CASE PRESENTATION

ON
DIABETES MELLITUS
TYPE II

DIABETES MELLITUS
  A chronic condition that affects people of all ages.
 It is critically an abnormal endocrine secretions by the pancreas (either an
absolute or relative insulin insufficiency), an insufficient number of insulin
receptor sites on cells, a post receptor defect or a combination of
abnormalities, alters the metabolism of food.
 Structural abnormalities develop in a number of different body tissues.

Four general components of DM:

a.) hyperglycemia

b) large blood vessels (macrovascular) disease

c) small blood vessel (microvascular) disease

d) neuropathy

 It is a symptomatic (polyurea, polydypsia and polyphagia) or asymptomatic state

of altered CHO, CHON and fat metabolism characterized by fasting blood
glucose level in excess of 140 mg/dL on two occasions and by 200 mg/dL 2 in
hours after a glucose load, if a glucose tolerance test is done.

CLASSIFICATION OF DIABETES MELLITUS

1. Insulin-Dependent Diabetes Mellitus (IDDM), Type 1
 Other names: Juvenile diabetes, Juvenile-onset Diabetes, Ketosis-Prone
Diabetes, Brittle Diabetes
 Clinical characteristics: Little or no endogenous insulin; requires exogenous
insulin for survival.
 Onset at any age, usually at young age (<25). Causes believed to be genetic,
environmental or acquired, probably involving abnormal immune responses.
  Other Names; Adult-Onset Diabetes (AOD), Maturity-Onset Diabetes
(MOD), Ketosis Resistant Diabetes, Stable Diabetes, Maturity-Onset Diabetes
of the Young (MODY)
 Clinical characteristics: Little or no endogenous insulin; requires exogenous
insulin for survival.
 Onset at any age, usually at young age (<25). Causes believed to be genetic,
environmental or acquired, probably involving abnormal immune responses.

2. Non – Insulin Dependent Mellitus (NIDDM), Type 2

 Other Names; Adult-Onset Diabetes (AOD), Maturity-Onset Diabetes
(MOD), Ketosis Resistant Diabetes, Stable Diabetes, Maturity-Onset Diabetes
of the Young (MODY)
 Clinical Characteristics: Rarely develop ketosis except during infection or
severe stress. Produce varying amounts of endogenous insulin, occasionally
require exogenous insulin. Most are obese and over 40 years of age at onset.
Cause thought to be genetic coupled with environmental factors.

DIABETES MELLITUS ASSOCIATED WITH OTHER CONDITIONS

1. Impaired Glucose Intolerance (IGT) (Obese and Non- Obese)

 Other Names: Asymptomatic Diabetes; Chemical Diabetes; Sub clinical

Diabetes; Borderline Diabetes; Latent Diabetes
 Characteristics: Glucose levels are between normal and diabetic levels.
Increased susceptibility to atherosclerosis disease

2. Gestational Diabetes
 Characteristics: women whose diabetes begins during pregnancy

3. Previous Abnormality Of Glucose Intolerance

 Other Names: Latent Diabetes, Prediabetes Glucose
 PATIENT’S PROFILE

Name: Granny Lou

Age: 59 years old

Gender: Female

Civil Status: Widow

Nationality: Filipino

Religion: Roman Catholic

Address: Amulung, Cagayan

Date Admitted: August 8, 2007

Chief Complain: body weakness

Attending Physician: Dr. R. Delos Santos

Final Diagnosis: Diabetes Mellitus Type II

 NURSING HEALTH HISTORY

Past Health History

According to the patient she has completed the different immunizations such as
DPT, BCG, OPV, TT and measles. She had experienced childhood illnesses such as
chickenpox, measles, colds, fever and cough. She had undergone surgery on her left eye
(when) because of inability to see clearly. She had also undergone an operation on her
right breast (removal of the cyst), 4 years ago. In addition, she was also diagnosed with
diabetes mellitus type II.

Family Health History

According to the patient, their family has history of heart disease, hypertension,
arthritis and diabetes. There are no other diseases related aside the mentioned above.

Present Health History

Three days prior to admission, the patient had experienced body weakness and
fever. She was brought to the clinic for check-up and was observed before
hospitalization. Patient Granny Lou was admitted on August 8, 2007 at SPH with chief
complaint of body weakness. The patient also has arthritis.
 GORDON’S 11 FUNCTIONAL HEALTH PATTERN

1. Health Perception/Health Management Pattern

Before Hospitalization
In the interview that transpired last August 9, 2007, the patient stated that health is
important to be able to do her activities. She also put emphasis on the idea that giving
importance to health should be made right from the start. She also stated that health is
being affected with traditional methods. She perceived that aside from the medications,
she can be healed with what is called “atang” in Ilocano- a means of offering foods in an
altar and a part of superstitious belief that can heal illnesses. (Medications)
She manages her health by taking a bath once a day and brushing her teeth once
or twice a day.
During Hospitalization
The patient verbalized that since she is being hospitalized, there is really
something wrong with her health. She can not take a bath, brush her teeth, and even comb
her hair. She takes metformin and mobic as her maintenance drugs.

