I.

PERSONAL DATA Name: Address: Hospital Number: Age: Sex: Date of Birth: Civil Status: Religion: Educational Attainment: Occupation: Chief Complaint: Admitting Diagnosis: Admitting Physician: Zenaida C. Simpliciano Brgy. Payas, San Nicolas, Ilocos Norte 560799 41years old Female June 15, 1970 Married Pentecost High School Undergraduate Barangay Captain Low back pain, pain in the calf, joint pain Low back pain R/O Nephrolithiasis, R/O Hypergycemia Melanie Grace Valdez, M.D. Annalyn G. Urbano, M.D. Attending Physician: Butch Bigornia, M.D.

Date and Time of Admission: July 01, 2011 01:45 AM Final Diagnosis: DM2 Insulin Resistant Non-Obese Fairly Controlled Peripheral Neuropathy Date and Time of Discharge: July 03, 2011 11:05 AM

II. ANATOMY AND PHYSIOLOGY A. B. C. D. E. F. Overview of the System Affected Overview of the Organ Affected Readings Pathogenesis of DM Type 2 Non-insulin Dependent Risk Factors Pathophysiology

A. Overview of the System Affected

 THE ENDOCRINE SYSTEM The endocrine system is made up of glands that produce and secrete hormones. These hormones regulate the body's growth, metabolism (the physical and chemical processes of the body), and sexual development and function. The hormones are released into the bloodstream and may affect one or several organs throughout the body.

Hormones are chemical messengers created by the body. They transfer information from one set of cells to another to coordinate the functions of different parts of the body. The endocrine system is regulated by feedback in much the same way that a thermostat regulates the temperature in a room. For the hormones that are regulated by the pituitary gland, a signal is sent from the hypothalamus to the pituitary gland in the form of a "releasing hormone," which stimulates the pituitary to secrete a "stimulating hormone" into the circulation. The stimulating hormone then signals the target gland to secrete its hormone. As the level of this hormone rises in the circulation, the hypothalamus and the pituitary gland shut down secretion of the releasing hormone and the stimulating hormone, which in turn slows the secretion by the target gland. This system results in stable blood concentrations of the hormones that are regulated by the pituitary gland.

THE MAJOR GLANDS OF THE ENDOCRINE SYSTEM 1. Hypothalamus 2. Pituitary Gland 3. Thyroid Gland 4. Parathyroid Gland 5. Adrenal Gland 6. Pineal Body 7. Reproductive Glands 8. PANCREAS

1. Hypothalamus This part of the brain is important in regulation of satiety, metabolism, and body temperature. It also secretes a hormone called somatostatin, which causes the pituitary gland to stop the release of growth hormone. 2. Pituitary Gland It is often considered the most important part of the endocrine system because it produces hormones that control many functions of other endocrine glands. (Growth hormones, TSH, ACTH, LH/FSH, Prolactin, ADH, Oxytocin) 3. Thyroid Gland It produces thyroid hormones, which helps maintain normal blood pressure, heart rate, digestion, muscle tone, and reproductive functions. 4. Parathyroid Gland releases parathyroid hormone, which plays a role in regulating calcium levels in the blood and bone metabolism. 5. Adrenal Gland produces corticosteroids and catecholamines.

6. Pineal Body secretes melatonin, which may help regulate the wake-sleep cycle of the body. 7. Reproductive Glands secretes sex hormones which affect both male characteristics, and the development of female characteristics. 8. Pancreas secretes hormones called insulin and glucagon. These hormones regulate the level of glucose (sugar) in the blood. B. Overview of the Organ Affected PANCREAS

 Size, shape, location: Larger in men than in women, but considerable individual variation; varies in length from 15 to 20 cm (6 to 8 in), has a breadth of about 3.8 cm (1.5 in), and a thickness of 1.3 to 2.5 cm (0.5 to 1 in) and with a usual weight of about 85 gm (3 oz); fish shaped, with body, head, and tail; extends from the duodenal curve to the spleen. Structure: that of both a duct gland and a ductless gland 1. Pancreatic cells: pour secretion (pancreatic juice) into the duct that runs length of the gland and passes out of the head of the pancreas to unite with the common bile duct (CBD) and enters the duodenum at the ampulla of Vater. 2. Islands of Langerhans (or islets cells); clusters of cells not connected with pancreatic ducts; two main types of cells compose islets (namely, alpha and beta cells); constitute the endocrine glands Functions and Structure 1. Pancreatic cells connected with pancreatic ducts secrete pancreatic juice (amylase, trypsin, lipase), enzymes of which to help digest all three kinds of foods. 2. Islet cells constitute endocrine gland a. Alpha cells secrete the hormone glucagon, which accelerates liver glycogenolysis, hence tends to increase blood sugar. b. Beta cells secrete insulin, one of the most important metabolic hormones, which exerts a profound influence on the metabolism of carbohydrates, proteins and fats. Insulin accelerates the active transport of glucose (along with potassium and phosphate ions) through cell membranes;

therefore it tends to decrease blood glucose (hypoglycemic effect) and to increase glucose utilization by the cells for either catabolism or anabolism. Insulin stimulates the production of liver cell glucokinase; therefore it promotes liver glycogenesis, another effect that tends to lower blood glucose. Insulin inhibits liver cell phosphatase and therefore inhibits liver glycogenolysis Insulin accelerates the rate of amino acid transfers into cells, so it promotes anabolism of proteins within the cells. Insulin accelerates the rate of fatty acid transfer into cells, promotes fat anabolism (also called fat deposition or lipogenesis) and inhibits fat catabolism.

METABOLISM Definition: sum of all the chemical reactions in the body Catabolism a) Consists of a complex series of chemical reactions that take place inside the cells and yield energy, carbon dioxide, and water; about half the energy released from food molecules by catabolism is put back in storage as unstable, high-energy bonds of ATP molecules; the rest is transformed

to heat; the energy is high energy bonds of ATP can be released as rapidly as needed for cellular work. b) Two processes involved: glycolysis and the Krebs citric acid cycle c) Purpose: to provide cells continually with utilizable energy. Anabolism a) Synthesis of various compounds from simpler compounds b) Cellular work that uses some of the energy made available by catabolism Metabolism of carbohydrates Consists of the following processes: a) Glucose transport through cell membranes and phosphorylation Insulin promotes this transport through cell membranes Glucose phosphorylation: conversion of glucose to glucose-6phosphate, catalyzed by the enzyme glucokinase; insulin increases the activity of glucokinase and promotes glucose phosphorylation, which is essential prior to both glycogenesis and glucose catabolism b) Glycogenesis: conversion of glucose to glycogen for storage; occurs mainly in the liver and muscle cells. c) Glycogenolysis In muscle cells glycogen is changed back to glucose-6-phosphate, which is then catabolized in the muscle cells. In liver cells glycogen is changed back to glucose; an enzyme, glucose phosphatase, is present in the liver cells and catalyzes the

final step of glycogenolysis, the changing of glucose-6-phosphate to glucose; glucagons and epinephrine accelerates liver

glycogenolysis. d) Glucose catabolism Glycolysis: series of anaerobic reactions that break one glucose molecule down into two pyruvic acid molecules, with conversion of about 5% of energy stored in glucose to heat and ATP molecules. Krebs citric acid cycle: series of aerobic chemical reactions by which two pyruvic acid molecules (from one glucose molecule) are broken down to six carbon dioxide and six water molecules, with the release of some energy as heat and some stored again in ATP; citric acid cycle releases about 96% and glycolysis only about 5% of the energy stored in glucose; citric acid cycle occurs in the mitochondria of cells. e) Gluconeogenesis: sequence of chemical reactions carried on in liver cells; process converts protein or fat compounds into glucose. f) Principles of normal carbohydrate metabolism 1. Principle of preferred energy fuel: cells first catabolize glucose, sparing protein and fats; when their glucose supply become inadequate, they next catabolize fats, sparing proteins and finally, when fats are used up, they catabolize their own cell proteins.

2. Principle of glycogenesis: glucose in excess of about 120 to 140 mg per 100 ml blood brought to the liver by the portal veins enters the liver cells, where it undergoes glycogenesis and is stored as glycogen. 3. Principle of glycogenolysis: when blood glucose decreases below the midpoint of normal, liver glycogenolysis accelerates and tends to raise the blood glucose concentration back toward the midpoint of normal. 4. Principle of gluconeogenesis; when blood glucose decreases below normal or when the amount of glucose entering the cells is inadequate, liver gluconeogenesis accelerates and tends to raise the blood glucose concentration. 5. Principle of glucose storage as fat: when the blood insulin content is adequate, glucose in excess of the amount used for catabolism and glycogenesis is converted to fat and stored in fat depots.

