenesis

Ketogenesis, which occurs in the liver, leads to the production of ketone bodies

(acetoacetate, beta-hydroxybutyrate, and acetone). This is a key characteristic of DKA

and contributes to metabolic acidosis.

5. Blood pH Regulation

The accumulation of ketone bodies disrupts the body's normal acid-base balance,

causing metabolic acidosis. This disturbance impacts normal cellular functions and

can lead to severe complications.

6. Kidneys

The kidneys play a role in excreting excess ketones and glucose in an attempt to

correct hyperglycemia and acidosis.

7. Lungs

To compensate for metabolic acidosis, the respiratory system increases its rate and

depth, leading to rapid and deep breathing (Kussmaul respirations) as the body tries to

expel excess carbon dioxide to regulate blood pH.

 8. Cardiovascular System

Diabetic Ketoacidosis can affect blood pressure and circulation, potentially leading to

shock if not treated promptly.

9. Central Nervous System

Altered mental status is common in DKA due to the effects of acidosis on the brain.

II. NURSING PROCESS:

A. Assessment

o Biographic data

i. Name: Abdulrajak, Shievalyn Bahari

ii. Address: Mangga Drive, Suterville, Zamboanga City

iii. Age: 51 years old

iv. Birthdate: March 12, 1972

v. Sex: Female

vi. Race: Filipino

vii. Marital Status: Married

viii. Occupation: Housewife (retired Hemodialysis Nurse)

ix. Religious Orientation: Islam

B. COMPREHENSIVE NURSING HISTORY

i. History of present Illness

 Patient Abdulrajak, Shievalyn Bahari, a 51-year-old housewife.Patient is a known

diabetic for 10 years and under maintenance medication of Metformin 500 mg. Patient was

complaining about loss of consciousness and difficulty breathing. Upon admission, her vital

signs are as follows: temperature: 36.0, Pulse rate: 121 bpm, Respiratory Rate: 38 b/min,

Blood pressure: 220/140, and Oxygen saturation: 95%. Complete Blood Glucose was also

taken as 634 mg/dl and the patient's weight was 65 kilograms. Patient is a known diabetic for

10 years and under maintenance medication of Metformin 500 mg. Other medications

include Nicardipine for hypertension, Regular Insulin and Insulin Glargine and Piperacillin +

Tazobactam.

ii. Past Illness

Previous admission was in 2021, due to severe covid and bronchial asthma. Patient

also has diabetes mellitus type 2 for 10 years.

iii. Family History

The patient's father and mother are both diagnosed with diabetes mellitus,

hypertension and tuberculosis.

vi. Marjorie Gordon’s 11 Health Functional Problem

Health Perception and Health Management

Prior to admission, Patient stated her unhealthy food intake, such as skipping

breakfast, drinking soft-drinks and drinking less water. The patient has been a known diabetic

for ten years and is under the maintenance medication of Metformin 500 mg. When she

experienced a productive cough associated with pleuritic chest pain, she took lagundi as an

alternative to relieve her pain and cough. During admission, patient SBA stated that she is

feeling fine but, the patient stated that she is a bit anxious about her health condition, and

does not want to be a burden to her husband.

Nutritional Metabolic Pattern

Prior to admission, the patient verbalized that she usually skips breakfast, and only

eats two-times a day. Whenever she feels hungry, she goes out to buy snacks and soft-drinks.

The patient drinks water less than the recommended amount in a day, and she often drinks

soft-drinks. During admission, the patient did not have any eating discomforts nor did she

lose weight after being admitted, her weight maintained at 65kg.

Elimination Pattern

Prior to admission, the patient verbalized that she has an irregular bowel elimination,

she usually defecates once or twice in a week with a stool consistency that is firm and soft,

she also urinates more often. During admission, she does not have any discomfort when

defecating. The patient stated that she still urinates more than usual, which the color of the

urine is reported to be tea-colored.

Activity-Exercise Pattern

She mentioned that before admission, she is able to do daily activities that she usually

does, and on leisure times, she just takes a seat and relaxes. The patient’s mobility is not

hindered, however, five days prior to admission, she started feeling chest pain, which limited

her activities. During admission, the patient verbalized that she is not into exercising, and

does her relaxation by resting and having a sit.

Cognitive Perceptual Pattern

Upon assessment, the patient experiences no difficulty in hearing, nor does she have

bad vision. She also doesn’t experience any changes in her memory. The patient is oriented to

time, place, and person.

Sleep and Rest Pattern

 Prior to admission, the patient mentioned that usually she is only able to have two

hours of sleep at night. Which causes her to wake up late and skip breakfast. During

admission, the patient stated that she sometimes experiences difficulty in sleeping due to

frequent urination brought on by the Diabetic Ketoacidosis. She mentioned that she just sits

down whenever she wants to relax, and takes naps during the afternoon.

Self-Perception and Self-Concept Pattern

Prior to admission, the patient mentioned that she didn’t have any problems with

herself nor did she feel bad about herself. However, during admission, the patient stated that

she feels anxious about her condition and what’s going to happen next, but other than that,

the patient doesn’t seem to have any problem with her self-body image, and capabilities.

Role-Relationship Pattern

The patient has a good relationship with her husband. She mentioned that her husband

is the one who manages the things needed to be done, especially paying the hospital bills. She

also mentioned that her husband is the one that is there by her side whenever she feels

anxious.

Sexuality and Reproductive Pattern

The patient verbalized that she did not have any problem with her sexuality pattern

and reproductive functions. She seems to have a satisfied and proper sex life with her

husband, one that is healthy and lively.

Coping-Stress Tolerance Pattern

Prior to admission, the patient stated that to relieve stress after her work she sits down

and watches television to relax herself. During admission, to relax herself she still does sitting

and resting whenever she feels like having difficulty breathing. Most of the time, her

husband is the one that talks with her and reassures her whenever she feels anxious or
stressed. She also stated that praying also helps her to cope up with the stress and anxiety she

is feeling.

Value Belief Pattern

The patient’s religion is Islam, and she is a firm believer of Allah. Praying helps the

patient to cope up with the stress and anxiety she is feeling. She believes in the Arabic

expression “Inshallah” which means “If God wills”, and surrenders her problems to Allah,

whom she believes helps her during hard times.

v. Physical Assessment

MENTAL STATUS
APPEARANCE

Grooming: Well-groomed Attire: _Casual attire

Personal Hygiene: Good
Gait: __not assessed_____ Posture: __not assessed_____ General Body Built: ___not
assessed___

BEHAVIOR
Level of Consciousness:
(✔) Awake ( ) Alert ( ) Lethargic
( ) Drowsy ( ) Stuporous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression: No facial grimace Speech: normal and comprehensible
Mood: stable Affect: __________________________

COGNITION

Oriented: (✔ )Person (✔) Place (✔ ) Time ( ) Confused ( ) Sedated

( ) Alert ( ) Restless ( ) Lethargic ( ) Comatose
Recent Memory: can recall what happened before admission
Remote Memory: can recall what food she usually eats

THOUGHT PROCESS

Thought Content: ( ) Logical (✔ ) Consistent

Client’s Perceptions: ( ) Reality-base (✔ ) Congruent with others
( ) Others: _______________
Suicidal Thoughts/Ideation: ( ) Present (✔ ) Absent
 INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: ( ) Normal ( ) Flushed (✔) Pale( ) Dusky
( ) Cyanotic ( ) Jaundiced ( ) Others: _________________________
Texture: smooth Tone: medium brown
Lesions: ( ) Yes, site: ______________ (✔ ) No
PALPATION
Moisture: ________a bit dry________ Temperature: ___________36.0 C_______
Turgor: _____normal______
Edema: ( ) Absent ( ✔ ) Present, site: ___lower legs or feet____________
( ) Mild ( ✔ ) Moderate ( ) Severe
Pruritus: ( ) Yes, site: _________________ (✔ ) No
Wound incision/pressure sore site: ____not assessed__ Dressing type: __not
assessed________
Odor: ( ) None ( ) Mild ( ) Foul
Drainage/Exudates: ( ) Serous ( ) Sanguinous ( ) Serosanguinous
Color: ( ) Yellow ( ) Creamy ( ) Green ( ) Beige/tan

NAILS
INSPECTION
Color: ____white______ Texture: _____smooth______ Configuration:
______________
Symmetry: _____symmetrical______ Cleanliness: ____well- groomed and clean____

HEAD AND NECK

HEAD
INSPECTION
Head Structure and symmetry: _______round, symmetrical, and normocephalic___
Hair Color: ____black_______ Thinning: ( ) Yes (✔) No
PALPATION
Temporal Artery: __not assessed_______
Cranium: ___not assessed________ Scalp: _____not assessed_____
Hair Texture: __smooth________
Maxillary & Frontal Sinuses: _____not assessed__________

EYES
INSPECTION
Conjunctiva: R: __normal__ L: _normal__ Sclera: R: ___normal__ L: ___normal____
Cornea: R: _________ L: _________ Iris: R: ___normal____ L:
___normal____
Ptosis: R: _________ L: _________
Visual Fields: R: _________ L: _________
Extraocular movements: : R: _______ L: _______
Pupil: Color: R: _________ L: _________ Size: R: _________ L: _________
Response to Light & Accommodation: R: _________ L: _________
 NOSE
INSPECTION
External Nose: ________symmetrical with no discoloration____________
Nostrils: R: _________ L: _________

MOUTH
INSPECTION
Mouth & Throat Mucosa: _____________________ Tongue: ____________________
Teeth and Gums: ____________________________
Floor of Mouth: _______________ Palate: _______________ Uvula:
______________
Lesions and Ulcers: ( ) Yes, site: ______________ (✔ ) No
Salivary Glands: ________________________

FACE
INSPECTION
Spasms: ( ) Yes, site: __________ (✔ ) No
Tics: ( ) Yes, site: __________ (✔ ) No
Lesions: ( ) Yes: ( ) Mild ( ) Moderate ( ) Severe (✔ ) No
Facial Paralysis: ( ) Yes R: _________ L: _________ (✔ ) No