2. Nutritional-Metabolic Pattern
Before hospitalization:
The SO verbalized that the patient eats three meals a day (breakfast, lunch and
dinner) with snacks in the morning and in afternoon. She eats whatever food is served.
The patient also added that whenever she feel something bad, she just eat 5 spoons of
food per meal. She drinks 7-8 glasses of water and another glass of ampalaya tea day. Her
weight was 75 kg.

During hospitalization:
The patient has a diabetic diet (low carbohydrate such as milk, egg and cheese) and
she eats three times a day. She eats with the help and assistance of the SO. She also
drinks about 1, 120 ml of water during our shift. Her weight was decreased to 70 kg as
verbalized by the SO.
3. Elimination Pattern
Before Hospitalization:
According to the SO, the patient usually defecates once a day with a color of
brown, consistency is semi- solid. She regularly voids three times during day time and
during night, the client’s arenola (medium size) is full, its color is yellow amber without
difficulty in urinating and defecating.

During Hospitalization
The patient urinates four times during our shift about 480 ml, has a color of dark
yellow and she did not defecate. She uses bedpan every time she eliminates.

4. Activity- Exercise Pattern

Before Hospitalization:
The patient could not perform any exercise due to body weakness. According to
the SO, she can not do any heavy works and she needs assistance in walking or when she
go outside their house. She stays at home spending 5-6 hrs. of sitting and the rest of the
time the patient perform simple activities such as watching TV, eating, lying on bed and
chatting with her children and grandchildren.
During Hospitalization
The patient is under CBR without BRP’s so she stays on her bed the whole day.

5. Cognitive-Perceptual Pattern
Before Hospitalization:
The client’s senses are at work except for her eyes, she experiences blurring
vision before she was confined for an eye operation. She has an impaired sense of
hearing. As to her sense of taste, she has no problem. She is well oriented with time,
place, persons and events.

During Hospitalization
 The patient has no problems with regards to her speaking capabilities even though
she delivers her statement in a very soft voice. She answers questions relevantly. She has
hearing defect. She is well oriented with time, place, persons around her and event.

6. Sleep-Rest Pattern
Before Hospitalization
Her typical sleep hour is from 8pm to 8am, about 10-12 hrs. her usual nap time is
30 mins.after lunch.

During Hospitalization:
The patient was not able to sleep at night because of the vital signs taking every 2
hrs. and drug administering.

7. Role-Relationship Pattern
Before Hospitalization
Being a responsible mother, she proudly says that she was able to fulfill her duties
and responsibilities. She has a very good relationship with her family. She claims that her
family is her priority. She emphasized that since all of them do their tasks and perform
their responsibilities well, they have a strong family ties. The moment she had her illness
and other signs of aging, she started to think she could no longer perform her duty

During Hospitalization
The SO verbalized that though her mother is suffering from DM and other illness, the
patient still have a close relationship with her family .

8. Self- Perception Pattern

Before hospitalization:
She views herself as a good mother and she added that she is strong woman who can
withstand the crisis she is currently facing in life. She believes that with the support of
her family, she could surpass whatever test of life comes her way.
During hospitalization:
She never changed her perception to herself. Though she felt being bed ridden
because she could not move that easily, with her family’s unending assistance, she gats
her strength from them not to give up no matter how painful her situation is.

9. Sexual- Reproductive Pattern

Before hospitalization:
The patient verbalized that she lives with her family in a compound. She has 6
children: 3 boys and 3 girls. She had her menarche when she was in grade 6. Her
menstruation period lasts at about 3 or 5 days and it was regular (monthly). Sometimes,
she was suffering from dysmenorrhea. She had undergone tubal ligation in the year 1982
and she also had her menopause when she was 50 years old..

During hospitalization:
Due to old age and her condition, she is no longer sexually active.

10. Coping- Stress Pattern

Before hospitalization:
She copes with stress by resting and sleeping. Whenever she thinks of her
condition, she prays to God to comfort herself.

During hospitalization:
The patient copes with stress by just merely talking to her daughter and she sleeps
when she feels drowsy. She also prays as her sign that she’ll never give up.