C. READINGS DIABETES MELLITUS 1. 2. 3. 4. 5. 6. Definition Incidence Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus Clinical Manifestations Normal Insulin Metabolism and Glucose Homeostasis

The term diabetes is derived from a Greek word meaning a passer through; a siphon and mellitus from the Greek word honey or sweet. Apparently, the Greeks named it thus because the excessive amounts of urine diabetics produce attracted flies and bees because of the glucose content. The ancient Chinese tested for diabetes by observing whether ants were attracted to a persons urine and called the ailment sweet urine disease.

Definition of Diabetes Mellitus Diabetes mellitus is a disorder of carbohydrate, protein and fat metabolism resulting from an imbalance between insulin availability and need. It is characterized by elevated levels of glucose in the blood resulting from defects in insulin secretion, insulin action or both. Normally a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food substances.

Incidence In 2004 according to the World Health Organization, more than 150 million people worldwide suffered from diabetes mellitus. Its incidence is increasing rapidly, and it was

estimated that by the last 2005, this number doubled. Diabetes mellitus occurs throughout the world, but is more common (especially Type 2) in more developed countries. The increase in incidence of diabetes in developing countries follows the trend of urbanization and life style changes. Diabetes is in the top 10 of the most significant diseases in the developed world and is gaining in significance. It is the 9th leading cause of mortality in the Philippines.

Type 1 Diabetes (Insulin Dependent Diabetes) Type 1 diabetes is characterized by destruction of the pancreatic beta cells. It is thought that combined genetic, immunologic and possibly environmental (eg. Viral factors contribute to beta cell destruction). People do not inherit type 1 diabetes; rather, they inherit a genetic predisposition, or tendency, toward developing type 1 diabetes. This genetic tendency has been found in people with certain HLA (human leukocyte antigen) types. HLA refers to a cluster of genes responsible for transplantation antigens and other immune processes. About 95% of Caucasians with type 1 diabetes exhibit specific HLA types. The risk of developing type 1 diabetes is increased three to five times in people who have one of these HLA types. The risk increases 10 to 20 times in people who have both DR3 and RD4 HLA types. There is also evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they are foreign. Auto antibodies against islet cells and against endogenous insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.

Regardless of the specific etiology, the destruction of beta cells result in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. In addition, glucose derived from food cannot be stored in the liver but instead remains in the blood stream and contributes to postprandial (after meals) hyperglycemia. If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually 180 to 200 mg/dL, the kidneys may not reabsorb all of the filtered glucose; the glucose appears in the urine (glucosoria). When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. This is called osmotic diuresis.

Type 2 Diabetes (Non-Insulin Dependent Diabetes) The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired insulin secretion. Insulin resistance refers to decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, thus rendering insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose levels by the liver. To overcome insulin resistance and to prevent build up of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose levels rises, and type 2 diabetes develops. Type 2 diabetes occurs most commonly in people older than 40 years, although its incidence is increasing in younger adults. Because it is associated with slow, progressive glucose intolerance, the onset of type 2 diabetes may be going undetected for many years. If symptoms

are experienced, they are frequently mild and may include fatigue, irritability, polyphagia, polyuria, polydipsia, skin wounds that heal poorly, or blurred vision (if glucose levels are very high).

Clinical Manifestations Clinical manifestations of all types of diabetes include the three Ps; polyuria, polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis. The patient also experiences polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Other symptoms include fatigue and weakness, tingling or numbness in hands or feet due to sluggish circulation present in DM, there is inadequate supply of oxygen going to the different tissues of the body. Because of sluggish circulation, there is insufficient blood supply therefore decreasing the transport of nutrients and blood components (WBC) responsible in fighting pathogens leading now to skin lesions, wounds that are slow to heal, and infections. Theres also sudden vision change due to sluggish circulation decreasing the blood supply going to the eyes thickening the basement membrane of small blood vessels of retina. Glucosuria is evident when the blood glucose level rises above 180 mg/dl, it exceeds the renal threshold and glucose spills into the urine. Protein is normally not excreted in the urine. Nephropathy is one of the complications of DM. In nephropathy, there is increased permeability of the glomerular basement membrane causing large particles such as protein to shift out from the glomeruli causing proteinuria.

Normal Insulin Metabolism and Glucose Homeostasis

Three inter-related processes tightly regulate normal glucose homeostasis:

glucose

production in the liver, uptake and utilization of glucose by peripheral tissues (mostly muscle), and insulin secretion. Insulin secretion is modulated such that glucose production and utilization rise or fall to maintain normal blood glucose levels. The human insulin gene is expressed in the beta cells of the pancreatic islets, where mature insulin mRNA is transcribed. Translation of the message occurs in the rough There follows proteolytic cleavage of the

endoplasmic reticulum, yielding preproinsulin.

prepeptide sequence to yield proinsulin and, in the Golgi apparatus, cleavage of the C-peptide to yield insulin sequences. Both insulin and C-peptide are then stored in secretory granules and secreted together after physiologic stimulation. Release of insulin from beta cells is a biphasic process involving two pools of insulin. A rise in the blood glucose levels results in glucose uptake into beta cells, facilitated by an insulin-independent glucose-transporting protein GLUT2, and leading to an immediate release of insulin, presumably that stored in the beta-cell granules. If the secretory stimulus persists, a delayed and protracted response follows, which involves active synthesis of insulin. The most important stimulus that triggers insulin release is glucose, which also initiates insulin synthesis. Calcium influx, alpha-adrenergic agents, camp, and GLP (glucagons-like peptide) are also involved in the process of insulin secretion. Other agents, including intestinal hormones, certain amino acids (leucine and arginine) and sulfonylureas, stimulate insulin release but not synthesis. Insulin is a major anabolic hormone. It is necessary for (1) transmembrane transport of glucose and amino acids, (2) glycogen formation in the liver and skeletal muscles, (3) glucose conversion to trigylcerides, (4) nucleic acid synthesis and (5) protein synthesis. Its prime metabolic function is to increase the rate of glucose transport into certain cells in the body.

These are the striated muscle cells, including myocardial cells, fibroblasts and fat cells, representing collectively about two-thirds of the entire body weight. In addition to these

metabolic effects, insulin and insulin-like growth factors initiate DNA synthesis in certain cells and stimulate their growth and differentiation. Insulin interacts with its target cells by first binding to the insulin receptor, composed of two glycoprotein subunits alpha and beta. Since the amount of insulin bound to the cells is affected by the availability of receptors, their number and function are important in regulating the action of insulin. Receptor-bound insulin triggers a number of intracellular responses,

including activation or inhibition of insulin-sensitive enzymes in mitochondria, protein synthesis, and DNA synthesis. One of the important early effects of insulin involves translocation of glucose transport protein units (GLUTs) from the Golgi apparatus to the plasma membrane, thus facilitating cellular uptake of glucose. Hepatic production of glucose by the liver is regulated by a number of hormones. Conversely after glucose enters muscle cells, it is metabolized by oxidation to carbon dioxide and water or is stored by nonoxidative metabolism as glycogen. Glycogen synthesis is catalyzed by the rate-limiting enzyme glycogen synthase.

D.

PATHOGENESIS OF TYPE 2 DIABETES Non-insulin Dependent Two metabolic defects that characterize NIDDM are (1) a derangement in insulin

secretion that is insufficient relative to the glucose load, and (2) an inability of peripheral tissues to respond to insulin (insulin resistance). The primacy of an insulin secretory defect versus insulin resistance is a matter of continuing debate. Most overtly diabetes patients exhibit both.

Insulin Deficiency Early in the course of type II diabetes, insulin secretion appears to be normal and plasma insulin levels are not reduced. However, subtle defects in the function of beta cells can be demonstrated. Perhaps the earliest detectable change is in the pattern of insulin secretion. In normal persons, insulin secretion occurs in a pulsatile or oscillatory pattern, whereas in patients with type II diabetes, the normal oscillations of insulin secretion are lost. At about the same time when FBS reach 115gm/ml, the rapid first phase of insulin secretion triggered by glucose is obtunded. This impaired insulin secretion caused by chronic hyperglycemia, referred to as glucose toxicity, is due in part to a reduction of GLUT-2 transporters which facilitate glucose entry into B cells. In due coarse, most patients develop mild-to-moderate deficiency of insulin. Assessment of insulin deficiency in type II diabetes is complicated by the frequent occurrence of obesity in these patients. Insulin resistance and hyperinsulinemia characterize obesity, even in the absence of diabetes, however, when obese type II diabetics are compared with weight-matched nondiabetics, the insulin levels of obese diabetics are below those observed in obese nondiabetics, suggesting a relative insulin deficiency. Furthermore, in patients with moderately severe type II diabetes, it is possible to demonstrate an absolute deficiency of insulin.