EARS
INSPECTION
Tympanic membrane: R: Intact (✔ ) Yes ( ) No L: Intact (✔ ) Yes ( ) No
Tragus of Ear: R: _________ L: _________
Canal: R: _________ L: _________
Lesions: ( ) Yes, site: ___________ (✔ ) No
Discharges: ( ) Yes, amount: ________ ( ) Left ( ) Right ( ) Both (✔ ) No

NECK
PALPATION
Thyroid gland size: ______normal_____ Shape: ______symmetric______
Tenderness: ______none_______ Nodules: _______none____
Position of Trachea: ____not assessed____________
Cervical Lymph Nodes: _________________none_____________

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: ____38 b/pm_____
Pattern: ( ) Shallow (✔ ) Dyspnea ( ) Tachypnea ( ) Shortness of Breath
Chest Symmetry: (✔ ) Even ( ) Uneven
Chest Deformities: ( ) Scoliosis ( ) Kyphosis ( ) Kyposcoliosis
PALPATION
Chest: ( ) Masses, site: ____________
( ) Bulges, site: ____________
 ( ) Muscle Tone, site: ______________
( ) Crepitus, site: ______________
( ) Areas of Tenderness, site: ______________
( ) Subcutaneous Emphysema, site: ______________
Excursion: ( ) Respiratory: R: ______cms. L: ______cms.
PERCUSSION
Notes elicited: ______________ Site: __________________
AUSCULTATION
Excursion: ( ) Diaphragmatic: R: ______cms. L: ______cms.
Breath Sounds:
Normal: ( ) Bronchial ( ) Bronchovesicular ( ) Vesicular
Adventitious: ( ) Crackles-Coarse, site: ____________
( ) Crackles-Fine, site: ____________
( ) Stridor, site: ____________
( ) Rhonchi/Gurgles, site: ____________
( ) Wheezes, site: ____________
( ) Pleural Friction Rub, site: ____________
Other Abnormal Findings: Voice Resonance:
( ) Bronchophony ( ) Egophony ( ) Whispered
( ) Pecteriloquy ( ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough: ( ) Yes: Type: ( ✔ ) Productive:
Color of Sputum: ___not assessed____ Amount: _not
assessed____
( ) Non-productive ( ) No

CARDIOVASCULAR SYSTEM
NECK VESSELS
PALPATION
Carotid Artery: R: ____not assessed______ L: _____not assessed_____
AUSCULTATION
Carotid Arteries: Bruits: (✔ ) Absent ( ) Present
Jugular Vein Distention: ( ) Yes: _______cms. ( ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): ___not assessed_______
Thrills: ( ) Present ( ) Absent
PALPATION – Perfusion: Capillary Refill: _____seconds
Murmurs: ___________

PULSES
(✔ ) Regular ( ) Strong ( ) Irregular ( ) Weak ( ) Absent
( ) Doppler ( ) Pacemaker
Radial: R: ____________ L: ____________
Pedal: R: ____________ L: ____________
Apical: R: ____________ L: ____________
BP: R: ____________ L: ____________
 GASTROINTESTINAL SYSTEM
Mouth: ____no lesions, nodules, or swelling _____________
Throat: ____no lesion, nodules, or swelling___________________________

ABDOMEN
INSPECTION
Contour: ____SLIGHLTY ROUND____ Symmetry: _______ symmetrical _________
Gastrostomy (specify):
_____________________________________________________
AUSCULTATION
Bowel sounds: (✔ ) High-pitched & Gurgling ( ) Hyperactive
( ) Low-pitched ( ) Hypoactive
( ) Tympany
Rate:___20___per minute
PERCUSSION
Notes: ______not assessed_________________ Site:___not
assessed__________________
PALPATION
Abdomen: ( ) Tender ( ) Soft/Non-Tender ( ) Firm ( ) Rigid
Mass: (✔ ) No ( ) Yes
Ascites: ( ✔ ) No ( ) Yes
Girth: ___not assessed_______ Inguinal Area:__not assessed____________

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry:_________symmetrical__________ Deformities:_________none________
Others: _________________
Peripheral pulses:
Upper Extremities: Radial: R: _____2+_____ L: _____2+_____
Ulnar: R: ____________ L: ____________
Brachial R: ____________ L: ____________
Lower Extremities: Popliteal: R: ____________ L: ____________
DorsalisPedis: R: ____________ L: ____________
Posterior Tibia:R: ____________ L: ____________
Edema: ( ) Yes ( )Pitting (Grade) _________ (✔) No
Temperature: ___________________________ Site: __________________________
RANGE OF MOTION: (✔ ) Yes ( ) No, area: _________________
Deformity:
______________________________________________________________
Discrepancy in Extremity (Leg) Length ( )Yes ______________ ( ) No
PALPATION
( ) Musculature ________________ ( ) Body articulation_____________________
( ) Crepitations ________________ ( ) Heat________________________________
( ) Swelling ____________________ ( ) Tenderness___________________________
Normal ROM of extremities: (✔ ) Yes ( ) No
( ) Weakness ( Paresis) ( ) Paralysis
( ) Contractures ( ) Joint Swelling
( ) Pain: ( ) Bone Pain ( ) Muscle Pain ( ) Joint Pain
( ) Others: __________________________________________
Hand Grasps: (✔ ) Equal ( ) Unequal ( )Weakness ( ) R & L
Leg muscles: (✔ ) Equal ( ) Unequal ( ) Weakness ( ) R & L

NEUROLOGIC SYSTEM
CRANIAL NERVES
Olfactory Nerve (CN I)
Can distinguish smells
Optic Nerve (CN II)
Can properly see, read notes, and determine objects
Oculomotor (CN III)
Expresses normal extraocular activities, and has normal reaction to light
Trochlear (CN IV)
Able to move eye balls obliquely
Trigeminal Nerves (CN V)
Able to distinguish different stimuli, and clench teeth
Abducens Nerve (CN VI)
Able to to move eyes ball laterally
Facial Nerve (CN VII)
Able to express normal facial expressions
Acoustic Vestibulocochlear Nerve (CN VIII)
Is ble to hear normall
Glossopharyngeal Nerve (CN IX)

Vagus Nerve (CN X)

Able to swall without any difficulty
Spinal Accessory Nerve (CN XI)

Hypoglossal Nerve (CN XII)

Able to pertrude tongue and can move it from side to side

CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: ( ) Yes ( ) No
Detect Vibration: ( ) Yes ( ) No
Discriminate Light Touch: ( ) Yes () No
Detect Temperature: ( ) Yes ( ) No
Detect Stereognosis: ( ) Yes () No
Detect Graphesthesia: ( ) Yes () No
Two-Point Discrimination: ( ) Yes () No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
________________________________________________________________
 ______
Insertion Tendon of Triceps (C7 to C8)
________________________________________________________________
______
Insertion Tendon of Brachioradialis (C5 to C6)
________________________________________________________________
______
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
________________________________________________________________
______
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
________________________________________________________________
______

SUPERFICIAL REFLEXES

Abdominal (upper T8 to T10, lower T10 to T12)

________________________________________________________________
______
Cremasteric Reflex (L1 to L2)
________________________________________________________________
______
Plantar Reflex
________________________________________________________________
______

GENITOURINARY
PERIANAL REGION
INSPECTION

( ) Hemorrhoids: ( ) Bleeding ( ) Not

( ) Fissures ( ) Scars ( ) Lesions ( ) Rectal Prolapse
( ) Fistula ( ) Discharge ( ) Blood in stool

PALPATION
( ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution: ________________________________________________________
Penis: Dorsal Vein: ( ) Yes ( ) No
Urethral Meatus Appearance: ___________Not assessed_____________________
Bumps: ( ) Yes, site: ___________ ( ) No
Blisters: ( ) Yes, site: ___________ ( ) No
Lesions: ( ) Yes, site: ___________ ( ) No
Redness: ( ) Yes, site: ___________ ( ) No
Scrotum: R: ____________ L: ____________
Urine: Color: ______________________ Character: ____________________
Frequency per day: ___________ Amount: _____________________
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): ______________________
Others (specify): _________________________

FEMALE GENITALIA
INSPECTION
Mons Pubis: _______________________ Labia Majora: ______________________
Labia Minora: _____________________ Clitoris:
____________________________
Vagina: _____________Not assessed_________ Urinary Meatus:
____________________
Skene’s and Bartholin’s Glands: ____________________________________________
Urine: Color: ______________________ Character: _____________________
Frequency per day: ___________ Amount: ______________________
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): ______________________
Other:_________________________
LMP: _________________________________ ( ) Vaginal Discharges: ___________
Menstrual Problems:
( ) Amenorrhea ( ) Dysmenorrhea ( ) Menorrhagia
( ) Metrorrhagia ( ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche: ________________ Length of Cycle: ____________________
Menopause: _____________________ Last Pap Smear: ____________________
Monthly Breast Self Examination( ) Yes ( ) No
Method of Birth Control: _____________________________
Obstetrical History: G___ P___A___L___ AOG______
POP: ______ Weight: ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: _____________________
Urine Test Result: ___________________ Pregnancy Test: ___________________
( ) Albumin _______ ( ) Sugar ________
( ) Protein _______ ( ) RBC ________ ( ) Pus ________
Bleeding: ( ) Yes, amount: ___________ ( ) No
Uterine Discharges:
Rubra: Color_______ Amount________ Odor_________
Serosa: Color_______ Amount________ Odor_________
Alba: Color_______ Amount________ Odor_________

PSYCHOSOCIAL
Recent Stress: ______paying the bills in the hospital and her
illness__________________________
Coping Mechanism: ______________her family’s support and
praying__________________
Support System: _________________her family_____________________
Calm: (✔ ) Yes____________________ ( ) No______________________
Anxious: ( ✔ ) Yes____________________ ( ) No______________________
Angry: ( ) Yes____________________ (✔ ) No______________________
Withdrawn: ( ) Yes____________________ ( ✔) No______________________
Irritable: ( ) Yes____________________ (✔ ) No______________________
Fearful: ( ) Yes____________________ (✔ ) No______________________
Religion:_________Islam__________________ Restrictions:_________________
Feeling of Helplessness: ( ) Yes (✔ ) No
Feeling of Hopelessness: ( ) Yes (✔ ) No
Feeling of Powerlessness: ( ) Yes (✔ ) No
Tobacco Use: ( ) Yes____________________ (✔ ) No______________________
Alcohol Use: ( ) Yes____________________ (✔ ) No______________________
Drug Use: ( ) Yes____________________ (✔ ) No______________________