11. Value- Belief Pattern

The patient is a Roman Catholic. They also believe with superstitions however
when disease gets worse, they seek medical assistance..
When the client was not yet suffering from DM, they go to mass as a family but when she
was diagnosed with this kind of disease and due to aging; they could no longer attend
mass; so they are just having their TV mass every Sunday.
 PHYSICAL ASSESSMENT

BT: 37.7oC – increased; doe to infection

BP: 110/70 mmHg
PR: 104 bpm (normal:60-110bpm)
RR: 24 cpm
GENERAL
APPEARANCE

1. Posture and gait Inspection Relaxed, erect posture, NOT Relaxed DUE to body
coordinated movement weakness

2. overall
Hygiene Inspection Clean and neat Poor hygiene Due to inability
to move

3. signs of health
and illness Inspection Healthy appearance Weakness Presence of
illness

Area assessed Technique Normal findings Actual findings Analysis

used
SKIN
1. Color Inspection Light to deep brown Tanned Normal
2. Moisture Inspection Dry skin folds Dry skin Due to aging
and Palpation
3. Temperature Palpation Warm to touch Warm to touch with Hyperthermia
temperature of 37.7º C related to
increased
pyrogen
production
4. Texture Inspection Smooth and firm with Rough and not flexible Due to aging
and Palpation an even surface
5. Edema Palpation No edema Looks puffy and tight; Due to
pitting at +1 point scale accumulation
of fluid in the
intercellular
spaces
HAIR

1. Distribution Inspection Evenly distributed Evenly distributed Normal

2. Texture Palpation Smooth and resilient; no Smooth; (+) dandruff Due to poor
dandruff hygiene

3. Color Inspection Black to dark Black with white Normal

NAILS

1. Fingernail plate Inspection Transparent smooth and Transparent smooth and Normal
shape and texture convex curvature convex curvature

2. Color of nail
beds Inspection Nail beds pink with Nail beds pink with Normal
translucent white tip in translucent white tip in
brown or black brown or black
HEAD
Size, shape and
Inspection Convex curvature, Convex curvature, Normal
symmetry
symmetrical symmetrical

FACE

Symmetry and
Inspection Symmetrical with no Symmetrical with no Normal
color
presence of edema; the presence of edema; the
same with body color same with body color

EYES

1. eyebrows Inspection Symmetrical in size, Symmetrical in size, Normal

extension, hair extension, hair
texture and texture and
movement movement
- evenly - evenly
distributed distributed

2. Eyelashes Inspection Evenly distributed and Evenly distributed and Normal

slightly curve outward slightly curve outward
3. Eyelid Inspection Skin intact, no Skin intact, no Normal
discharge, no discharge, no
discoloration, lids close discoloration, lids close
symmetrically symmetrically

4. Conjunctiva Inspection Pink Pink Normal

5. Pupil Inspection PERRLA PERRLA (in left eye) Normal

EARS
Auricles

1. Symmetry of Inspection Symmetrical Symmetrical Normal

size

2. Color Inspection Same as facial skin Same as facial skin Normal

3. Position Inspection Aligned with outer Aligned with outer Normal

cantus of the eye cantus of the eye

4. Texture Palpation Firm Firm Normal

5. Elasticity Palpation Mobile Mobile Normal

6. Hearing acuity Normal voice Can hear clearly Cannot hear clearly Due to aging
tones
NOSE
1. Skin color Inspection - light to deep - light brown Normal
brown
2. Tenderness Palpation - no tenderness - no tenderness Normal
4. Discharge Inspection - no discharge - no discharge Normal
MOUTH
Lips
1. Color Inspection Uniform pink or dark Dark red Normal
color
2. texture Palpation moist Slightly dry due to
insufficient
fluid intake
Teeth and gums
Color of teeth Inspection - smooth, white, Slightly yellow Normal
shiny tooth
enamel

Color of gums Inspection Pink Pink Normal

No. of teeth Inspection 32 teeth 9 teeth Due to aging

BUCCAL
MUCOSA
Inspection Pink Pink Normal
Color
Palpation moist moist Normal
Moisture

TONGUE

Color Inspection Pink Pink Normal

Texture Palpation Smooth Smooth Normal

Movement Inspection Moves freely Moves freely Normal

Neck

Position Inspection Head centered Head centered Normal

Masses Palpation No nodules No nodules Normal

POSTERIOR
THORAX
Symmetry Inspection Chest symmetric Chest symmetric Normal

Spinal alignment Inspection Spine vertically aligned Spine vertically Normal

aligned
Integrity of the Inspection Skin intact Skin intact Normal
skin
Tenderness Palpation No tenderness No tenderness Normal