We can conclude therefore, that most patients with type II diabetes have a relative or absolute deficiency of insulin. However, this insulin deficiency is not an early feature of this variant of diabetes.

Insulin Resistance Insulin resistance is a condition characterized by an inability of the body to utilize the hormone insulin properly. Insulin, produced by the beta cells of the pancreas, is responsible for 'unlocking' cells to let glucose inside to be metabolized for energy. If there are too few insulin receptors (i.e., the cell 'lock' where insulin binds), or if the insulin receptors don't respond as they should, insulin resistance is the result. The majority of people with type 2 diabetes are insulin resistant. They have plenty of insulin, but their bodies do not process it correctly. People with type 1 diabetes may also have some degree of insulin resistance, but are primarily insulin insufficient (i.e., their pancreas produces little to no insulin). Some people with type 2 diabetes may also develop insufficiency along with insulin resistance over time. People who are insulin resistant have high levels of circulating insulin (i.e., hyperinsulinemia) in the body. This is because their pancreas continues to pump out more and more insulin in an effort to lower rising blood glucose levels. When an individual can no longer produce enough insulin to compensate for the rise, type 2 diabetes develops.

E. Risk Factors 1. General Risk Factors Family History of DM II Age Group (40 y/o and above) Race/Ethnic Factor Obesity Pregnancy Low Physical Activity Stress Family History of DM II Non-modifiable In the presence of diabetes mellitus, one of the parents or next of kins probability are diabetes, according to data from different sources ranging from 30 to 80%. If both parents are ill, then the probability of occurrence of diabetes in their child is 60-100%. Studies found out that a mutation in the insulin receptor gene impairs its normal function thus causing insulin resistance. However, the exact mechanism on how or why mutation of insulin receptor gene occurs is unknown. According to other studies, insulin deficiency results due to a defective gene (gene responsible in stimulating Glukokinase production). Glukokinase is the one responsible in stimulating the cells to produce insulin. The decrease stimulation of the cells to produce insulin results to insulin deficiency. Age of 40 y/o and above Non-modifiable According to studies, as a person grows older especially reaching the age of 40, its insulin receptors decreases in number. The decrease in insulin receptors can lead to insulin resistance. Scientists have found out that cell secretion of insulin decreases starting from the age of 40 thus leading to insulin deficiency. Also, people in this age bracket tend to exercise less, lose muscle mass, and gain weight.

 Race/Ethnic Factor Non-modifiable Ethnic factor may contribute to a greater or lesser prevalence of diabetes. The risk of developing diabetes is higher in the indigenous population of America, Canada, India, Australia, Africa, the Islanders Pacific and Indian Oceans. Obesity Modifiable It is the most significant risk factor for Diabetes Mellitus II. Obesity, particularly abdominal obesity is associated with insulin resistance and insulin deficiency. It was found out that obese persons have lesser insulin receptors thus causing insulin resistance. In addition, obese persons requires greater amount of insulin for the transport of glucose into cells and for the storage of fats. The increase in the insulin demand may lead to cell exhaustion which may lead to impaired insulin secretion causing insulin deficiency. Pregnancy Modifiable Just like in obese persons, pregnant women needs greater amount of insulin thus may lead to insulin deficiency. At risk include the following categories of women: o Women, who during pregnancy had an increase in body weight is greater than the normal proceeding of pregnancy; o Women, who during pregnancy were noted carbohydrate metabolism (a positive test for glucose tolerance, abnormal increase in blood glucose after meals, increased fasting glucose, the symptoms of diabetes). About 20% of these women for 5-10 years develop diabetes; o o o Mothers, whose children had birth weight 4000 g; Mothers, whose children had congenital malformation; Women with a history of miscarriages or stillbirths.

 Low Physical Activity Modifiable People leading a sedentary lifestyle have the risk of morbidity from diabetes in 3 times higher than people with active lifestyles. The less active a person is, the greater the risk of type 2 diabetes. Physical activity helps one to control weight, uses up glucose as energy and makes cells more sensitive to insulin. Stress Modifiable Strong and long-term negative stress provoke disturbances of carbohydrate metabolism that precede diabetes. Studies have shown that events such as illness or loss of a loved one, the unstable financial situation and financial problems increase the risk of developing diabetes. Such persons subsequently in 5% of cases developed diabetes, and 60% of the patients were identified carbohydrate metabolism, is a precursor of diabetes.

2. Risk Factors True to the Patient RISK FACTORS MODIFIABILITY Family History of DM- our Non-modifiable patient has a family history of Diabetes as evidenced by her father undergoing the said disease process. JUSTIFICATION In the presence of diabetes mellitus, one of the parents or next of kins probabilities is diabetes, according to data from different sources ranging from 30 to 80%. Insulin deficiency results due to a defective gene (gene responsible in stimulating Glukokinase production). Glukokinase is the one

responsible in stimulating the Age group- our patient was born on June 15, 1970 which makes her 41 years old, and it is in the ages of 40 years old and above in which there are increased incidences of the disease. Pregnancy- Our patient gave birth last 1988 and 1989, respectively, and no complications were noted. Modifiable Non-modifiable cells to produce insulin. We cant stop the aging process and whether we like it or not we are all going to age as time pass by. As a person grows older especially reaching the age of 40, his/her insulin receptors decreases in number. Just like in obese persons, pregnant women needs greater amount of insulin thus may lead to insulin deficiency.

Family History* 40 y/o and above* Obesity Pregnancy Stress*

ed Insulin Demand Ed Insulin receptor

Insulin Resistance
Mutation of Insulin receptor gene
Defective gene (gene that stimulates Glucokinase Prodiuction)

cell exhaustion
Impaired Insulin secretion

Insulin Deficiency glucose by cell

Ed utilization of

Impaired receptor gene function

Degenerative changes

retinopathy nephropathy
MI & CVD

eyes
Kidney

Ed stimulation on the production of insulin on cell

Heart

Dizziness*
Nausea and vomitting

Ed utilization of Glucose by Brain cells

Cell starvation

activation of hunger mechanism

Tingling sensation*

Peripheral neuropathy*

Polyphagia*

Pain*

Ed CHON metabolism
Ed Serum amino acid Ed nitrogen by products Ed serum creatinine and urea

Ed K loss bycell

Ed CHO metabolism Hyperglycemia* (FBS>180mg/dl) Ed glycerol Ed glucose

Ed fat metabolism Ed fatty acid serum

hyperkalemia

Ed Ketones

Ed blood viscosity

Ed urine pH

Glucosuria*
Ketoacidosis

Liver converts fatty acids into phospholipids and cholesterol

Sluggish circulation Ed wound healing Legends: Complications:

Modifiable Risk: Factors
Non-Modifiable: Risk Factors

Favors Growth of Microorganism*

Osmotic Diuresis

Polyuria*
Nucleation
crystalization
Nephrolithiasis

Ketones diffuse to blood brain barier

Ed phospholipid and cholesterol

Tissue dehydration

atherosclerosis Ketones injure brain cells

Stimulation of the thirst center

convulsion

Polydipsia*
True to the client:

Coma

DEATH

Diabetic neuropathy, or nerve damage caused by diabetes, is one of the most common known causes of neuropathy. It is one of many complications associated with diabetes, with nearly 60 percent of diabetics having some form of nerve damage. It is a progressive disease that can involve loss of sensation, as well as pain and weakness, in the feet and sometimes in the hands. Peripheral neuropathy may be more prevalent in people who have difficulty managing their blood sugar levels, have high blood pressure, are overweight, and are over 40 years old. A clinical examination may identify early signs of neuropathy in diabetics without symptoms. The first sign of diabetic neuropathy is usually numbness, tingling or pain in the feet, legs or hands. Over a period of several years, the neuropathy may lead to muscle weakness in the feet and a loss of reflexes, especially around the ankle. As the nerve damage increases, the loss of sensation in the feet can reduce a person's ability to detect temperature or to notice pain. Because the person can no longer notice when his/her feet become injured, people with diabetic neuropathy are more likely to develop foot problems such as skin lesions and ulcers that may become infected. Diabetic neuropathy may suddenly flare up and affect a specific nerve or group of nerves. When this occurs, the result may be weakness and muscle atrophy in various parts of the body, such as involvement of the eye muscles or eyelid (e.g., causing double vision or a drooping eyelid) or thigh muscles. Alternatively, neuropathy caused by diabetes may slowly progress over time. It also can interfere with the normal functioning of the digestive system and sexual organs.