NUTRITION
General Appearance: (✔ ) Well Nourished ( ) Malnourished
( ) Emaciated ( ) Other
Body Built:___________ Weight: ____65 kg_______ Height: ___________
Diet:________________ Meal Pattern:___________________________
(✔ ) Feeds Self ( ) Assist ( ) Total Feed

Mastication/Swallowing Problem ( ) Yes_________ (✔ ) No_________

Dentures: ( ) Yes (✔ ) No
Appetite: ( ) Increased ( ) Decreased ( ) Unusual
Decreased Taste Sensation: ( ) Yes (✔ ) No
Nausea: ( ) Yes ( ) No
Stool frequency: ___________________ Characteristics: _________________________
Last Bowel Movement: ______________
NGT/ Gastrostomy:__________________

VENOUS ACCESS RECORD

Date Gauge (color)/ Date
# Site Fluid Reason
Inserted Number of Drops Removed

PAIN ASSESSMENT
Location of pain: _____not assessed___________ Frequency:
__________________
Intensity Pain Scale(0-10): ___________________ Quality: _____________________
Onset: (When did your pain start?) ______________________________________
Duration:_______________________ Body Reaction: __________________________
Alleviating Factors:
_______________________________________________________
Precipitating
factors:______________________________________________________
 Special Assessment Devices
( ) Wheelchair ( ) Contacts ( ) Venous Access device
( ) Braces ( ) Hearing aid ( ) Epidural catheter
( ) Cane/ Crutches ( ) Prosthesis ( ) Walker
( ) Glasses
Others:_______________________________________________________________
________________________________________

SELF-CARE
Need Assist With:
( ) Ambulating ( ) Elimination
( ) Bed Mobility ( ) Meals
( ) Hygiene ( ) Dressing

PATIENT EDUCATION
( ) Safety / Restraint Use ( ✓ ) Signs & Symptoms to Report
( ) Ordered Therapies ( ✓) Lifestyle Change
( ) Diagnosis / Disease ( ) Rehabilitation Measures
( ) Pain Management ( ) Hygiene / Self care
( ) Hospital Referrals ( ) Diet or Nutrition
( ) Community Referral ( ) Mobility / Ambulation
( ✓) Medication

Specify Plan of Care Intended:

Example medications (List Down all medications to be taken at home with special nursing
care instruction to be given to the client like, dosage, time, frequency.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
____________

C. DIAGNOSTIC TEST

TYPE OF TEST PURPOSE OF PROCEDURE RESULT AND SIGNIFICANCE

Blood Chemistry A blood sample is checked to
measure the amounts of certain
substances released into the blood by
organs and tissues in the body. An
unusual (higher or lower than
normal) amount of a substance can be
a sign of disease in the organ or tissue
that makes it (Stanford Health Care,
The patient’s result in blood chemistry
are the following: creatinine 153.70
(normal range: 50-110 umol/L); BUN
8.50 (normal range: 2.5 - 6.10 mmol\
L); HBA1C 15.80 (normal range: 4.3
- 6.4%), Potassium 3.4 mmol/L
(normal range: 3.50- 5.10 mmol/L),
Phosphorus 1.09 with a normal range
of 0.81 -1.45 mmol/L and the last is
 2023). Blood chemistry gives
providers information about the
organs such as kidney, heart and
liver.
Blood chemistry is used during a
checking of blood sugar level. If
there isn't enough insulin in the body
to allow sugar to enter cells, the
blood sugar level will rise. This is
known as hyperglycemia.
the magnesium result of the patient
which is 0.7 (normal range: 0.70 -
1.00 mmol/L). Based on the results,
we can see that the results are all
abnormal, either above or below the
normal range. Abnormal blood
chemistry test findings could be
related to several health conditions,
including metabolic disorder
(diabetes), kidney disease, liver
disease or hormonal imbalances.

ARTERIAL An arterial blood gas test, or arterial
BLOOD GAS blood gas analysis measures the
( ABG ) amounts of arterial gasses, such as
oxygen and carbon dioxide in our
body. It also checks the acidity of
our blood. This is called the acid-base
balance or the pH level. The blood
sample is taken from an artery, which
is a blood vessel that carries oxygen-
rich blood from the lungs to the body
according to Castro D., & Patil S.M
(2021). Keenaghan M. Arterial
Blood Gas retrieved on October 16,
2023 from
(https://www.ncbi.nlm.nih.gov/book
s/NBK536919/).
The arterial blood gas result of the
patient is all normal except the HCO3
and pO2. The HCO3 or the
bicarbonate result of the patient is
abnormal 26.1 and the normal range
of bicarbonate is 22-26. It is a little
higher than the normal range. While
the pO2 result of the patient is 122.7
with a normal range of 80-100 mmHg.
This is significantly high which may
lead to many complications.

D. LABORATORY RESULTS

The Laboratory test is a medical procedure that involves testing of blood in the body,
and checking the urine of the patient. This blood test is called Complete Blood Count (CBC),
while checking the urine is called Urinalysis. A complete blood count, also known as a full
blood count, is a set of medical laboratory tests that provide information about the cells in a
person’s blood. A complete blood count or (CBC) is used to assess the overall health and to
diagnose a variety of illnesses, such as anemia, infection and leukemia. Even in the absence
of infection, the CBC shows an increased white blood cell count in patientspatients with
diabetic ketoacidosis. On the other hand, a urinalysis is a test of the urine, it is used to detect
and manage a wide range of disorders, such as urinary tract infections, kidney disease and
diabetes. A urinalysis involves checking the appearance, concentration and content of urine.
Urinalysis is part of the laboratory test to identify signs and symptoms of diabetes or kidney
disease, and diagnosed urinary tract infection (UTI).

Test Result Normal Range Clinical

Significance
Urinalysis
Color Yellow Yellow Normal
The patient's
urine color is
normal. This
indicates that the
patient is well
hydrated.
Transparency Clear Clear Normal
The patient's
urine clarity is
normal. Urine
clarity, like urine
color, suggests
that substances
may be present
in the urine.
pH 6.0 5.0-7.0 Normal
The patient’s
urine pH level is
normal. Urine
pH is an
important
screening test for
the diagnosis of
renal disease,
respiratory
disease, and
certain metabolic
disorders.
Glucose +3 Negative Abnormal
The glucose
result of the
patient is high
which can be an
indication of
diabetes.
White Blood 2 0-3 Normal
Cells (WBC) The WBC
result of the
patient is normal.
The patient’s
immune system
is functioning as
 normal.
Red Blood Cells 3 0-2 Abnormal
(RBC) The RBC
result of the
patient is higher
than the normal
range. An
abnormally high
RBC can impose
a possibility to
the patient’s
blood to thicken
and slow,
making the
patient
vulnerable to
blood clots.
Epithelial Cells 26 0-3 Abnormal
The epithelial
cells result of the
patient is
significantly
high; it may
indicate urinary
tract infection,
kidney disease or
other serious
medical
condition. This
can also lead to
tissue swelling or
edema.
Bacteria 88 0-50 Abnormal
The patient's
result is
significantly
high. This could
make the patient
vulnerable to
having bacterial-
related diseases
that may affect
the lungs,
kidney, and other
parts of the body
if not treated
properly.
Test Result Normal Range Clinical
Significance
Complete Blood
Count (CBC)
Hemoglobin 86.00 125.00-165.00 Abnormal
The patient’s
hemoglobin result is
low which indicates
that the patient may
have anemia.
Having low
hemoglobin can
have many different
causes including
vitamin deficiencies,
bleeding and chronic
diseases.
Hematocrit 0.27 0.37- 0.47 The patient’s
hematocrit is low
which means the
blood has a very few
healthy red blood
cells.
White Blood Cells 10.94 5.00- 10.00 Abnormal
The white blood
cell result of the
patient is a bit
higher than the
normal range, which
signifies that the
patient has an
 infection or
inflammation in the
body.
Neutrophil 71 40-70 Abnormal
The patient’s
result is high. The
body may be a little
bit under stress.
Infection,
inflammation, stress
and vigorous
exercise can cause
increased neutrophil
levels.
RDW-CV 15.00 11.50- 14.50 The red cell
distribution width
(RDW) of the
patient is high. It
measures the
variation in red
blood cell size or red
blood cell volume as
a part of a complete
blood count. If
RDW-CV is high it
may be a sign of
anemia or a related
condition.
MCH 26.80 27.80- 35.70 The mean
corpuscular
hemoglobin of the
patient is below the
normal range, which
signifies anemia.

E. DRUG STUDY

Drug Mechanism of Indication/ Nursing responsibilities

action/Side
effects Contraindication

Generic name: Mechanism of Indication: The ● Check the doctor’s order.

Nicardipine Action: It treatment of ● Observe the 14 rights of medication.
inhibits the hypertension, 1. Right drug
Brand name: transmembrane including 2. Right patient
Cardene influx of calcium hypertensive 3. Right dose
 4. Right route
Classification: ions into cardiac urgency and 5. Right time and frequency
Calcium Channel muscle and hypertensive 6. Right assessment
blockers smooth muscle emergency. 7. Right approach
without changing 8. Right education
Route: IV serum calcium Contraindication: 9. Right to evaluation
concentrations. 10. Right documentation
Dosage: 20 mg The contractile Contraindicated in 11. Right to refuse
processes of patients with 12. Right principle of care
Frequency: Q8H cardiac muscle hypersensitivity to 13. Right prescription
and vascular the drug, in 14. Right nurse clinician
smooth muscle patients with ● Monitor the patient’s vital signs.
are dependent advanced aortic ● Monitor the patient’s laboratory
upon the stenosis. results.
movement of Reduction of ● Monitor the side effect and
extracellular diastolic pressure therapeutic response.
calcium ions into in these patients ● Notify the doctor if side effects
these cells may worsen rather occur.
through specific than improve
ion channels. The myocardial oxygen
effects of balance. Caution
nicardipine HCI In liver
are more impairment,
selective to extensively
vascular smooth metabolized by
muscle than liver. May cause a
cardiac muscle. decrease in GFR.