ANTERIOR
THORAX
Breathing pattern Inspection Quiet, rhythmic, Quiet, rapid Due to
(rhythm) effortless respirations overexpansion
of the lungs
Breath sounds Auscultation resonant resonant Normal

Symmetry Inspection Symmetrical Symmetrical Normal

Color Inspection Same as body color Same as body color Normal

BREAST
Color Inspection Same as body color Same as body color Normal

Skin intact, no Presence of scar on

Skin quality Inspection discharge, no the right breast Due to the
discoloration , no operation done
scar, no lesion on her right
breast (removal
of cyst)

Generally symmetric Change in the right Due to

Symmetry Inspection breast size operation

AREOLA
Round and oval Round and oval Normal
Size and shape Inspection
From light pink to deep brown Normal
Color Inspection brown

NIPPLES
Round,, elevated, equal Round,, elevated, equal Normal
Size and shape Inspection in size in size

Similar in color Similar in color Normal

Color Inspection

Both nipples point in Both nipples point in Normal

Direction Inspection the same direction the same direction

ABDOMEN
a. skin integrity Inspection - uniform color - uniform color Normal
and unblemished and unblemished
skin, presence of skin, presence of
stretch marks, stretch marks,
striae striae
gravidarum gravidarum
b. Skin Color inspection Same as body color Same as body color Due to
except for the areas pregnancy
 with stretch marks
Upper Extremities
1. symmetry Inspection - symmetrical - symmetrical Normal
2. alignment of Palpation - Joints feel stable - Joints feel stable Normal
joints and and
symmetrical, no symmetrical, no
tenderness. tenderness
3. ROM Inspection - full mobility of - Limited motion in IV line inserted
each joint the right arm @ the right
- movement is arm
deliberate,
accurate, smooth
and coordinated
LOWER
EXTREMITIES:
1. Symmetry Inspection symmetrical Symmetrical Normal
2. Alignment of Palpation - Joints feel stable Joints feel stable Normal
joints and and symmetrical, no
symmetrical, no tenderness
tenderness
3. ROM Inspection - Full mobility of Limited range of
each joint motion in one or
- movement is more joints
deliberate,
accurate,
smooth, and
coordinated
NEUROLOGIC
SYSTEM
1. Level of Inspection - oriented to time, - oriented to time Normal
consciousness place, person (4:00), place
(SPH),
person(SO)
 LABORATORY RESULTS
Urinalysis
August 8, 2007
PARAMETERS RESULTS ANALYSIS
Color Yellow Normal
Transparency Turbid Due to food or medicines the patient is taking
Reaction 6 Normal
Specific Gravity 1.020 Normal
Sugar Trace Due to inability of renal tubule to absorb all glucose filtered by glumeruli
Protein Trace Due to increase glumeruli filtration
PARAMETERS RESULTS ANALYSIS
Squamous Epithelial Few Normal
Cells
Mucus Thread Few Due to infection
Pus Cells 8-10 Due to infection; also due to possible cause of UTI
RBC 3-4 Due to glomerular damage as a result of renal strictures
secondary to disease process
Armorp. Urates / Few Normal
Phosphates
Microscopic Examination
BLOOD CHEMISTRY
August 8, 2007
PARAMETERS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Random blood sugar 70 – 120 md/dL 463 mg/dl Increased; due to defective
receptor sites
Creatinine F: 50-100 81.4 umol/L Normal
Sodium 135-155 mmol/L 131 mmol/L Decreased; due to osmotic
diuresis
Potassium 3.6-5.5 mmol/L 4.78mmol/L Normal
August9, 2007
PARAMETERS NORMAL FINDINGS ACTUAL FINDING ANALYSIS
Random Blood Sugar 70 – 120 md/dL 487 mg/dl Increased; due to defective
receptor sites
Uric Acid 178-345 mmol/L 247 mmol/L Normal

Fasting Blood Sugar 3.89-5.84 mmol/dL 21.43 mmol/dL Increased; due to defective
receptor sites
Cholesterol 3.87- 6.71 mmol/dL 7 mmol/dL Increased; due to increased
dietary fat intake
HDL – C Female: >1.7 mmol/L 0.7 mmol/L Decreased; due to increased
dietary fat intake
LDL – C < 3.88 mmol/L 0.63 mmol/L Normal
Triglyceride Female: 0.46 – 1.6 1.50 Normal

August 10,2007
PARAMETERS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
RANDOM BLOOD SUGAR 70 – 120 md/dL 289 mg/dl Increased; due to defective
receptor sites
SODIUM 135-155 mmol/L 140 mmol/L Normal
POTASSIUM 3.6-5.5 mmol/L 4.91mmol/L Normal