III. FAMILY BACKGROUND

Members Jose Simpliciano Zenaida Simpliciano Twinker Steine Simpliciano Jacob Simpliciano Reinalyn Simpliciano Josh Simpliciano

Sex M F M M F M

Age 44 41 24 22 21 2

Civil Status Married Married Single Married Married Single

Relationship to the patient Spouse Patient Child Child Daughter-inlaw Grand child

Educational Attainment High school Graduate High school Under Graduate Vocational Graduate High school Graduate High school Graduate ---------------

Occupation Tricycle Driver Brgy. Captain Sales Lady Tricycle Driver House wife ---------------

Religion Pentecost Pentecost Pentecost Pentecost Pentecost Pentecost

Place of Residence #16 San Nicolas #16 San Nicolas #16 San Nicolas #16 San Nicolas #16 San Nicolas #16 San Nicolas

Zenaida Simpliciano is a 41 year old, the eldest child of Mr. Carlito Culannay (father) and Mrs. Rufina Culannay (mother) and is currently residing at residing in # 16 Payas San Nicolas Ilocos Norte which is 19-20 kilometers from the town proper. Hence, their Barangay is considered rural. She is affiliated to Pentecost Church and she never fails to go to worship during Sundays. She is an undergraduate of Bingao National High School. She only finished second year for she got pregnant at the age of 17. She was married to Mr. Jose Simpliciano in the year 1988. Mr. Jose Simpliciano, 44 years of age, is a high school graduate. He is also affiliated to Pentecost church. He is a tricycle driver. She has been a good wife to her husband since they were married. Such as when, they have a misunderstanding, they will calmly talk to each other about that matter and not letting the day pass not resolving it. In rearing her family, she made sure she had hands-on guidance in the upbringing of her children. She is also a loving mother. Even though both her children are already of legal age, she doesnt forget to still give them the guidance and advises. She guides

them with the decisions they make, support them when they have problems. She taught her children values such as being honest, thrifty, responsible and respectful. She is updated on what is happening to each member of the family to ensure that they are doing well. She treasures her family so much and considers them as an inspiration. She is also a good neighbor. As what she had said, even though they too dont have a lot of money, when one of her neighbors is in need, she extends her hands to help them as long as she thinks she can be of help. She also maintains good interpersonal relationship with the people around her. She stated that she is honest, trustworthy, and having positive outlook. She holds her temper as long as possible. As much as possible, she doesnt want to have an enemy. She also has a good camaraderie with her friends and neighbors. She also gives advice when someone asks her to. In every actions she make, she make sure that it will not hurt anybody. She is easily pleased. She easily smiles and laughs. Even now that she is ill, she still has the positive outlook regarding her condition. However, when her leg pains and also her lower back, shes a little irritable. She also loves going to social activities such as attending to birthday parties, weddings, baptismal, and church activities. She finds time to go the said activities and considers it as her leisure activities. She is presently the Barangay Captain of Brgy. 16 Payas, San Nicolas, Ilocos Norte and is really dedicated to serve her fellow co-Barangay. As a Baranggay Captain, she has to do several tasks. She extends her concern to the community by letting herself go to the people rather than wait for them to come if they have problem or concerns within their community. She asks what her fellow co-barangays need, and problems within their community and acting on it as soon as possible if she can. She coordinates with other officials to settle a certain issue concerning their

barangay such as floods during rainy seasons and storms, proper garbage disposal, and the like. She actively involve herself when there are events in their Barangay like clean and green, supervises meetings, and the like. She is also a generous neighbor. As what she had said, even though they too dont have a lot of money, when one of her neighbors is in need, she extends her hands to help them as long as she thinks she can be of help. And lastly, she is an effective leader. She can perform well the tasks expected of her in their Barangay. Even though she is the Barangay Captain, she follows the rules and regulations within their community. She also actively participates in the activities within their barangay. She can balance her obligations between her family and her obligations within their community. However, her physical activities decrease from time to time as she stated that she is in the process of aging. Still she finds a way to help her family in their daily living and also in their community since it is her job to ensure their barangay is in good terms. But as she gets old, she verbalized that she is becoming more mature and knowledgeable. Rufina Culannay, the patients mother who is 65 years old, is not residing with them. She lives with her other children namely Henry Culannay (38 y/o), Gerald Culannay (35 y/o), Gilbert Culannay (32 y/o) and Jennifer Culannay (27 y/o) on another house which is beside to Mrs. Zenaidas residence. While Mr. Carlito Culannay, 61 years of age and father of the patient, is currently residing in Manila with his another family. Mr. Carlito Culannay and Mrs. Rufina Culannay got separated when Zenaida was 17 years of age. Their father rejected them and they were left behind. Their mother, Rufina Culannay, did everything for a living in order for them to survive even though without the presence of her husband. She did farming, selling kakanin, and entered different jobs for her childrens survival. Rufina Culannay has hypertension. Even if their father does not give them financial support, they still visit him when they have time. He is

suffering from diabetes mellitus. He was diagnosed in Manila but our patient failed to know who diagnosed his father and what the prescribed medications were. Twinker Stein Simpliciano, 23 years of age, is the eldest child of Mr. Jose Simpliciano and Mrs. Zenaida Simpliciano. She is a vocational graduate in Data Center College in Laoag, Ilocos Norte. She graduated with a vocational course in Nursing Aid. But she didnt pursue it because she stated that she lost her interest. Instead, she works as a sales lady in grocery store in front of the PLDT in Laoag. Jacob Simpliciano, 22 years of age, is their second child. He is a high school graduate in Bingao National High School and didnt pursue in going to college due to laziness. He is a tricycle driver at present. He is married to Reinalyn Simpliciano, 22 years of age. Jacob was married to Reinalyn in the year 2009. Reinalyn Simpliciano is a high school graduate in Bingao National High School. She is a housewife. They have a child named Josh Simpliciano who is 2 years of age. Twinker Stein Simpliciano, Jacob and his family reside with their mother. They are considered to be extended type of the family since Jacob and his family stays at Zenaidas residence. However, Twinker Stein only stays in their house every weekend because she is staying in an apartment in Laoag due to her work. As regard to decision making, she (Zenaida) and her husband (Jose) decides but they are open for opinions from their children. However, the final decision is both in their hands. Hence, they are egalitarian type of family with regards to decision making. She and her husband are the ones who are budgeting for the familys income and distribute it in the different aspect of their daily needs. They are matrilocal type of family in terms of residence since their residence is near the relatives of Zenaida. According to their descent, they are classified as bilineal wherein blood links and rights of inheritance through both male and female ancestors are of equal importance. Their family is affiliated to Pentecost

Church. They do attend masses every Sunday. They also stated that each member of the family pray before they go to sleep. On the other hand, Zenaida claimed that each member of the family has a good family tie and each one of them knows how to understand someones situation. Thus, if they have conflicts and misunderstandings which are usually about division of labor in their house, and the like, they easily solve it by calmly talking to each other. They dont let the day pass without resolving it. As regards to the household chores, the patient together with the wife of Jacob do the household chores such as cleaning the house, cooking, washing the dishes, watering the plants and doing the laundry without difficulties and without any assistance. She considers these activities as her exercise. Then she goes to the Barangay Hall afterwards. However, when she was diagnosed with DM. Her daily activities were limited to dusting the furniture, watering the plants, cooking, or dishwashing. The heavy ones (household chores) were done by his husband, however, she still helps him. Her responsibilities in the Barangay are also limited. The family members go to social or recreational activities such as going to a picnic at least once in two months time. They also go to Robinsons Ilocos Norte during Sundays after they attend mass. They also spend the night watching the television or sometimes listening to the radio. These are the only time wherein they can gather together as a family after a long day. Here they can address their problems or needs and at the same time share their experiences of the day. They also participate in community activities such as clean and green programs and town fiestas, brgy. meetings, dental and medical missions. As regards to the familys lifestyle, the family prefers eating meat than fish and poultry. The meat they eat is also coupled with vegetables. As our patient had said, they cant eat if there

is no vegetable serving in their dining table. They also love drinking soda especially our patient wherein she can drink two litters of coke every day. As regards to their vices, the husband of our patient (Jose Simpliciano) and their second child (Jacob Simpliciano) only drinks occasionally. On the other hand, our patient (Zenaida Simpliciano) and their first child (Twinker Stein Simpliciano) dont drink liquor at all. The family dont smoke. The familys source of income is from the profit of Mr. Jose Culannay and Jacob Culannay (tricycle drivers), Mrs. Zenaida Culannays honorarium, and Twinker Steins salary. Mr. Joses profit from his work as a tricycle driver ranges from Php. 2600 3900 per 26 days (1 month 4 Sundays = 26 days). The family owns the tricycle. Meanwhile, Mr. Jacob Simplicianos profit as a tricycle driver also ranges from Php. 2600 3900 per 26 days. However, they do not own the tricycle that is why he only gives Php 500 per month to her mother as a contribution and the rest goes to his own family for their own expenses. He also gives Php 300 per week to the owner of the tricycle. So all in all, the profit Jacob gains per month is Php 900 2200 that goes to his own damily. Mrs. Zenadais honorarium ranges from Php 4,300 4,400 per month. They also gain profit from raising pigs. In a year, they gain Php 50, 000. The other half (25, 000) is their profit per year while the other 25,000 is spent for the maintenance of the piggery and for the feeds and vitamins of the pigs also. Php 25, 000 divided by 12 months equals Php 2083 - 2084 is their profit per month in raising pigs. Twinker Steins salary is Php 200 per day. Her salary is Php 5600 per 28 days. She gives Php 600 to her family as a contribution. And the rest goes to her for her daily expenses. Therefore the total monthly income of the Simplicianos family ranges from Php 9,983 11, 384.