Adverse effect
(Side effects):

● Headache
● Flushing
● Palpitatio
n
● Tachycar
dia
● Dizziness
● Rash

Drug Mechanism of Indication/ Nursing responsibilities

action/Side
effects Contraindication
Generic name: Mechanism of Indication: To ● Check the doctor’s order.
Insulin glargine Action: manage type 1 ● Observe the 14 rights of
insulin- medication.
Brand name: It lowers blood dependent)diabete 1. Right drug
glucose by s in patients who 2. Right patient
Lantus increasing need basal (long 3. Right dose
transport into acting)insulin to 4. Right route
Classification: cells and control 5. Right time and
Antidiabetic promoting the hyperglycemia. It frequency
(Long acting conversion of also manage type 6. Right assessment
insulin glucose to 2 (non-insulin 7. Right approach
glycogen. dependent) her 8. Right education
Route: SubQ
Promotes diabetes in 9. Right to evaluation
Dosage: 90 units conversion of patients who need 10. Right documentation
amino acids to basal (long-acting) 11. Right to refuse
Frequency:QD proteins in insulin to control 12. Right principle of care
AC muscle and hyperglycemia 13. Right prescription
stimulates 14. Right nurse clinician
triglyceride Contradiction: ● Monitor the patient’s vital signs.
formation. Contraindicated ● Assess for symptoms of
Inhibits release during hypoglycemia.
of free fatty hypoglycemic ● Monitor body weight
acids. episodes and in periodically.
patients ● Monitor the blood glucose
Adverse effect hypersensitive to regularly.
(Side effects): drug or its ● Monitor injection sites for local
components. reactions.
● Hunger ● Notify the doctor if side effects
● Shaking occur.
● Dizziness
● Chills
● Sweating
● Tachycar
dia

Drug Mechanism of Indication/ Nursing responsibilities

action/Side
effects Contraindication
Generic name: Mechanism of Indication: ● Check the doctor’s order.
piperacillin + Action: Piperacillin and ● Observe the 14 rights of
tazobactam Piperacillin is a tazobactam medication.
beta lactam combination 1. Right drug
Brand name: antibiotic that injection is used to 2. Right patient
Tazovex inhibits bacterial treat bacterial 3. Right dose
cell wall infections in many 4. Right route
Classification: synthesis. different parts of 5. Right time and
piperacillin and Tazobactam is a the body (eg, frequency
beta-lactamase beta lactamase stomach or bowel, 6. Right assessment
inhibitors inhibitor that has lungs, skin, female 7. Right approach
no intrinsic reproductive 8. Right education
Route: IV antimicrobial organs) 9. Right to evaluation
activity but 10. Right documentation
Dosage: 16 mcg prevents Contradiction: 11. Right to refuse
breakdown of 12. Right principle of care
Frequency: Q8H beta lactam by Contraindicated in 13. Right prescription
beta lactamase patients with a 14. Right nurse clinician
enzyme. history of allergic ● Monitor the patient’s vital signs.
reactions to any of ● Watch the patient for seizures.
Adverse effect the penicillins, ● Monitor signs of allergic
(Side effects): cephalosporins, or reactions and anaphylaxis,
beta-lactamase including pulmonary symptoms
● Nausea inhibitors. ● Notify the doctor if side effects
● Fever occur.
● Dizziness
● Swelling
of face,
arms and
legs

Drug Mechanism of Indication/ Nursing responsibilities

action/Side
effects Contraindication
Generic name: Mechanism of Indication: ● Check the doctor’s order.
Regular Insulin Action: Moderate to severe ● Observe the 14 rights of
Increases glucose diabetic medication.
Brand name: transport across ketoacidosis or 1. Right drug
Novolin R muscle and fat hyperglycemia, 2. Right patient
cell membranes mild diabetic 3. Right dose
to reduce glucose ketoacidosis, 4. Right route
Classification: level. It promotes newly diagnosed 5. Right time and
Antidiabetic conversion of diabetes mellitus frequency
(short acting glucose into its to control 6. Right assessment
insulin) storage form, hyperglycemia. 7. Right approach
glycogen 8. Right education
Route: IV Contradiction:Co 9. Right to evaluation
ntraindicated in 10. Right documentation
Dosage: 0.1ml hypoglycemia and 11. Right to refuse
Adverse effect in patients 12. Right principle of care
Frequency: TID (Side effects): hypersensitive to 13. Right prescription
AC insulin or its 14. Right nurse clinician
● Sweating ingredients. ● Assess the patient’s glucose
● Dizziness level before starting therapy and
● Shaking regularly after.
● Fast heart ● Monitor the patient's vital signs.
rate ● Monitor the patient’s
● Blurred glycosylated haemoglobin level
vision regularly.
● Monitor urine ketone level
when glucose is elevated.
● Monitor injection sites for local
reactions.
● Notify the doctor if side effects
occur.
Drug Mechanism of Indication/ Nursing responsibilities
action/Side
effects Contraindication

Generic name: Mechanism of Indication: ● Check the doctor’s order.

Metformin Action: Treatment of type ● Observe the 14 rights of
Mechanism of 2 diabetes mellitus medication.
Brand name: action is thought in patients not 1. Right drug
Riomet to be due to both controlled with 2. Right patient
increasing the diet alone. 3. Right dose
binding of insulin 4. Right route
to its receptorContradicted: 5. Right time and frequency
Classification:
Hypersensitivity
and potentiating 6. Right assessment
Biguanide class
insulin action.to metformin; 7. Right approach
Route: Oral renal, hepatic, or 8. Right education
cardiopulmonary 9. Right to evaluation
Dosage: 500mg insufficiency;alco 10. Right documentation
Adverse effect holism; concurrent 11. Right to refuse
Frequency: TID (Side effects): infection. 12. Right principle of care
PC 13. Right prescription
● Decrease 14. Right nurse clinician
d appetite ● Monitor the patient’s vital signs.
● Fever ● Monitor urine or serum glucose
● Muscle levels frequently to determine
pain effectiveness of drug and dosage.
● Tachycar ● Notify the doctor if side effects
dia occur.
● Abdomin
al
discomfor
t
F. NURSING CARE PLAN

CUES NURSING PLANNING NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS INTERVENTION
Subjective Impaired Gas Goals: Improve Independent The patient was After (8) hours of
“Nahihirapan talaga Exchange related to respiratory status by Intervention positioned in a semi- implementing nursing
ako makahinga at pleuritic chest pain, maintaining a clear Position the patient in Fowler's position (30-45 interventions,
sumasakit din ang presence of rales sound airway, optimizing lung a semi-Fowler's degrees) to facilitate lung
dibdib ko.” on lung auscultation, function, and position (30-45 expansion and ease ● The patient’s
"I'm really having and community alleviating pleuritic degrees) to facilitate breathing. respiratory status
difficulty breathing, acquired pneumonia. chest pain. lung expansion and has significantly
and my chest also ease breathing. improved,
hurts." - as verbalized Desired Outcomes: demonstrated by a
by the patient. After (8) hours of Rationale: Elevating respiratory rate
implementing nursing the head of the bed within the normal
Objective: interventions, the helps to improve The patient was range. The patient
● Pain scale: 6 out of patient will be able to: lung expansion, encouraged and assisted has experienced
10 (Moderate) reduces pressure on with deep breathing and substantial relief
● Increased respiratory The patient will achieve the diaphragm, and coughing exercises to from pleuritic chest
rate (RR) 38 b/min a respiratory rate within enhances prevent atelectasis. pain, contributing
● Pulse rate: 121 bpm the normal range, will oxygenation by to improved
● Oxygen saturation: experience relief from decreasing the work comfort and ease of
95% pleuritic chest pain, and of breathing. It can breathing.
● Presence of rales on lung sounds will ease breathing
lung auscultation become clear on efforts, particularly Oxygen therapy was ● Furthermore, lung
● Diagnosis of auscultation. in patients with administered as required sounds have
Community respiratory distress. to maintain adequate become notably
Acquired oxygenation. clearer on
Pneumonia. Encourage and assist auscultation,
● Pallor with deep breathing indicating enhanced
and coughing lung function and
Labs: exercises to prevent optimal gas
● HCO3 (Bicarbonate) atelectasis. exchange.
 levels: 26.1 mmol/L
(Normal range: 22- Rationale: Deep
26 mmol/L) breathing and Emotional support and
● pO2 (Partial Pressure coughing exercises reassurance were
of Oxygen) levels: are essential to provided to reduce
122.7 mmHg prevent atelectasis, anxiety, contributing to an
(Normal range: 80- which can occur due improved sense of well-
100 mmHg) to decreased lung being for the patient.
expansion. These
exercises help
maintain airway
patency, clear Adequate fluid intake
secretions, and within prescribed limits
optimize lung was encouraged, helping
function. to maintain proper
hydration and facilitate
Administer oxygen effective coughing.
therapy as required to
maintain adequate
oxygenation.

Rationale: Oxygen Prescribed analgesics

therapy is were administered for
administered to pleuritic chest pain relief.
maintain adequate
oxygen saturation in
the blood. It helps
ensure that the
patient receives
sufficient oxygen,
improving oxygen
delivery to body
tissues and reducing
the workload on the
respiratory system. Prescribed antibiotics
were administered to treat
Provide emotional the underlying
support and pneumonia.
reassurance to reduce
anxiety.

Rationale: Anxiety
can exacerbate
respiratory distress.
By offering
emotional support
and reassurance, the
patient's anxiety
levels can be
reduced, promoting a
sense of well-being
and potentially
improving
respiratory effort

Encourage adequate
fluid intake within
prescribed limits.

Rationale:
Maintaining proper
hydration can help in
thinning respiratory
secretions and
promoting effective
coughing, which is
essential for
preventing
atelectasis and
improving gas
exchange.

Dependent
Intervention

Administer the
prescribed analgesics
for pleuritic chest
pain relief as per the
doctor’s order.