HEMATOLOGY
August 8, 2007
PARAMETERS NORMAL FINDING ACTUAL FINDING ANALYSIS
WBC 5 x 10 g/L 8.9 Normal
RBC: Hemoglobin Female: 12 – 16 g/dL 11.4 g/dL Decreased; due to
vasoconstriction of minute
vessels
Hematocrit Female: 37 – 48% 35% Decreased; due to
vasoconstriction of minute
vessels
Differential Count:
Segmenters 0.60 – 0.70 0.94 Increased; due to inflammatory
response
Decreased; due to presence of
infection
Lymphocytes 0.20 - .30 0.06
August 9, 2007
PARAMETERS NORMAL FINDING ACTUAL FINDING ANALYSIS
WBC 5 x 10 g/L 11.5 Increased; due to inflammatory
response
RBC: Hemoglobin Female: 12 – 16 g/dL 13 g/dL Normal
Hematocrit Female: 37 – 48% 40% Normal
Differential Count:
Segmenters 0.60 – 0.70 0.90 Increased; due inflammatory
response

Decreased; due to presence of

Lymphocytes 0.20 - .30 0.10 infection
HEMOGLUCO TEST (HGT)
DATE TIME NORMAL FINDING ACTUAL FINDING ANALYSIS
AUGUST 11:45 A.M. 80-120 408 Increased; due to
8, 2007 1:00 P.M. 80-120 333 defective receptor sites
8:00 P.M. 80-120 307
AUGUST 12:30 A.M. 80-120 326 Increased; due to
9, 2007 2:30 A.M. 80-120 487 defective receptor sites
5:00 P.M 80-120 274
ANATOMY AND PHYSIOLOGY
Pancreas, insulin, and diabetes
 The endocrine part of the pancreas consists of pancreatic islets dispersed
among the exocrine portion of the pancreas. The islets secrete two hormones-
insulin and glucagons which function to help regulate blood nutrient levels,
especially blood glucose. Alpha cells of the pancreatic islets secrete
glucagons, and beta cells of the pancreatic islets secrete insulin.
 It is very important to maintain blood glucose levels within a normal range of
values. A decline in the blood glucose level below its normal range causes the
nervous system to malfunction because glucose is the nervous system’s main
source of energy. When blood glucose decreases, fats and proteins are broken
down rapidly by other tissues to provide an alternative energy source. As fats
are broken down, some of the fatty acids are converted by the liver to acidic
ketones, which are released into the circulatory system. When blood glucose
levels are very low, the breakdown of fats can cause the release of enough
fatty acids and ketones to cause the pH of the body fluids to decrease below
normal, a condition called acidosis. The amino acids of proteins are broken
down and used to synthesize glucose by the liver.
 If blood glucose levels are too high, the kidneys produce large volume of
urine containing substantial amounts of glucose. Because of the rapid loss of
water in the form of urine, dehydration can result.
 Insulin is released from beta cells primarily in response to the elevated blood
glucose levels and increased parasympathetic stimulation that is associated
with digestion of a meal. Increased blood levels of certain amino acids also
stimulate insulin secretion. Decreased insulin secretion results from
decreasing blood glucose levels and from stimulation by the sympathetic
divisio0n of the nervous system. Sympathetic stimulation of the pancreas
occurs during physical activity. Decreased insulin levels allow blood glucose
to be conserved to provide the brain with adequate glucose and to allow other
tissues to metabolize fatty acids and glycogen stored in the cells.
 The major target tissues for insulin are the liver, adipose tissue, muscles, and
the area of the hypothalamus that controls appetite, called the satiety center.
 Insulin binds to membrane-bound receptors and, either directly, increases the
rate of glucose and amino acids uptake in these tissues. Glucose in converted
to glycogen or fat, and the amino acids are used to synthesized protein.
 Diabetes mellitus can result from any of the following: type 1 diabetes
mellitus is caused by the secretion of too little insulin from the pancreas and
type 2 diabetes mellitus is caused by insufficient numbers of insulin receptors
on target cells, or defective receptors that do not respond normally to insulin.
 In people who have type 1 diabetes mellitus, tissues cannot take up glucose
effectively, causing blood glucose levels to become very high, a condition
called hyperglycemia. Because glucose cannot enter cells of the satiety center
of the brain without insulin, the satiety center responds as if there were very
little blood glucose, resulting in an exaggerated appetite. The excess glucose
in the blood is excreted in the urine, causing the urine volume to be much
greater than normal. Because of excessive urine production, the person has a
tendency to become dehydrated and thirsty. Even though blood glucose levels
are high, fats and proteins are broken down to provide an energy source for
metabolism, resulting in the wasting away of body tissues, acidosis, and
ketosis. People with this condition also exhibits a lack of energy.
 Glucagons is released from the alpha cells when blood glucose levels are low.
Glucagons binds to membrane-bound receptors primarily in the liver and
cause the conversion of glycogen stored in the liver to glucose. The glucose is
then released into the blood to increase blood glucose levels. After a meal,
when blood glucose levels are elevated, glucagons secretion is reduced.
 Insulin and glucagons function together to regulate blood glucose levels. When blood
glucose level increase, insulin secretion increases, and glucagons secretion decreases.
When blood glucose levels decrease, the rate of insulin secretion declines, and the
rate of glucagons secretion increases. Other hormones, such as epinephrine, cortisol,
and growth hormone, also function to maintain blood levels of nutrients. When blood
glucose levels decrease, these hormones are secreted at a greater rate. Epinephrine
and cortisol cause the breakdown of protein and fat and the synthesis of glucose to
help increase blood levels of nutrients. Growth hormone slows protein breakdown
and favors fat breakdown.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Fluid volume deficit At the end of 30 - kept fluid within - to minimize effort Goal met. At the
r/t pain when minutes, the patient client’s reach and and replace losses of end of 30 minutes,
“ Tuyo ang swallowing will be able to: encourage frequent fluid the patient was able
lalamunan ko dahil - stabilize fluid intake as to stabilize fluid
sa di ako masyado volume at a appropriate intake at functional
makainom, masakit functional level level.
kasi oag lumunok - have an adequate - recorded and - to be aware of
ako,” as verbalized urinary output monitored I and O insensible water losses
by the patient. - balanced I and O accurately to ensure accurate
and VS within picture of fluid status
Objective Data: client’s normal limit
- dry skin/ - monitored VS - to note any changes
mucous in VS
membrane - changed position - to promote proper
- weight loss frequently circulation
- increased - administered IV - to promote fluid
urine output fluid as ordered management
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data: Altered body At the end of 30 >Monitor vital signs >To determine basal Goal met. The
-flushed skin temperature: minutes, the patient & recorded body temperature, to patient was able to
- T= 37.7 o C Hyperthermia r/t will be able to particularly have baseline data & obtain core body
- RR= 24 cpm increased obtain body temperature to have a basis for temperature within
production of temperature within evaluating the normal range.
pyrogens in the normal range. effectiveness of
body interventions.