Others ----------------------------------------------------------------- Php. 3394.22-3870.56 Grocery Products ---------------------------------------------------- Php. 2096.43-2390.64 Food ------------------------------------------------------------------- Php. 998.3-1138.4 Electricity ------------------------------------------------------------ Php. 998.3-1138.4 Health Service ------------------------------------------------------- Php. 898.47-1024.56 Water ----------------------------------------------------------------- Php. 798.64-910.72 Php 9184.36 10473.28 Savings ---------------------------------------------------------------- Php. 798.64-910.72

The familys income yields to Php. 9,983 11,384. They spend Php 3394-3870 or 34% of the total income mostly for important things like gasoline for the two tricycles, gasul, load and other necessities. The second allocation is for grocery products that yield to Php 20962390 or 21% of the total income such as canned goods, as well as soap, shampoo, tooth paste and other necessities. 1 case of coke is also added to their grocery items. The third allocation is on food that consists like rice, meat, fish, and vegetables that yields to

Php. 998-1138 or 10% of the total income. Fourth allocation is spent on Electricity that consists of Php. 998-1138 or 10% of the total income of the family. Fifth allocation is on health services like medications such as Bioflu, Medicol, Decolgen, Biogesic, Mefenamic Acid, and Lomotil and consultations that yield to Php. 898 1024 or 9% of the total income. Sixth allocation is on water wherein the family spends Php 798 - 910 or 8% of the total income of the family. The family prefers Wilkins to drink. They also stated that they believe that Wilkins is the cleanest and safest purified water. And lastly, the familys savings ranges from 798 910 or 8% of the total income.

IV. HEALTH HISTORY

A. Family Health History The family of Zenaida, our patient, had a family history of serious diseases such as Hypertension, Diabetes Mellitus and Lung Cancer. In fact, her paternal grandfather, Leonardo Culannay, died because of Hypertension at the age of 76. However, her paternal grandmother, Beatriz Culannay, died because of car accident at the age of 50. On the other hand, her maternal grandfather, Frederico Rodriguez, died because of Lung Cancer at the age of 75. In addition, her maternal grandmother, Jessa Rodriguez, died at the age of 73 because of Tuberculosis. Her father, Carlito Culannay (61 years of age), is currently suffering from Diabetes Mellitus.

However, when we asked our patient who diagnosed him, when he was diagnosed, and what are the medications he is taking, our patient was unable to answer our queries because her parents separated since she was 17 years of age. Even though, their father left them, she didnt hold a grudge against him and visits him still in Manila if they have time. Besides, he is still their father. The sibling of her father namely Rodolfo Culannay has no serious disease too. Her mother, Rufina Culannay (65 years of age), was diagnosed to have Hypertension on the year 2000 at Philippine General Hospital (PGH) by Dr. Cabresos. She was prescribed with medications such as Nifedipine 30 g PO but she only takes this when she feels the signs and symptoms of hypertension such as increased blood pressure, dizziness, and nape pain. She was also prescribed with Amlodipine 5 mg PO every day. He mother is suffering from visual difficulties and decreased ability to walk at present due to aging. As regards to her mother, she makes sure she is in good terms. Our patient bought an eyeglass and a cane for her to use in her daily activities. The siblings of her mother, Nardo Rodriguez (58 y/o) and Jessica Rodriguez (60 y/o) dont have serious diseases. Unfortunately, only Zenaida (41 years of age; eldest) inherited the disease of her father which is Diabetes Mellitus. Cherry Culannay (38 years of age; 2nd child), Gerald Culannay (35 years of age; 3rd child), Gilbert Culannay (32 years of age; 4th child), and Jennifer Culannay (27 years of age; youngest child) dont have serious diseases at present. Aside from having the aforementioned diseases, the Culannay Family just like every other individual experienced childhood diseases such as measles, mumps, and chickenpox. The chickenpox usually lasts for 2 weeks. According to our patient, they manage the chickenpox through suob, bed rest, taking a bath with guava leaves when lesions are starting to heal. They also isolate themselves from other people. In cases of mumps, they manage it by applying akut-

akot on the parotid area, and having bed rest. The mumps usually last for a week. And for measles, they manage it by wearing black clothes and taking adequate rest and sleep. The measles usually lasts for maximum of 1 week. Measles is also managed by boiling burned hay which we call arutang in our dialect. They use this for bathing the family member who has the disease. Our patient claimed that she cannot remember if all the family members received full vaccinations such as 1 dose of BCG, 3 doses of OPV, DPT and Hepa B, and 1 dose of Measles vaccine. However, she assured us that all family members received a dose of BCG. BCG scars were present in all the family members at right deltoid and others, at the left deltoid. Same with other individuals, every member of the family had experienced common diseases such as headache, stomachache, fever, cough, colds, and toothache. Whenever a member of the family had fever, they perform tepid sponge bath, and bed rest. If fever does not subside, thats the only time they use over-the-counter drugs in the management of these common diseases like Bioflu 500mg tablet PO every 6 hours for the normalization of body temperature and the fever usually lasts for 3-4 days. According to the patient, if fever does not subside within 2 days, they will go first to quack doctors but if the fever still, doesnt subside then thats the time they go to the RHU for consultation. For cough and common colds, drinking a lot of water is their common intervention plus having adequate rest. If the signs and symptoms persist, they take Medicol 500 mg tablet PO thrice a day and Decolgen 500 mg tablet PO thrice a day and the coughs and colds usually last for 2-3 days. For headache, they take Biogesic 500 mg tablet PO once a day and it usually last for 30 minutes to an hour. For toothaches, they usually do mouth gurgling with a mixture of tap water and salt. When it still persists, they also take

Mefenamic Acid 500 mg tablet PO once a day and it usually last for 1-2 days. And for stomachache, they take 1 tablet of Lomotil 2.5 mg once a day. The family also believes in quack doctors. In fact, there are some instances that they sought consultation first to quack doctors before going to the Rural Health Center. In here, they are being healed using herbal leaves and taught to make decoctions from it to relieve any of their common illnesses. For sometimes, the herbal medicines were effective according to our patient but mostly, they find this ineffective because of the improper preparation. But still, they continue and prefer consulting the quack doctor first because of its near proximity from their house. At times of simple ailments, they prefer to manage it by themselves initially with herbal medicines available near them or sometimes with the use of OTC drugs. But when cases become severe, they consult a physician in their municipal health center. No one of the members of their family had experienced hospitalization not until her mother was hospitalized because of hypertension, her father because of diabetes mellitus, and the patient herself. In their family, they utilize Philhealth. They considered this as a great help especially in times of hospitalization. The family prefers to eat meat rather than fish and poultry. They also like eating vegetables (in any preparation). They also love drinking coffee every morning coupled with rice. They also love drinking soda especially our patient. The family has no known allergies such as to food, medicines, dust, pollen, and the likes. As regards to their vices, her siblings, her husband, Jacob (2 nd child) only drink alcohol occasionally. They only drink 2 bottles of red horse consisting 330 ml each. No one in their

family smokes. As to their hygiene of family, they take full bath once a day and sponge bath at night and brush their teeth twice a day. They also experience minor injuries such as wounds and scratches which they managed by just washing it with soap, applying beta dine and left it exposed until it heals.