Rationale: Pleuritic
chest pain, often
experienced in
pneumonia, can
hinder deep
breathing and
coughing exercises.
Administering
analgesics helps to
alleviate the pain,
making it easier for
the patient to breathe
deeply and effectively
perform respiratory
exercises.

Administer
prescribed antibiotics
to treat the
 underlying
pneumonia as per the
doctor’s order.

Rationale:
Antibiotics are
necessary to target
and eliminate the
infection causing
pneumonia. Timely
administration of
antibiotics is critical
to control the spread
of infection and
support the recovery
of lung function.

CUES NURSING PLANNING NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Unstable Blood Goals: To stabilize Independent After (8) hours of
The patient verbalized Glucose Levels related blood glucose levels Intervention The patient has been implementing
"Matagal na akong may to a history of diabetes, within the target range Teach the patient to educated on how to use a nursing
diabetes sa loob ng hyperglycemia and a through medication self-monitor blood glucometer to monitor interventions,
sampung taon at nag- need for insulin and management and glucose levels and their blood glucose levels
aalala ako sa patuloy other medications. education on self- provide guidance on accurately. They have ● The patient's blood
na mataas ang blood monitoring. interpreting and also received guidance on glucose levels have
sugar. Gusto kong acting upon the interpreting the results stabilized and are
malaman kung paano Desired Outcome: results. and taking appropriate consistently within
ito ayusin ang After (8) hours of actions based on the normal ranges.
Rationale: Patient
 kondisyon ko." implementing nursing education on self- readings. ● The patient has
"I've had diabetes for interventions, the monitoring is a demonstrated a
10 years and I'm patient will be able to: fundamental profound
concerned about my component of understanding of
persistently high blood The patient's blood diabetes care. It self-monitoring
sugar levels. I'm eager glucose levels will be empowers the patient techniques, adeptly
to learn how to at normal ranges. to actively participate
The patient has been interpreting and
effectively address this in managing their made aware of the critical responding to their
issue." The patient will condition. Teaching importance of adhering to glucose levels. The
demonstrate knowledge the patient how to use the prescribed patient showed
Objective: of self-monitoring and a glucometer to
medications and insulin commitment to
● Pulse rate: 121 bpm appropriate actions in measure blood
regimen. adhering to the
● Respiratory Rate: 38 response to glucose glucose levels allows prescribed
b/min, levels., as well as them to monitor their medications and
● Blood pressure: adhering to the progress and detect insulin regimen.
220/140 mm Hg, prescribed medications fluctuations promptly. ● The patient is now
● Oxygen saturation: and insulin regimen. Guidance on better equipped to
95%. interpreting the manage their
● Weight: 65 kilograms. results helps the diabetes with
patient make confidence,
Labs: informed decisions actively
● Complete Blood about diet, exercise, Continuous monitoring participating in
Glucose at admission: and insulin dosage for signs and symptoms their healthcare
634 mg/dl, adjustments, of hypoglycemia has journey.
contributing to betterbeen in place. This ● The risk of
glycemic control. ensures early detection complications
and timely intervention if associated with
Stress the importance hypoglycemia occurs. unstable blood
of adherence to the glucose levels
prescribed were reduced.
medications and
insulin regimen.

Rationale:
 The patient has been
Medication encouraged to make
adherence is crucial lifestyle modifications,
to maintaining including adopting
consistent blood healthy eating habits and
glucose levels. Non- incorporating regular
adherence can lead to physical activity into
hyperglycemia, which their routine.
can result in severe
complications.
Emphasizing the The patient actively
significance of participated in the one-
following the on-one diabetes
prescribed education session, where
medication and she received a
insulin regimen comprehensive health
reinforces the teaching plan that
patient's commitment covered vital aspects of
to managing their diabetes management,
diabetes effectively. equipping her with the
Understanding the knowledge and skills
consequences of non- required to make
adherence can informed dietary choices,
motivate the patient monitor blood glucose
to prioritize levels, and effectively
medication adherence manage her condition.

Monitor for any signs

of hypoglycemia.

Rationale: While Educated the patient

addressing about the glycemic index
hyperglycemia, it's (GI) and how to make
essential to be aware food choices based on GI
 values to manage blood
of potential glucose levels more
complications such as effectively.
hypoglycemia. Rapid
or excessive Encouraged the patient to
correction of keep a daily diary to track
hyperglycemia can food intake, physical
lead to hypoglycemia. activity, and blood
Monitoring for signs glucose levels.
and symptoms of
hypoglycemia,
including dizziness,
shakiness, sweating,
headache, pallor,
confusion, seizures,
and mental status
changes, allows for The patient has received
early detection and the prescribed insulin in
intervention. accordance with the
healthcare provider's
Encourage lifestyle orders.
modifications.

Rationale: Lifestyle
modifications are
important for
diabetes
management.
Encouraging healthy
eating habits and Collaborated with a
regular exercise registered dietitian to
helps the patient create a customized meal
maintain normal plan that aligned with the
glucose levels and patient's dietary
 preferences, culture, and
prevents diabetes management
hyperglycemia. A needs.
balanced diet and
physical activity
support glycemic
control by regulating
blood sugar levels.

Provide a one-on-one
session about diabetes
education through the
use of a health
teaching plan to
empower the patient
with the knowledge
and skills needed to
make informed
dietary choices and
manage her blood
glucose levels
effectively.
Rationale: This is
essential to address
the patient's
unhealthy eating
habits. By offering
personalized diabetes
education on meal
planning and
carbohydrate
counting, the patient
can better understand
how her food choices
impact her blood
glucose levels. This
knowledge empowers
her to make informed
decisions about her
diet, promoting better
glycemic control and
reducing the risk of
hyperglycemia and its
associated
complications.
Additionally,
providing one-on-one
education ensures
that the patient
receives tailored
guidance and the
opportunity to ask
questions, fostering a
deeper understanding
of diabetes
management.

Educate the patient

about the glycemic
index (GI) and how to
make food choices
based on GI values to
manage blood glucose
levels more
effectively.

Rationale:
Understanding the GI
helps the patient
make informed food
choices, emphasizing
lower GI foods to
maintain stable blood
sugar levels.

Encourage the patient

to keep a daily diary
to track food intake,
physical activity, and
blood glucose levels.
Allow them to review
the diary regularly for
insights into the
effects of various
foods and activities
on blood sugar levels.
Rationale:
Maintaining a diary
helps the patient
identify patterns and
make informed
decisions regarding
dietary choices and
physical activity,
fostering active self-
management.

Dependent
Intervention

Administer prescribed
insulin, such as
Regular Insulin and
Insulin Glargine,
according to the
healthcare provider's
orders.

Rationale:
Administering
prescribed insulin is
essential to regulate
blood glucose levels
in diabetic patients.
Regular insulin acts
quickly to reduce
high blood glucose
levels after meals,
while Insulin
Glargine provides a
long-acting, steady
release of insulin to
maintain baseline
blood glucose levels.

Collaborative
Intervention
Collaborate with a
registered dietitian to
create a customized
meal plan that aligns
with the patient's
dietary preferences,
culture, and diabetes
management needs.
Rationale:
Collaboration with a
dietitian ensures that
the meal plan is
tailored to the
patient's individual
needs and
encourages
compliance with
dietary restrictions,
contributing to stable
blood glucose levels.
CUES NURSING PLANNING NURSING IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Ineffective Health Goals: Independent Intervention A health assessment was After (8) hours of
“Mahilig ako kumain Management related To promote patient Conduct a comprehensive conducted to identify implementing the
ng junk foods at to noncompliance compliance with health assessment to health management nursing
uminom ng soft with dietary and recommended identify the patient's needs. interventions, the
drinks. Hindi rin ako exercise healthy lifestyle specific challenges and patient was able
masyadong umiinom recommendations, as changes, including health management needs. to:
ng tubig. Pati hindi rin evidenced by a dietary
regular ang history of unhealthy modification, Rationale: A thorough Demonstrate an
pagdudumi ko. Atsaka food intake, irregular regular exercise, assessment is crucial to improved
hindi ako masyadong bowel elimination, and necessary understand the patient's Educated the patient on understanding of
nakakatulog lalo na sa poor sleep patterns, immunizations. unique health management the importance of a the significance
gabi” - as verbalized lack of Desired Outcome: issues, enabling the balanced diet and its role of adhering to a
by the patient immunizations, and a At the end of 8 development of in overall health, healthy lifestyle,
“I love eating junk lack of exercise. hours of nursing personalized interventions. emphasizing portion including
food and drinking soft intervention, the Educate the patient on the control, meal planning, recognizing the
drinks, and I don’t patient shall be able importance of a balanced and food choices. importance of
drink water that much. to: diet and its role in overall dietary
I also have an health, emphasizing portion modifications,
irregular bowel To fully control, meal planning, and the value of
elimination. comprehend the food choices. Provided guidance on regular exercise,
Moreover, I also vital role of establishing regular and the role of
cannot sleep properly adhering to a Rationale: Patient bowel elimination immunizations in
at night.” healthy lifestyle. education provides them patterns, including the overall well-
This includes with the knowledge needed importance of adequate being.
Objective: recognizing the to make informed dietary fluid intake, fiber-rich
Vital signs significance of choices, promoting foods, and routine Actively commit
T: 36.0 dietary healthier eating habits. toileting practices. to adopting a
BP: 220/140 mmhg modifications, the balanced diet,
O2sat: 95% importance of Provide guidance on making more
RR: 38 bpm regular exercise, establishing regular bowel Sleep and hygiene nutritious food
PR: 121 bpm elimination patterns,education to enhance choices, and
and the value of including the importance of sleep quality were implementing
Other Data: immunizations in adequate fluid intake, fiber- offered, covering topics portion control to
maintaining overall rich foods, and routine like maintaining a promote better
● Unhealthy diet well-being. The toileting practices. consistent sleep schedule glycemic control
● Poor sleeping patient will actively and providing a sleep and increased
pattern commit to adopting Rationale: Ensuring environment that is energy levels.
● Limited physical a balanced diet, regular bowel elimination within the patient’s
activity incorporating patterns contributes to comfortability. Display
● Lack of regular exercise, improved digestive health motivation and
immunizations and ensuring and prevents complications Facilitated access to engagement in
● Irregular bowel immunization related to constipation. necessary immunizations following a
elimination compliance, all of by coordinating personalized
which are essential Offer sleep and hygiene vaccination schedules exercise plan,
for effective health education to enhance sleep and providing resulting in
management and an quality, covering topics like information about the increased stamina
improved quality of maintaining a consistent importance of and overall well-
life. sleep schedule, creating a immunizations for being.
comfortable sleep preventing diseases.
environment, and managing Comprehend how
stress. Promoted lifestyle dietary choices
modifications, such as can influence
Rationale: Proper sleep encouraging daily regular and
hygiene practices support physical activity, healthy bowel
better sleep quality and healthier food choices, elimination
overall well-being. regular bowel habits, patterns, taking
improved sleep hygiene, steps towards
and immunization maintaining
Facilitate access to compliance. digestive health.
necessary immunizations
by coordinating vaccination Regularly monitored the Show a proactive
schedules and providing patient's progress and approach to
information about the adjusted the plan as receiving
importance of needed, offering ongoing necessary
immunizations for support and motivation.
immunizations,
preventing diseases. reducing the risk
of preventable
Rationale: Access to diseases and
vaccines and education actively
about their significance Collaborated with a participating in
promotes immunization registered dietitian to healthcare
compliance, contributing to create a customized preventive
disease prevention. dietary plan. measures.