>provided the >To promote surface

patient continues cooling and heat lose
TSB by evaporation and
conduction.

>Positioned the > Promote client

patient in a safety & to maintain
comfortable and patent airway to
safe position. address increased
 respiratory rate.

>Provided proper >To promote surface

room ventilation by cooling & heat loss by
opening the fan & convection.
window panes.

>Advised the >Loose clothing &

patient’s SO to light colored clothing
change the patient’s promotes body surface
clothing to loose & cooling. Light colored
light colored clothes are more
clothes. absorbent to address
diaphoresis.

>Advised the >To replace fluids &

patient to increase electrolyte to support
fluid intake to 8-10 circulatory volume &
glasses/day. tissue perfusion and to
prevent dehydration.
>Instructed the >To reduce metabolic
client to maintain demands & oxygen
bed rest. consumption.

>Administered >To restore normal

antipyretics & due body temperature & to
medications treat underlying
intravenously as conditions.
ordered.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Pain r/t At the end of 1 > determine diagnosis > to determine immediate Goal partially met.
discomfort hour, the that contribute to deviation or complication
“ Hindi ako patient will be immobility such as on patient’s condition At the end of 1
makagalaw kasi able to: arthritis hour, the patient
sumasakit ang was able to:
katawan ko, as > verbalize > Assessed degree of > to provide necessary
verbalized by the understanding pain by listening to intervention to lessen > verbalized
patient. of situation and client’s description and client’s discomfort understanding of
individual facial expression situation and
Objective Data: treatment individual
regimen and > note emotional or > Feelings of treatment regimen
>Facial grimace safety measures behavioral responses to frustrations/powerlessness and safety
problems of immobility may impede attainment of measures but did
>Difficulty in > increase goals not increase d the
turning strength and strength and
function of > supported affected > to maintain position of function of
>Slowed affected body body parts by using function and reduce risk of affected body part
movement part pillows pressure on the affected
area
 >Jerky movement