B. Past Health History

As our patient grew older, her health was exposed to different factors that had led her in suffering different diseases in her childhood. Same with most of the other children of her age, she had experienced childhood disease like measles. She was six years old then. They managed it by making her wear black long sleeves and letting her take adequate rest and sleep. Aside from this, they also bathe her with ararutang (boiling burned hay) which is effective according to them. It lasted for 1 week. In addition, she experienced having chickenpox when she was in 6th grade. They manage the chickenpox through suob, bed rest, taking a bath with guava leaves when lesions are starting to heal. They also isolate themselves from other people. It lasted for 2 weeks. In cases of mumps, they manage it by applying akut-akot mixed with vinegar on the parotid area, and taking a bed rest. The mumps lasted for a week. The patient also experienced common manifestations such as cough, fever, colds, headache, dizziness, stomachache, and toothache. The initial responses to these common illnesses are to take adequate rest, consulting the quack doctor, making herbal medicines such as oregano for cough and colds, or taking over-the-counter drugs. Some of the OTC drugs that were taken by the patient are Paracetamol or Bioflu 500 mg tablet PO every 6 hours for the normalization of body temperature and the fever usually lasts for 3-4 days. According to the patient, if fever does not subside within 2 days, she goes to the quack doctor located in their Barangay then to the RHU. For cough and common colds, drinking a lot of water is her common

intervention plus having adequate rest. If the signs and symptoms persist, she takes Medicol 500 mg tablet PO thrice a day and Decolgen 500 mg tablet PO thrice a day and the coughs and colds usually last for 2-3 days. For headache, she takes Biogesic 500 mg tablet PO once a day and it usually last for 30 minutes to an hour. For toothaches, she usually does mouth gurgling with a mixture of tap water and salt. When it still persists, she takes Mefenamic Acid 500 mg tablet PO once a day and it usually last for 1-2 days. And for stomachache, she takes 1 tablet of Lomotil 2.5 mg once a day and stomachache usually lasts for one day. As regards to incidence, the fever typically occurs once a month and is usually accompanied by common colds and cough. Headache and stomachache commonly occur once a week while toothaches occur once in two weeks time. The patient has no known allergies to foods, medicines, dusts, pollen, and the like. The patient also experienced minor injuries such as bruises and scratches. According to her, she just washes it with water and soap, applies betadine, and leaves it to be exposed to heal. As regards to her immunizations, the only vaccine she can recall was the BCG. BCG scar was seen at her right deltoid. She didnt experience any accidents. As regards to surgeries, she delivered her two children through Normal Spontaneous Vaginal Delivery (NSVD) in MMMH and MC in the year 1988 and 1989 respectively. According to the client, there were no complications in all her deliveries and all of them reached their full term. According to her, she only received 2 doses of Tetanus Toxoid. TT1 had been received by Mrs. Zenaida during her 1st pregnancy specifically on her 7th month in the year 1988. The second dose, TT2, was also received on the 7th month of her second pregnancy in the year 1989.

Our patient has no vices. As to the clients preference to food, she likes meat more than fish and poultry. The quantity of the meat she eats is commonly 2 servings. She also loves eating vegetables. Her meals usually comprises of vegetables like squash, horse radish and spinach. She usually consumes 1 serving of vegetables and 2 cups of rice. She also likes drinking soda, coffee, and fruit juices. She actually can consume up to 2 litters of coke per day. She also likes eating sweet foods like molasses, rice cake, chocolates and kakanin. After eating, our patient has the habit of eating fruits like banana and sweets like molasses, chocolates, or yema. She admits that she tends to eat a lot. C. Present Health History On March 2011, the patient started to experience increase urge of oral fluid intake, easily gets hungry, eats more than what she usually eats, but she never went for any consultation because she thought those were just normal. On June 2011, she started to experience vaginal itchiness, urinary frequency for ten consecutive days and ten nights (10 to 12 times a day) and have a sweet like odor urine. She also experienced burning sensation when urinating. She rated it with 6/10, 10 being the highest. She stated that salt-like crystals were found in her urine. She also stated that whenever she does laundry every Sundays, ants were present in her clothes. Because of this, she consulted Nazarene Hospital at San Nicolas Ilocos Norte and was diagnosed of Urinary Tract Infection (UTI) by Dr. Noble. She was prescribed with an ointment called LadySoothe to be applied at the genital area after taking a bath and also with Cotrimoxazole for her vaginal itchiness. She was prescribed with Bactrim 160 mg PO for every 12 hours. However, according to her, it was not fully

managed. After 3 days, she decided to consult Dr. Gertes at Gertes Hospital in San Nicolas, Ilocos Norte. She had undergone blood tests and physical assessment in the genital area. There is increased WBC in the blood tests results and physical assessment was done. The results of the Physical Assessment were pinkish to reddish vaginal color, and swelling on the itchy part. She was then diagnosed of having Diabetes Mellitus and was prescribed with Cefuroxime 250 mg for every 12 hours PO and Metformine 500 mg PO twice a day. After which, she was advised to go to Provincial Hospital at Laoag City for further consultation. On June 21, 2011, she experienced leg pain on both legs which is characterized as a tingling sensation, and with a pain scale of 6/10, 10 being the highest. The pain is intermittent and can be relieved by elevating both her legs. On June 23, 2011, she went to Polyclinic for laboratory tests because she expected for possible fracture. She had undergone leg X-ray and the result was normal. On June 28, 2011, she consulted the Provincial Hospital at Laoag City, Ilocos Norte. She was prescribed with Vitamin B complex for numbness and Diclofenac 75 mg PO twice a day for the leg pain and low back pain. She was prescribed by Dr. Lani Flor. She had undergone Complete Blood Count. Increased glucose was seen in the result of Complete Blood Count. Due to her dissatisfaction with the hospitals service, she consulted Mariano Marcos Memorial Hospital and Medical Clinic. She also stated that Provincial Hospital has incomplete facilities that prompted her to go to MMMH and MC. On June 29, 2011, she decided to transfer from Provincial Hospital at Laoag City to Mariano Marcos Memorial Hospital and Medical Center at Batac for further consultation and for better diagnosis. During her consultation, she complained of back pain and calf pain with a rating scale of 6/10, both for the pain at the back and at the calf. The pain she felt is continuous and

cant be relieved by just elevating both her legs and relaxing her back. She had undergone Complete Blood Count, Urinalysis, Fecalysis, Ultrasound, and X-ray ordered by Dr. Bigornia. Increased glucose was seen in the Complete Blood Count and glucose was also seen in her urine. She was prescribed with Diclofenac to alleviate the pain and PNSS was ordered. She stayed there for 8 hours (2 PM - 10 PM) and by 10 PM she went home with alleviated condition. On July 1, 2011 at 1:45 AM, she was rushed at Mariano Marcos Memorial Hospital by her husband due to dizziness, fatigue, low back pain, and severe pain in the calf with a pain scale of 10/10, 10 being the highest. She was then admitted at Mariano Marcos Memorial Hospital and Medical Center with an admitting diagnosis of DM Type 2 by Dr. Melanie Grace Valdez, M.D. and Annalyn G. Urbano, M.D.

V. DEVELOPMENTAL DATA All humans experience and follow the pattern of growth and development. It is predictable however the time of onset, the length of the stage, and the effects of the stage vary with the person. It may help or hinder the maturational process, depending on what is learned. A. Erick Erickson`s Theory of Psychological development Erik Erickson believes that people continue to develop throughout life. He describes eight stages of development. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial, or unsuccessful. Erickson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve a task influences the persons ability to achieve the next task. These developmental tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to the persons ego. Failure to resolve the crises is damaging to the ego. After attaining one stage, the person may fall back and need to approach it again. Erick Erickson described eight developmental stages covering the entire life span. At each stage, there is a conflict between two opposing forces. The completion of accomplishment of the developmental task of that stage allows the individual to go on to the next phase of development but the challenges of stages not successfully completed may be expected to reappear as problems in the future. Our patient is under Erik Ericksons theory of Psychosocial Development and falls under the stage of middle adulthood, which has a central task of Generativity vs. Stagnation.

Generativity is reflected in the individual establishments and in guiding the next generation. The person is both productive and creative in both career and family. There is

willingness to assume responsibility for others. The major task is the acquisition of ability to care. Stagnation, on the other hand, suggests a lack of psychosocial movement or growth. When generativity is not achieved, the individual may turn into self- indulgence, self-concern and lack of interest and commitment and eventually, crisis would exist. Under the said resolution, there are expected task for her age. It includes (a) extending of concern to the community, (b) becoming politically active (c) work to solve environmental problems, (d) able to assume various roles, (e) raising a family, and (f) guiding children. Tasks Degree of Achievement Not Partially Fully Achieved Achieved Achieved

Extending concern to the community Becoming politically active Work to solve environmental problems Able to assume various roles Raising a family Guiding children