Promote lifestyle
modifications, such as
encouraging daily physical
activity, healthier food
choices, regular bowel
habits, improved sleep
hygiene, and immunization Collaborated with a
compliance. physical therapist or
exercise specialist to
Rationale: Promoting create an exercise plan
lifestyle modifications is tailored to the patient's
essential to empower the fitness level and goals.
patient to take active steps
toward effective health
management and well-
being.

Regularly monitor the

patient's progress and adjust
the plan as needed, offering
ongoing support and
motivation.
Rationale: Monitoring and
adjustments ensure that the
patient remains engaged
and committed to their
health management plan.

Collaborative
Intervention

Collaborate with a
registered dietitian to create
a customized dietary plan
that emphasizes balanced
and nutritious meals,
considering the patient's
preferences and cultural
background.

Rationale: Collaboration
with a dietitian ensures that
the dietary plan aligns with
the patient's individual
needs, making it more
likely to be followed.

Collaborate with a physical

therapist or exercise
specialist to create an
exercise plan tailored to the
patient's fitness level and
goals.
Rationale: A customized
exercise plan increases the
likelihood of patient
adherence and benefits
overall health.
G. HEALTH TEACHING PLAN

Topic/s: Promoting Health and Understanding the Disease Process about Diabetic Ketoacidosis

Venue: West Metro Medical Center (Room 362)

General Objectives: To empower the patient with comprehensive knowledge, practical skills, and a deep understanding of their health
condition to manage their diabetes effectively, promote overall health, and foster a sense of empowerment and well-being.

Learning Objectives Content Time Allotment Strategies/ References Evaluation

Methodology

At the end of 1 hour of

teaching sessions the
client will:

I. MEDICATION

● Understand Diabetic Medication: 10 minutes Lecture Method Diabetic

about the Medication
advantages and ● Regular Insulin (Novolin R)
disadvantages ● Insulin Glargine (Lantus) https:// Question and
of insulin ● Metformin (Riomet) www.healthli Answer
compliance to ne.com/
patients with Pros of insulin compliance: health/
diabetes diabetes/
● Blood sugar Control 5 minutes Lecture Method medications-
mellitus and
diabetic ● Prevention of diabetes list#type-2-
complications. Question and
ketoacidosis. diabetes
● Improved quality of life Answer
 Cons of insulin compliance:

● Hypoglycemia Insulin
● Weight gain Compliance
● Injection site reaction
● Treatment adherence https://
● Fear of needles nowpatient.c
om/blog/the-
pros-and-
cons-of-
insulin-
therapy-for-
diabetes

II. ECONOMY/EXERCISE

● Learn and Regular exercise and physical activity play a 5 minutes Brief orientation Becker, G. The patient
understand the crucial role in effectively managing on the (2001). The demonstrated a
importance of diabetes. Engaging in physical activity, such significance of First Year: clear
exercise and as walking, swimming, or cycling, can help exercise. Type 2 understanding of
physical improve insulin sensitivity and lower blood Diabetes: An the importance of
activity. glucose levels. Exercise also aids in Essential exercise in
maintaining a healthy weight, reducing the Guide for the diabetes
risk of complications associated with Newly management
diabetes, and enhancing overall well-being. Diagnosed. based on the
It is essential to recognize that exercise Da Capo provided
doesn't need to be strenuous; even moderate Lifelong information.
activities, when performed consistently, can Books.
have significant benefits for individuals with
diabetes. Understanding the positive impact
 of exercise on diabetes management
empowers patients to take an active role in
their health and incorporate regular physical
activity into their daily lives.

● Recognize the In the pursuit of effective diabetes 10 minutes Visual aids and Colberg, S. The patient can
different types management, it's crucial for individuals to demonstrations to R. (2013). identify various
of exercises to be able to distinguish between various types showcase various The Diabetes types of exercises
be done. of exercises. Recognizing the diversity of exercise types. and Exercise to do for diabetes
exercises, from aerobic activities like Handbook: A management.
walking and swimming to strength training Step-by-Step
exercises such as weight lifting, is essential. Guide to the
This knowledge enables patients to tailor Exercise
their exercise routines to their specific needs Program
and preferences. By identifying the different That
exercise options available, individuals can Improves
create a well-rounded fitness plan that aligns Your Blood
with their goals, whether it's improving Sugar
insulin sensitivity, maintaining a healthy Control.
weight, or enhancing overall physical American
fitness. Diabetes
Association.

III. TREATMENT/THERAPY

● Understand the It is crucial for individuals to grasp the 5 minutes Smith, S. J., The patient
importance of significance of consistently adhering to their & Sewell, J. understands the
medication prescribed medications as a core element of L. (2021). importance of
adherence in effective diabetes management. Recognizing Managing taking their
diabetes the vital role of medication adherence Medication medications for
 management. ensures that patients maintain stable blood Adherence in managing diabetes
glucose levels and reduce the risk of Type 2 and is committed
complications. By understanding this Diabetes: A to their treatment
importance, individuals can actively Patient- plan.
participate in their treatment plan and Centered
prioritize their long-term health. Approach.
Cureus.
Retrieved
from
https://www.
ncbi.nlm.nih.
gov/pmc/artic
les/PMC9883
658

● Learn about the Gaining knowledge about the critical role of 10 minutes Centers for The patient has
significance of regular medical check-ups and laboratory Disease shown
regular check- tests in diabetes care is imperative. These Control and understanding of
ups and assessments serve as essential tools for Prevention the role that
laboratory tests tracking blood sugar control, detecting early (CDC). medication
in monitoring signs of complications, and adjusting (2022). adherence plays in
diabetes and its treatment plans as necessary. Understanding Blood effective diabetes
complications. the significance of these monitoring Glucose management,
practices empowers patients to stay Monitoring. emphasizing their
proactive in their healthcare and ensure Retrieved awareness of the
timely interventions, ultimately contributing from importance of
to better diabetes management. https://www. consistent and
cdc.gov/diab responsible
etes/managin medication usage
g/managing- for controlling the
 blood-sugar/b condition.
loodglucose
monitoring.ht
m

● Acquire a more Patients are encouraged to adopt a holistic 5 minutes Juanamasta, The patient has
comprehensive perspective regarding their diabetes I. G., taken steps to
approach management. This approach encompasses Aungsuroch, understand the
toward her understanding not only the immediate Y., Gunawan, bigger picture of
current aspects of glucose control but also J., her condition,
condition. considering the broader implications on Suniyadewi, showing a
overall health. By acquiring a more N. W., & commitment to a
comprehensive view of their condition, Nopita Wati, more
individuals can appreciate the N. M. (2021). comprehensive
interconnectedness of diet, exercise, Holistic Care approach to her
medication, and emotional well-being. This Management health.
holistic outlook enables patients to make of Diabetes
informed decisions and embrace a well- Mellitus: An
rounded strategy for effectively managing Integrative
their diabetes. Review.
International
Journal of
Preventive
Medicine,
12(69).
Retrieved
from
https://www.
ncbi.nlm.nih.
gov/pmc/artic
 les/PMC8356
953/

● Understand the Fluid and electrolyte resuscitation for 15 minutes Joint British
importance of insulin therapy is essential in the Diabetes
fluid and management of patients with severe Societies
electrolyte hyperglycemia or diabetic ketoacidosis Inpatient
resuscitation in (DKA). The primary goal is to restore Care Group.
managing intravascular volume and electrolyte balance (2013). The
severe while addressing hyperglycemia. Here is Management
hyperglycemia some additional content: of Diabetic
and diabetic Ketoacidosis
ketoacidosis, Fluid Resuscitation: in Adults.
Retrieved
In cases of severe hyperglycemia or DKA, October 18,
fluid replacement is crucial to combat 2023, from
dehydration and improve circulation. https://abcd.c
Intravenous (IV) fluids, typically isotonic are/resource/t
solutions like Normal Saline (0.9% NaCl), he-
are administered to replace lost fluids and management-
correct electrolyte imbalances. of-diabetic-
ketoacidosis-
Electrolyte Replacement: in-adults
Patients with DKA often have imbalances in Kitabchi, A.
electrolytes, particularly potassium. Insulin E.,
therapy can cause potassium to shift from Umpierrez,
the extracellular to the intracellular space, G. E., Miles,
which can lead to hypokalemia. As such, J. M., &
potassium levels should be monitored Fisher, J. N.
closely, and potassium replacement may be (2009).
necessary. Hyperglycem
 ic crises in
adult patients
with
diabetes.
Diabetes
Care, 32(7),
1335-1343.
DOI:
10.2337/dc09
-9032.