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Goal partially met
Subjective Data: Pain r/t upper and At the end of 1 > determined level > to be able to
lower extremeties hour, the patient of pain from 8/10 know what The patient
“Masakit ang katawan will be able to: particular reported pain
ko kapag ginagalaw intervention to controlled and a
ko”, as verbalized by > report pain if relieve pain decreased in pain
the patient relieved/ controlled > positioned patient scale of 5/10
- pain scale of 8/10 and a decreased in comfortably on bed > To promote
pain scale of 0/10 wellness
> provided patient
Objective Data: adequate rest
> to prevent fatigue
 facial grimace > provided quiet
 expressive environment
behavior > to be able to have
 restlessness > Provided comfort enough rest
measures such as
changing the > to alleviate pain
patient’s position caused by pressure
frequently on nerve endings

> administered
analgesia as ordered
> to maintain
acceptable level of
pain

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

At the end of 1 > monitored vital > to provide

Subjective data: Activity intolerance hour, the patient signs every 2 hours baseline data; to Goal met.
r/t body weakness will be able to: evaluate the degree
“Madali akong of condition and the At the end of 1
mapagod kahit na >Participate effectiveness of the hour, the patient
mag – iba lang ako willingly in intervention was able to:
ng posisyon”, as necessary activities
verbalized by the > encouraged > to determine the
patient. > report measurable expression of necessary >Participate
increase in activity feelings intervention to be willingly in
- Body weakness intolerance contributing to the made for the client’s necessary activities
condition condition
Objective Data: > report measurable
> Planned care with > to reduce fatigue increase in activity
BP: 110/70 mmHg rest periods between and to have enough intolerance
RR: 24 cpm activities rest periods.
PR: 104 bpm
HCT: 35% > Involved client > involvement of
HGB: 11.4 g/dL and SO in planning client and SO
of activities as much during the plan of
as possible care helps to attain
goals
 DRUG STUDY

1. Generic Name: Colchicine

Brand Name: Colsalide, Novocolchine
Classifications: Antigout
Action: Inhibits microtubule formation of lactic acid in leukocytes which decreases
phagocytosis and inflammation in joints.
Uses: Prevention or treatment for gout, gouty arthritis to arrest progression of neurologic
disability in multiple sclerosis
Contraindications: Hypersensitivity; serious GI, renal, hepatic, cardiac disorders; blood
dyscariasis
Side Effects:
Miscellaneous: myopathy, alopecia, reversible azoospermia, peripheral neuritis
GU: Hematuria, Oliguria, Renal Damage
HEMA: Anemia, thrombocytopenia
GI: nausea, vomiting, anorexia, malaise, metallic taste, cramps, peptic ulcer,
diarrhea
INTEGU: cdhills, dermatitis, pruritis, purpura, erythema
Route and Dosage: 1 tab every 1 hour
Nursing Implications:
Assessment: > Assess I and O ratio, observe for decrease in urinary output.
> Administer on empty stomach, only to facilitate absorption
Family / Client Teaching: > Instruct SO or family members to increase fluids to
3-4 L/day.
> Encourage patient or SO to report any pain, redness
hand area.

2. Generic Name: Omeprazole

Brand Name: Prilosec
Classifications: Proton Pump Inhibitor
Action: Thought to be a gastric pump inhibitor in that it blocks the final step of acid
production by inhibiting the hydrogen, potassium, ATP system at the secretory surface of
the gastric parietal cell.
Uses: Used to treat ulcers, gastroesophageal reflux disease or heartburn
Contraindications: pain with swallowing; had heartburn for 3 months; frequent chest
pain
Side Effects: CNS: headache, dizziness, insomia, apathy
GI: diarrhea, constipation, anorexia
CV: chest pain, bradycardia, palpitation
Respi: URI, cough, bronchospasm
Derm: rash, severe generalized skin reaction including toxic epidermal
necrolysis
GU: UTI, urinary frequency, hematuria, glycosuria
Hema: thrombocytopenia, anemia
Musculo: Back Pain, Muscle Cramps and Weakness
Misc: fever, pain, gout, fatigue, malaise, weight gain
Route and Dosage: 40 mg ANST ( - )
Nursing Implications:
Assessment: > Perform skin test
> Check for vital signs
> Monitor for any episodes of chest pain
Family / Client Teaching: > The capsule should be taken 30 minutes before
eating and is to be swallowed whole; it should not be opened, chewed or crushed.
> Review drug associated side effects; report if
diarrhea persists. Report any changes in urinary elimination or pain and
discomfort.