She was able to accomplish the task of extending concern to community, becoming politically active, working to solve environmental problems, and work to solve environmental problems since she is actively involved not only in their family but also to their community. She is presently the Barangay Captain of Brgy. 16 Payas, San Nicolas, Ilocos Norte. As a Barangay Captain, she has to do several tasks. She extends her concern to the community by letting herself go to the people rather than wait for them to come if they have problems. She asks what her fellow co-barangays need, and problems within their community and acting on it as soon as possible if she can. She is also politically active. She actively involves herself when there are events in their Barangay like clean and green, supervises meetings, encouraging her neighbors to participate in dental and medical mission within their barangay. She also works to solve

environmental problems by collaborating with the barangay officials. These problems are floods during rainy seasons and storms, proper garbage disposal, and the like. She coordinates with other officials to settle a certain issue concerning their barangay. Even now that she is suffering from DM, she still does her responsibilities but limited only. She participates in the fieldworks but not as often as before. Instead, she stays most of the time in their Barangay Hall and collaborates with her barangay officials. However, if her presence is badly needed, she tries her best to be there. She was able to accomplish the task of assuming various roles, raising a family, and guiding her children. She has been a good wife to her husband since they were married. Such as when, they have a misunderstanding, they will calmly talk to each other about that matter and not letting the day pass not resolving it. She also helps her husband in heavy house works when her husband needs help. She is also a loving mother. In rearing her family, she made sure she had hands-on guidance in the upbringing of her children. Even though both her children are already of legal age, she doesnt forget to still give them the guidance and advises. She guides them with the decisions they make, support them when they have problems. She made sure she had inculcated to her children values such as being honest, thrifty, responsible and respectful. She gives unconditional love and care to her husband and to her children. She says she makes sure she knows whats happening to each member of the family without mandating their lives. She does the household chores like cleaning the house, cooking, washing the dishes, watering the plants and doing the laundry without difficulties and without any assistance. Even now that she is ill, she still thinks of ways of maximizing her strength and tries to do things for her family. She still does household chores but only the light ones. She considers her family as her source of inspiration and that is why she and her husband had worked hard for them. She is also a good

daughter. Even though, their father left them, she didnt hold a grudge against him and visits him still in Manila if they have time. Besides, he is still their father. As regards to her mother, she makes sure she is in good terms. She bought her an eye glass and a cane for her to use in her daily activities. She is also a good citizen. She is law abiding. Even though she is the Barangay Captain, she follows the rules and regulations within their community. She also actively participates in the activities within their barangay. She is also a generous neighbor. As what she had said, even though they too dont have a lot of money, when one of her neighbors is in need, she extends her hands to help them as long as she thinks she can be of help. In addition to this, she also maintains good interpersonal relationship with the people around her. According to her, her secret in establishing rapport with other people is to be honest, trustworthy and to have a positive outlook in life. She avoids conflicts as much as possible and avoids speaking ill about anyone she knows. She is the type of person who can hold her temper whenever she gets angry or irritated. All in all, she has still managed to maintain good camaraderie with her friends and neighbors. Also, when someone asks for an advice, she was never selfish in sharing to them the best advice she had received herself, which is to ask for heavenly guidance. In everything that she does, she makes it a point to think of how much this will affect others. This shows her concern towards other people, and of course, towards her family. She is the type of person that is easily pleased. She laughs and smiles at things that interest her. However, now that she is ill, she easily gets irritated due to her condition but can still control herself to avoid conflicts. And lastly, she is an effective leader. She can perform well the tasks expected of her in their Barangay. She can balance her obligations between her family and her obligations within their community.

ANALYSIS: Mrs. Simpliciano is said to be on the right tract of developing into a wholesome individual since she was able to achieve the tasks under Erick Ericksons Psychosocial Theory. Mrs. Simplicianos behavior reflects a generative lifestyle. She had assumed parental and societal responsibilities that show her concern and care for the welfare of others. She succeeded in instilling values to her children. Therefore she has a greater possibility to proceed on the next developmental stage.

B. Robert Havighurst`s Theory of Developmental Task Robert Havighurst believes that learning is basic to life and that the people continue to learn throughout life. He describes growth and development as occurring during six stages. He also believes that once a person learns to talk, it is mastered for life. Havighurst stressed that developmental task is a task which arises at or about a certain period in the life of an individual, successful achievement of which leads to her happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by the society, and difficulty with later tasks. Our patient is 41 years of age and she belongs to the Middle Adulthood, in which the following tasks are very important to accomplish. These expected tasks includes (a) achieving adult civic and social responsibility, (b) relating oneself to ones spouse as a person, (c) accepting and adjusting to the physiologic changes of middle age, (d) establishing and maintaining an economic standard of living, (e) developing adult leisure time activities, (f) adjusting to aging parents, (g) assisting children to become responsible and happy adults.

Tasks

Achieving adult civic and responsibility Relating oneself to ones spouse Accepting and adjusting to the physiologic changes of middle age Establishing and maintaining an economic standard of living Developing adult leisure time activities Adjusting to aging parents Assisting children to become responsible and happy adults

Degree of Achievement Not Partially Fully Achieved Achieved Achieved social

Our patient reported that in the aspect of Achieving adult civic and social responsibilities, she was able to carry out her role as an adult and a part of the society. As mentioned, she is presently the Barangay Captain. She visits her neighbors to know their concern especially when there are calamities and problems in their community. She also attends barangay meetings, barangay fiestas, Clean and Green, dental and medical missions, and social responsibilities such as attending to birthday parties, weddings, baptismal, church activities. Even now that she is suffering from DM, she finds time to support the said activities whenever her health condition permits her. As observed Zenaida achieved the task of Relating oneself to one`s spouse as a person. She stated that she and her husband have good relationship. According to her, life isnt easy to both of them and to their children for they have faced the most difficult trials of their life such as family problems like the separation of our patients parents. These trials were easily resolved with their determination and courage to countenance all these things and they were able to

surpass it. She also admitted that though there were times of arguments. She avoids conflicts as much as possible or if there are any, she and her husband would talk about it and solve it immediately. She also added that throughout the years, they have been fulfilled because of the love and harmony they have always shared together. In the aspect of Accepting and adjusting to the physiologic changes of middle age, our client stated that her physical and physiologic activity gradually decreases from time to time and she is aware of this things and somehow, accepts the process of aging due to degenerative changes and the fact that all beings undergo aging. She is responsible enough to look after the welfare of her family. And even she had already admitted that she is getting old, she still finds a way to help her children in their daily living. Mrs. Zenaida admitted that she is getting older, and she finds herself becoming more mature and more knowledgeable for as she believes that experience is the best teacher. In the aspect of Establishing and maintaining an economic standard of living, our client stated that she has no problem on financial matters. Each member of the family contributes for their expenses in their household. She and her husband are the ones who are budgeting for the familys income and distribute it in the different aspect of their daily needs. Shes able to develop adult leisure time activities. Our patient enjoys performing some leisure activities. She loves watching TV, listening to radio and helping her neighbors. She also attends to social activities such as birthday parties, weddings, town fiestas which she considers as her leisure activities. She stated that she enjoys going to social activities. Shes able to adjust to her aging parent. Zenaida verbalized that her parents were separated since she was 17 years old. She doesnt know fully the condition of her father since he is currently in Manila together with his new family. However, she knew that hes also suffering

from Diabetes Mellitus. They dont usually visit him in Manila because they have no time and it is far. Her mother on the other hand, does not live with them but they just reside within the same neighborhood. She bought her an eye glasses for her mother in order for her to visualize things clearly because she is now suffering from visual difficulties. She also gave her mother a cane due to decreased strength of her mothers legs to walk. Shes able to assist her children to become responsible and happy adults. For the reason that she, together with her husband, never fail to supervise, guide and love them unconditionally. Aside from being a good mother of two, she is also a good provider and mentor to her children. She wanted them to be trained well and become better, productive individuals. She taught them of becoming honest, thrifty, responsible and respectful. ANALYSIS: Based on the information we gathered, we believed that Mrs. Zenaida is normally developing with respect to Havighurst's theory. She is doing well with the tasks she is expected to acquire and to perform. Moreover, if she continuously carries out these tasks, most definitely, she would be able to move to the next stage and could perform the succeeding task.