IV. HEALTH TEACHINGS/HYGIENE

● To educate the Educating patients about essential hygiene 10 minutes Childs, B. P., The patient was
patient about practices and lifestyle modifications is a Di Lorenzo, able to learn about
essential fundamental component of effective M. S., & important hygiene
hygiene diabetes management. Emphasizing daily Cipriano, C. practices and
practices and foot inspection, proper skin care, oral E. (2005). lifestyle changes
lifestyle hygiene, and staying well-hydrated helps Complete for better diabetes
modifications prevent complications. Additionally, Nurse's management.
for effective lifestyle changes like a balanced diet, Guide to
diabetes regular exercise, and stress management Diabetes
management. contribute significantly to controlling Care (2nd
diabetes and promoting overall well-being. ed.).
This holistic approach empowers patients to American
take charge of their health and enhance their Diabetes
quality of life. Association.
● To emphasize Foot Care: Proper foot care is vital for 20 minutes Han, M. A. The patient
the importance individuals with diabetes. Diabetes can lead (2019). Hand understands the
of preventive to nerve damage and poor blood flow to the Hygiene significance of
measures to feet, increasing the risk of infections and Practices prevention to
avoid diabetes- complications. Daily foot inspections are Among avoid diabetes-
related crucial to identify any wounds, blisters, or Adults with related
complications. redness. Wearing comfortable, well-fitting Diabetes complications.
shoes and avoiding walking barefoot Living in The patient also
outdoors helps prevent injuries. Regular Communities learned different
visits to a podiatrist are recommended to : The 2015 hygienic
ensure professional foot care. Korea approaches for
Community diabetes.
Oral Hygiene: Diabetes can affect oral Health
health, increasing the risk of gum disease Survey.
and cavities. Regular dental check-ups and International
cleanings are essential, so it's important to Journal of
schedule routine dental appointments. Environment
Proper oral hygiene practices, such as al Research
brushing teeth twice daily and daily and Public
flossing, are necessary to maintain oral Health,
health. Monitoring oral health for any issues 16(7), 1279.
or infections and seeking dental care https://www.
promptly is vital. ncbi.nlm.nih.
gov/pmc/artic
les/PMC6480
019/
Skin Care: Skin health is important,
especially for those with diabetes. The
condition can make the skin prone to
dryness and infections. To maintain healthy
skin, regular use of mild, fragrance-free
moisturizers is recommended. Address any
skin abnormalities, such as cuts or wounds,
promptly to prevent complications.
Persistent skin issues should be discussed
with healthcare providers for proper
management.

Hydration: Hydration is key to diabetes

management and overall well-being. Staying
well-hydrated helps regulate blood glucose
levels and supports bodily functions.
Recommendations for daily water intake
should be followed, and it's important to
monitor fluid balance. Balanced hydration
plays a significant role in controlling blood
sugar levels and promoting overall health.
● Identify the Three types of diabetes mellitus: 5 minutes Interactive/ Diabetes
difference Participative
between three ● Type 1 diabetes - autoimmune Method https://
types of reaction (the body attacks itself by www.cdc.gov
diabetes mistake). /diabetes/
mellitus and ● Type 2 diabetes - body doesn’t use basics/
causes. insulin well diabetes.html
● Gestational diabetes - diabetes
develops in pregnant women
V. OUT-PATIENT CONSULTATION

● Recognize the Recognizing the importance of regular 5 minutes The The patient
significance of outpatient consultations in diabetes American recognizes the
regular out- management is essential for ensuring Diabetes importance of
patient optimal health outcomes. These Association. regular out-patient
consultations in consultations offer a vital platform for (2023). The consultations in
diabetes healthcare professionals to closely monitor a American diabetes
management, patient's condition, track changes in blood Diabetes management,
ensuring proper glucose levels, and make timely treatment Association showing a
monitoring and adjustments as necessary. This proactive Guide to proactive
timely treatment approach not only helps in preventing Diabetes commitment to
adjustments for potential complications but also promotes Care. The better health.
better health the patient's overall well-being. By American
outcomes. acknowledging the significance of these Diabetes
consultations, individuals with diabetes can Association.
take a proactive role in their health,
fostering a partnership with their healthcare
team to achieve better diabetes control and
an improved quality of life.

VI. DIET

● To educate the Educating the patient about the fundamental 10 minutes American The patient
patient about role of diet in managing diabetes is Diabetes recognizes the
the fundamental paramount to their overall well-being. Diet Association. fundamental role
role of diet in serves as a critical component in diabetes (2021). of diet in diabetes
managing care, influencing blood glucose levels and Standards of management,
 diabetes. the body's response to insulin. By Medical Care demonstrating a
understanding the relationship between food in Diabetes— proactive
choices and diabetes, the patient gains the 2021. commitment to
knowledge and tools needed to make Diabetes their well-being.
informed dietary decisions. This knowledge Care,
empowers them to create a balanced and 44(Suppleme
personalized meal plan that supports stable nt_1), S16-
blood sugar levels, ultimately contributing S38.
to better health outcomes and an improved
quality of life.

● To provide Guiding individuals in making appropriate 20 minutes American The patient has
guidance on food choices to control blood glucose levels Diabetes shown
making is a pivotal aspect of diabetes care. This Association. understanding
appropriate food guidance empowers individuals to select (n.d.). about the
choices to foods that help stabilize their blood sugar, Nutrition. significance of
control blood reducing the risk of spikes and crashes. By https://diabet making
glucose levels. emphasizing the importance of balanced es.org/nutriti appropriate food
meals, portion control, and carbohydrate on. choices in
monitoring, patients gain the tools needed to controlling blood
actively manage their condition. In doing so, Mayo Clinic. glucose levels.
they take significant steps toward achieving (n.d.). This willingness
better blood glucose control and overall Diabetes to learn and
health. Diet. engage in dietary
https://www. adjustments
Diet and Diabetes: Explain the critical role mayoclinic.or reflects their
of diet in managing diabetes. Discuss how g/diseases- dedication to
the types and quantities of food directly conditions/di managing their
impact blood glucose levels. abetes/in- diabetes
depth/diabete effectively and
Carbohydrate Management: Educate the s-diet/art- achieving better
patient on the effect of carbohydrates on
 blood sugar. Provide a list of foods rich in 20044295. health outcomes.
carbohydrates to be mindful of.

Meal Planning: Describe the importance of

balanced meals and regular eating
schedules. Present strategies for creating
well-rounded, diabetes-friendly meals.

Portion Control: Teach the patient how to

manage portion sizes to prevent blood sugar
spikes. Share visual aids or tools that aid in
portion control.

Consulting a Dietitian: Emphasize the value

of consulting with a registered dietitian or
nutritionist for personalized meal planning
and dietary guidance.

VII. SEX

● To provide Offering information on maintaining sexual 15 minutes Connell, K. The patient has
information on health while managing diabetes is a crucial (2023, June shown a proactive
maintaining aspect of comprehensive diabetes care. 28). Type 2 interest in
sexual health Diabetes can impact various aspects of Diabetes and understanding
while managing sexual health, and educating patients on this Sexual how to maintain
diabetes. topic is essential. By discussing the potential Health. their sexual health
effects of diabetes on sexual function and Healthline. while managing
providing strategies for managing these Retrieved
issues, healthcare providers empower October 19, diabetes.
patients to maintain a healthy and fulfilling 2023 from
sex life. This open and supportive dialogue https://www.
encourages individuals to address concerns, healthline.co
seek appropriate treatment, and prioritize m/health/type
their overall well-being while effectively -2-diabetes/se
managing their diabetes. x-health..
III. EVALUATION

After the nursing students conducted their case study, with thorough assessment of the
Nursing History, the Marjorie Gordon’s 11 Functional Health Patterns along with the Bates
Cephalocaudal Assessment, researchers were able to identify the causative factors that lead
Patient SBA to her diagnosis of Diabetic Ketoacidosis such as prior being diagnosed with
Diabetes Mellitus type 2 as evidenced by being under maintenance of Metformin for 10 years
and also due to her lifestyle that according to the patient, she drinks soft drinks more often
than drinking water regularly. Along with Diabetic Ketoacidosis, she was also diagnosed with
comorbidities of Community Acquired Pneumonia which is due to ketoacidosis that weakens
the immune system and later on causes infections to the body and will lead to pneumonia.
After doing some diagnostic such as blood chemistry and arterial blood gas, it shows the
certain abnormal results in the blood chemistry that signifies findings as a result to metabolic
conditions (diabetes) and also manifestations typical to metabolic acidosis which is known to
patients with diabetic ketoacidosis. Urinalysis and CBC (Complete Blood Count) was also
done and shows the abnormal glucose level and elevated white blood cells which indicates
presence of infection. With the data gathered, formulated a drug study, nursing care plan
regarding Risk for Unstable Blood Glucose Levels, Impaired Gas Exchange and Ineffective
Health Management; all interventions of these nursing care plans were implemented and had
a positive result and the patient was able to self-manage her insulin compliance and avoid
risk for much more threatening complications. Patient was given regular insulin and insulin
glargine for lowering glucose level, she was also prescribed Nicardipine for her hypertensive
urgency and Piperacillin + Tazobactam as her antibiotics. Patient SBA is now stable and is
now monitored and given health education regarding her lifestyle changes and self-
management with compliance to her insulin to not lead to much more serious complications
and difficult to manage symptom
IV. RECOMMENDATIONS

Upon conducting a case study about Diabetic Ketoacidosis, the nursing students

recommend the following to help manage its signs and symptoms and to prevent Diabetes

Mellitus from developing along with its complications.

To society in general, the nursing students recommend that there should be balance in

the way they live their life. Being physically active and healthy should be their topmost

priority hence, engaging with physical activities should be practiced to achieve a healthy

lifestyle. The nursing students also recommend that people should as well watch out for their

diet and avoid consuming unhealthy food that is abundant in sodium like processed meats

such as bacon, hotdogs, and deli meats and limit their intake on food rich in sugars and fatty

foods as these can impose them to being at risk of developing diabetes mellitus. When it

comes to choosing their meal plan, they should include high protein in their diet as well as

vegetables and fruits. With this, they need to strictly follow their meal plan to avoid

developing diabetes mellitus. Various studies talk about how lifestyle modification or

maintaining a healthy lifestyle is essential to avoid Diabetes Mellitus - which can also include

avoiding cigarette smoking or stop smoking and drinking alcoholic and carbonated

beverages. Anything that is unhealthy which can be potentially harmful to the body should be

avoided or ceased to keep the body healthy.