3. Generic Name: Vigocid (Piperacillin Sodium + Tazobactam Sodium)

Action: Bactericidal in action by inhibiting septum formulation and cell wall synthesis of
susceptible bacteria
Use: used as antibiotic
Contraindications: Patients with a history of allergic reactions to any of the penicillins,
cephalosporins, beta-lactamase inhibitors
Side Effects: nausea nad vomiting, diarrhea, constipation, rash, red skin, allergic reaction
(hives), difficulty in sleeping, headache, diaphoresis, eczema
Route and Dosage: 4.5 g / IV every 8 hours ANST ( - )
Nursing Implications:
Assessment: > Document indications for therapy, symptom onset and weight
history
> Assess for other medical conditions that require careful
monitoring
Family / Client Teaching: > Take drug within ordered intervals to prevent
further aggravation
> Do not engage in activities that require mental
alertness.

4. Generic Name: Meloxicam

Brand Name: Mobic
Classifications: NSAID
Action: Reduces the production of prostaglandin that initiate the cause of inflammation
Uses: used to treat inflammation and pain of arthritis
Contraindications: with asthma attacks, hives or allergic reactions
Side Effects: GI: abdominal pain, diarrhea, dyspepsia, constipation, flatulence
CNS: dizziness, headache,
Route and Dosage: 15 mg / tab; 1 tab OD
Nursing Implications:
Assessment: > Perform skin test
> Document indications for therapy, onset and characteristics of
disease, ROM.
> Determine any GI bleed or ulcer history, aspirin or other
NSAID-induced asthma, urticaria or allergic type reactions.
 Family / Client Teaching: > Take exactly as directed and at the same time each
day. May take with or without food.
> Avoid activities that require mental alertness until
drug effects realized; may cause dizziness or
drowsiness.
> Report any unusual or persistent side effects
including dyspepsia, abdominal pain, dizziness and
changes in stool or skin color.

5. Generic Name:Metformin HCl

Brand Name: Glocophage
Classifications: Antidiabetic
Action: Decreases hepatic glucose production, decreases intestinal absorption of glucose
and increases peripheral uptake and utilization of glucose.
Uses: Alone as an adjunct to diet to lower blood glucose in client having NIDDM whose
blood glucose cannot be managed satisfactorily via diet alone.
Contraindications: acute or chronic metabolic acidosis, including diabetic ketoacidosis,
with or without coma. Abnormal hepatic function.
Side Effects: GI: Diarrhea, abdominal bloating, flatulence, anorexia, unpleasant or
metallic state, abnormal stools, taste disorders
CNS: lightheadedness, headache
Misc: hypoglycemia, myalgia, chest discomfort, palpitation
Route and Dosage: 500 mg / tab (tab BID during meals)
Nursing Implications:
Assessment: > Individualize dosage based on tolerance and effectiveness
> Give with meals starting at a low dose with gradual escalation.
This will reduce GI side effects and allow determination of the
minimal dose necessary for adequate control of blood glucose.
> Document age at diabetes onset, previous therapies utilized and
outcome.
 Family / Client Teaching: > Take with food to decrease GI upset
> Warn users that the inactive components in the
extended-release tablets may pass into the feces and
appear as a soft, hydrated mass.

6. Generic Name: Humulin - N

Brand Name: Isophane Insulin Human
Action: intermediate-acting insulin with slower onset of action that keep blood glucose at
a nearly normal level
Uses: indicated for treatment of patient with diabetes mellitus who require insulin for the
maintenance of glucose homeostasis
Contraindications: contraindicated during episodes of hypoglycemia; also patient with
hypersensitivity to human insulin
Route and Dosage: OD every 9 pm
Nursing Implications:
Assessment: > Monitor VS particularly BP
> Be alert for signs of hypoglycemia, loss of glucose control,
kidney, eye or foot problems
Family / Client Teaching: > Do not take if without medical advice.

7. Generic Name: Paracetamol

Brand Name: Acephen, Campain
Classifications: Antipyretic
Action: Reduces fever by direct action on the hypothalamus, heat-regulating center with
consequent vasodilatation and sweating.
Uses: Fever reduction; temporary relief of mild to moderate pain. Generally, as substitute
for aspirin when it is not tolerated.
Contraindications: Renal insufficiency, anemia, cardiac or pulmonary disease
Side Effects: rash, anorexia, nausea and vomiting, diaphoresis, abdominal pain
Route and Dosage: 500 mg, 1 tab PRN for fever
Nursing Implications:
Assessment: > Do not exceed a dose of 4 g/ 24hr in adults and 75 mg/kg/day in
children.
> Do not take more than 5 days for pain in children, 10 days for
pain in adults, or more 3 days for fever in adults or children without consulting
Health care provider.
Family / Client Teaching:> Warn not to combine products containing
acetaminophen.
> Take only as directed and with food or milk to
decrease GI upset.