To the diabetic patients, strict compliance with medication and other recommended

treatments prepared by their healthcare provider should be adhered to to prevent

complications from developing including the frequency, time it is taken, and the dosage.

Because hyperglycemia or hypoglycemia may occur anytime especially if the person had

missed the dosage, it is important to keep track of the administration of the medication to
avoid this. The person may set an alarm clock on his/her phone so when it is already time to

take the medication, the phone will just ring or alarm. Other than that, if in case the person is

unable to check the sugar level on his/her blood or administer the medication by

himself/herself, it is recommended that she/he should educate his/her family member so when

an unforeseeable event happens like the diabetic person is too sick to do it by himself/herself,

someone can help him/her. Moreover, the diabetic person should always bring a simple sugar

diet with him/her to manage hypoglycemia if in case he/she suffers from it such as apples and

candy. The diabetic person should also have a tailored meal plan according to his/her

physiologic needs which can include foods with a sufficient amount of proteins,

carbohydrates, and not much sugar to meet the right portion which the body needs. Other

than that, diabetic patients must also engage with physical activities to lower their blood

glucose levels and blood pressure and as well as improve their blood flow.

In addition, to the future nursing student researchers, the nursing students

recommend that they should include a specified tailored proper meal plan to aid in managing

diabetic mellitus or prevent this from developing. Also, further research on the treatment and

management of DM to prevent complications may be done to better the medical care given to

diabetic patients.

Lastly, to the healthcare providers, the nursing students recommend that they should

provide a thorough and clear health teaching plan so the diabetic patients would comply with

their medical treatments and have a better understanding of what their condition entails.

Because oftentimes, although these diabetic patients comply with their medications, they

have little discipline when it comes to their diet and lifestyle modification hence conducting a

thorough health teaching plan is recommended to improve their health condition.

 REFERENCES/BIBLIOGRAPHY

American Association for Respiratory Care. (2019). AARC clinical practice guidelines:
Endotracheal suctioning of mechanically ventilated patients with artificial airways.
Respiratory Care, 64(6), 782-789.

American Diabetes Association. DKA (ketoacidosis) and ketones.

https://diabetes.org/diabetes/dka-ketoacidosis-ketones. Accessed Sept. 17, 2022.

American Diabetes Association. (2019). Standards of Medical Care in Diabetes—2019

Abridged for Primary Care Providers. Diabetes Care, 42(Supplement 1), S4-S6.

American Sleep Association. (2021). Sleep hygiene. Retrieved October 16, 2023 from
https://www.sleepassociation.org/about-sleep/sleep-hygiene-tips/

Barhum L., Sisson B. (2023). The link between diabetes and hypertension. Medical News
Today. Retrieved October 17, 2023 from
https://www.medicalnewstoday.com/articles/317220

Becker, G. (2001). The First Year: Type 2 Diabetes: An Essential Guide for the Newly

Diagnosed. Da Capo Lifelong Books.

Brutsaert, E. (2022). Diabetic Ketoacidosis (DKA). MSD Manuals. Retrieved October 16, 2023 from

https://www.msdmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-

disorders-of-carbohydrate-metabolism/diabeticc-ketoacidosis-dka

Centers for Disease Control and Prevention. (2021). Vaccines & immunizations. Retrieved
October 16, 2023 from https://www.cdc.gov/vaccines/index.html

Centers for Disease Control and Prevention (CDC). (2022). Blood Glucose Monitoring.
Retrieved from
https://www.cdc.gov/diabetes/managing/managing-blood-sugar/bloodglucosemonitoring.htm

Childs, B. P., Di Lorenzo, M. S., & Cipriano, C. E. (2005). Complete Nurse's Guide to

Diabetes Care (2nd ed.). American Diabetes Association.

Colberg, S. R. (2013). The Diabetes and Exercise Handbook: A Step-by-Step Guide to the
Exercise Program That Improves Your Blood Sugar Control. American Diabetes Association.

Connell, K. (2023, June 28). Type 2 Diabetes and Sexual Health. Healthline. Retrieved October
19, 2023 from https://www.healthline.com/health/type-2-diabetes/sex-health..

Deeb, A., Yousef, H., Abdelrahman, L., Tomy, M., Suliman, S., Attia, S., et al. (2016)
Implementation of a Diabetes Educator Care Model to Reduce Paediatric Admission for
Diabetic Ketoacidosis. Journal of Diabetes Research, 2016, Article ID: 3917806.
Egyptian Journal of Health Care (2022). Factors Affecting the Patients Safety with Diabetic
Ketoacidosis in Intensive Care Unit. Science Direct. Retrieved October 17, 2023 from
https://www.sciencedirect.com/science/article/abs/pii/S1555415518304185#preview-section-cited-by

Eledrisi, M., Elzouki, A. (2020). Management of Diabetic Ketoacidosis in Adults: A Narrative

Review. Research gate. Retrieved October 17, 2023 from
https://www.researchgate.net/publication/343778701_Management_of_Diabetic_Ketoacidosis_in_Ad
ults_A_Narrative_Review

Evans K. Diabetic ketoacidosis: Update on management. Clinical Medicine. 2019;

doi:10.7861/clinmed.2019-0284

Gropper, S. S., Smith, J. L., & Groff, J. L. (2017). Advanced nutrition and human metabolism.

Cengage Learning.

Han, M. A. (2019). Hand Hygiene Practices Among Adults with Diabetes Living in
Communities: The 2015 Korea Community Health Survey. International Journal of
Environmental Research and Public Health, 16(7), 1279.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6480019/

Ignatavicius, D. D., & Workman, M. L. (2018). Medical-Surgical Nursing: Patient-Centered

Collaborative Care. Elsevier.

Joint British Diabetes Societies Inpatient Care Group. (2013). The Management of Diabetic
Ketoacidosis in Adults. Retrieved October 18, 2023, from https://abcd.care/resource/the-
management-of-diabetic-ketoacidosis-in-adults

Juanamasta, I. G., Aungsuroch, Y., Gunawan, J., Suniyadewi, N. W., & Nopita Wati, N. M.
(2021). Holistic Care Management of Diabetes Mellitus: An Integrative Review. International
Journal of Preventive Medicine, 12(69). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356953/

Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises
in adult patients with diabetes. Diabetes Care, 32(7), 1335-1343. DOI: 10.2337/dc09-9032.

Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM.
Management of hyperglycemic crises in patients with diabetes. Diabetes Care 24: 131–153,
2001. doi: 10.2337/diacare.24.1.131.

Kreider, K. (2018). Updates in the Management of Diabetic Ketoacidosis. The Journal for Nurse
Practitioners. Retrieved October 18, 2023 from
https://www.sciencedirect.com/science/article/abs/pii/S1555415518304185

Lippincott Williams & Wilkins. (2007). Nursing2007 drug handbook

Mayo Clinic. (n.d.). Diabetes Diet.

https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-diet/art-20044295

Metformin. (n.d) Retrieved from: https://medlineplus.gov/druginfo/meds/a696005.html#:~:

Nicardipine. (n.d) Retrieved from: https://go.drugbank.com/drugs/DB00622?
fbclid=IwAR20irUBPR0R624tH89_Wb-aM_CPqMpj-j6IwE7qL2nA9XXwxKd4VkDpXwM

National Institute of Diabetes and Digestive and Kidney Diseases. (2021). Tips for daily life.
Retrieved October 16, 2023 from https://www.niddk.nih.gov/health-information/weight-
management/tips-get-active/tips-for-daily-life

Potter, P. A., & Perry, A. G. (2016). Fundamentals of Nursing. Elsevier.

Prochaska, J. O., & Prochaska, J. M. (2016). Changing to thrive: Using the stages of change to

overcome the top threats to your health and happiness. Hazelden Publishing.

Saunders. (2010). Nursing drug handbook

Srakocic, S. (2022). What’s the Connection Between Diabetes and Pneumonia? Health line.

Retrieved October 16, 2023 from https://www.healthline.com/health/pneumonia/whats-the-

connection-between-diabetes-and-pneumonia

Smith, S. J., & Sewell, J. L. (2021). Managing Medication Adherence in Type 2 Diabetes: A
Patient-Centered Approach. Cureus. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9883658

The American Diabetes Association. (2023). The American Diabetes Association Guide to
Diabetes Care. The American Diabetes Association.

Urinalysis (2021) . Retrieved October 16, 2023 from

https://my.clevelandclinic.org/health/diagnostics/17893-urinalysis

Wayne, G. (2023). Impaired Gas Exchange. Nurseslabs. Retrieved October 14, 2023, from
https://nurseslabs.com/impaired-gas-exchange/
Wagner, M. (n.d.). Pneumonia Nursing Diagnosis & Care Plan. NurseTogether. Retrieved
October 14, 2023, from https://www.nursetogether.com/pneumonia-nursing-diagnosis-care-
plan/

Wagner, M. (2022.). Hyperglycemia Nursing Diagnosis & Care Plan. NurseTogether.

Retrieved October 14, 2023, from https://www.nursetogether.com/hyperglycemia-nursing-
diagnosis-care-plan/

Wehrman, A., & Wagner, M. (2016). Nutrition and diet therapy: Self-instructional modules.

Jones & Bartlett Learning.

WebMD (2023) . What to know About Neutrophils. Retrieved October 16, 2023 from
https://www.webmd.com/a-to-z-guides/what-to-know-neutrophils?
fbclid=IwAR1FbXq6Q74NLGyMXE52AQ0R6F12b8VgdbZ9U48BZ8xvNS0MfqIPV66cG80
Whitney, E., Rolfes, S. R., Crowe, T., Cameron-Smith, D., & Walsh, A. (2019). Understanding
nutrition: Australian and New Zealand edition. Cengage AU.

Why do nurses need research (2017). Retrieved

from:https://nursingonline.nsuok.edu/degrees/rn-to-bsn/why-nurses-need-research