VI. PATTERNS OF FUNCTIONING A. Eating Pattern DURING ILLNESS Before Hospitalization March, she started to During Hospitalization She was on low purine diet on the

BEFORE ILLNESS Mrs. Zenaida eats at least 5 times Last

a day - breakfast, lunch, dinner, experience

polyphagia

and first day of hospitalization then

and morning & afternoon snack. polydypsia. She started to crave for converted to low salt and low fat She usually eats breakfast at 8 food even more and she also diet. am, lunch at 12 noon, and dinner experienced increase in By the time she was

thirst. hospitalized, she already consumes

at 6 pm. She eats her morning During this time, for breakfast, these quantities each for breakfast, snacks around 10 am and lunch and dinner, she consumes 2 lunch and dinner: She would eat 2

afternoon snacks around 3 pm. to 3 cups of rice, 2 to 3 servings pieces of pandesal/bread in the She eats a lot and has a very good of meat, and 1 to 2 servings of morning or half bowl of oatmeal , appetite. For breakfast, she vegetables. Her food preferences are cup rice and 1 serving of ulam (

usually consumes 5-6 pieces of still the same. She also consumes 2 pinakbet, malunggay,kalabasa with pandesal dipped in a cup of bananas for breakfast and lunch and utong, chopseuy, balatong) at lunch, coffee. For lunch and dinner, she sometimes, she eats chocolates also and cup rice and 1 serving of consumes 2 cups of rice and 2 (about 1-2 servings). For snack, she ulam for dinner. For her snack, she servings of meat: chicharon, already consumes 2 servings or would consume 1 of sky flakes.

adobo, sinigang (about 2 saucers), slices of kakanin. She still eats at the fried and grilled meat, and 1 same time when she eats before serving of vegetable dish: (breakfast 8AM, lunch 12NN, and

inabraw, tabungaw, balatong or dinner 6PM).

kalabasa. She stated that food of When she was finally diagnosed her choice as to fruits is banana, with DM, she started controlling the which she eats 1 piece at quantity of her food intake. She also

breakfast and 1 piece at lunch. controlled her meat intake and ate Sometimes, she also eats more vegetables ginisang (inabraw, kalabasa)

chocolates (1 serving only). And tabungaw, for snack (mid-morning

and during meals. She started eating

afternoon), she usually consumes oatmeal (1 bowl) for breakfast, sky 2 servings or 2 slices of kakanin flakes (1-2 packs) for snack. The (such as bibingka, suman, time she eats didnt change though.

patupat, linapet, baduya, dudol, By the time she controlled the etc.) coupled with coke probably amount of food she eats, she already she can consume up to 2 litters of consumes these quantities each for soda in a day. She loves to eat lunch and dinner: cup of rice and lots of rice, meat (especially fried 1 serving of meat, and 2 servings of and grilled meat), chocolates, and vegetables. For breakfast, she eats 2 kakanin. She doesnt wash her pieces of pansesal hands before eating because she oatmeal, and for or 1 bowl of snack, she

doesnt think it is very necessary consumes 1-2 pack of sky flakes. because they use spoon and fork Like before, she doesnt wash her anyway. Before eating, they hands. Before eating, they usually

usually pray as a family. Mrs. pray as a family. She maintains this Zenaida does not have any food eating pattern up to date.

allergies. 3-DAY DIET RECALL Breakfast Day 1 -2 slices of bread -1 1/2 glasses of water (360ml) Snack -1 pack sky flakes -1 glass of water (240ml) Lunch - cup of rice -1 serving of pinakbet (1 saucer) -2 glasses of Day 2 - bowl oatmeal -1 1/2 glasses of water (360ml) -1 pack sky flakes -1 glass of water (240ml) water (480ml) - cup of rice -1 serving of inabraw nga tabungaw (1 saucer) -2 glasses of Day 3 - bowl oatmeal -1
1/2

Snack -1 pack sky flakes -1 glass of water (240ml)

Dinner - cup of rice -1 serving of malunggay (1 saucer) -2 glasses of

-1 pack sky flakes -1 glass of water (240ml)

water (480ml) - cup of rice -1 serving of kalabasa with utong (1 saucer) -2 glasses of

-1 pack sky flakes glass

water (480ml) - cup of rice -1 serving of of chopseuy (1 saucer) -2 glasses of water (480ml)

-1 pack sky flakes -1 glass

water (480ml) - cup of rice -1 serving of of balatong (1 saucer) -2 glasses of water (400ml)

glasses of -1

water (360ml)

water (240ml)

water (240ml)

ANALYSIS:

There is a significant change in her eating pattern before illness and during illness before hospitalization. She began to crave for more food due to her polyphagia which is a symptom of Diabetes Mellitus. There is an evident increase on her food intake during illness before hospitalization due to cell starvation secondary to decreased utilization of glucose by the cells that causes hunger. There is also a change in her eating pattern during illness before hospitalization and during illness during hospitalization. She controlled her food intake in terms of quantity. The food preference was also altered. She began to eat more vegetables than meat. She avoided eating sweets as advised by the doctor. The alteration of her diet at the hospital was attributed to doctors prescribed diet.

B. Drinking Pattern DURING ILLNESS BEFORE ILLNESS Before Hospitalization During Hospitalization

Our patient consumes 2580 ml per Since the time she suffered from She drinks water every after intake day. She consumes 1 cup of coffee polydyspia, she consumes 2580- of food. 1

of water for breakfast

for breakfast (180 ml), 2 glasses 3600ml per day of fluids. She (360ml), 1 glass of water for snack (480 ml) of water for breakfast, consumes 1 cup of coffee (180 ml)2- in the morning (240ml), 2 glasses of and 2 glasses (480 ml) of coke for 3 glasses (480-720ml) of water for water at lunch (480ml), 1 glass of lunch, dinner and snack (mid- breakfast, and 2-3 glasses (480- water for snack in the afternoon morning and afternoon), for a total 720ml) of coke for lunch, dinner and (240ml), and 2 glasses of water for of 1920ml of coke per day. She loves coke, she said she can snack (mid-morning and afternoon), dinner (480ml). She consumes 1800 for a total of 1920-2880ml of coke ml of water in a day. She stopped per day. But by the time she was

consume up to 2 liters of coke per diagnosed with UTI and DM until drinking coke already. day. She has been addicted to now, she shifted from drinking coke drinking coke since she was in her to purely water. She was also 20s. Before, she can even drink advised not to drink coffee anymore. up to 3 liters. She became so

addicted to it that she even said Kasla nak la pay-payapayan, pertaining to coke. They even always has a supply of coke in their refrigerator, they usually buy 1 case of coke (1L) every time they buy groceries. She usually drinks coke without ice cubes.

ANALYSIS: There is a change in her drinking pattern before illness and during illness before hospitalization. Due to increased water loss brought about by osmotic effect of increased glucose secondary to disease process, polydipsia occurs. She felt to thirst more than she usually did due to polydypsia which is a symptom of Diabetes Mellitus. But by the time she was diagnosed with DM, she stopped drinking coke out of her fear that her situation might get worse if she keeps on drinking it. There is also a significant change in the drinking pattern during illness before hospitalization and during illness during hospitalization. There is decreased fluid intake during

hospital stay since glucose is already controlled and polydipsia is ruled out. Also, there is a decreased demand for hydration, brought about by decreased activity of the client. C. Bladder Elimination DURING ILLNESS Before Hospitalization During Hospitalization

BEFORE ILLNESS

Mrs. Zenaida usually urinates 6-7 Since June, she already urinates 10- She usually urinates 6-10 times a times a day, each urination 12 times a day, each urination day. Approximately 1000-1120 ml

amounts to 180-240 ml. She amounts to 180 ml. She can urinate yellowish colored urine every day. usually urinates whenever she 1800-2160 ml in a day. Last June, No burning pain during urination takes a bath and whenever she she noticed white salt-like crystal with sweet aromatic urine. No feels the urge to urinate. It will be particles in her urine, she also started vaginal itchiness. Usually urinate discussed in the bathing pattern to experience itch and pain (with after drinking of water. that she takes 1 full bath in the bearable pain, 6/10). Her urine is afternoon and a sponge bath in the still yellow in color but it already evening. She also urinates once at smells quite sweet. She also said that mid-morning, afternoon, and there are times when ants would

before sleeping. Her urine was crawl unto her used underwear. She yellow in color and aromatic. The usually wipes with tissue after urine is slightly turbid. She didnt urinating. experience any difficulty or

discomfort urinating. She usually wipes with tissue after urinating. She can urinate 1080-1440 ml per

day.

ANALYSIS: There is a significant change in the bladder elimination of the patient before illness and during illness before hospitalization. It was caused by her present condition. Because in diabetes, the concentration of sugar in the blood is higher, therefore promoting osmotic attraction of water. Hence, causing polyuria. She experienced itchiness and as reported, she was diagnosed with UTI, because the urine droplet in her underwear is a good environment for bacterial growth. There is also a change in the bladder elimination of the patient during illness before hospitalization and during illness during hospitalization. There is a decrease in the urine output. The decrease in the urinary frequency during confinement is attributed to the decreased fluid intake and decreased activity.

D. Bowel Elimination DURING ILLNESS Before Hospitalization During Hospitalization

BEFORE ILLNESS

She typically defecates every other She defecates every day (usually in No passage of stool. day (usually in the morning). The the morning). The quantity of the amount of the defecated stool is stool defecated is moderate in

scanty to moderate. The color is amount. The color is brownish and brownish and sometimes sometimes yellowish. The odor is

yellowish. The odor is not foul and not foul and the consistency is the consistency is formed. She formed. She uses water, soap, and uses water, soap, and tissue to tissue to clean after she defecates. clean after she defecates.

ANALYSIS: There is an alteration as to the bowel pattern of the patient before illness and during illness before hospitalization since she defecates every day during illness before hospitalization and the quantity is moderate due to increased appetite of the patient (polyphagia) as one manifestation of DM. In addition, there is a significant change in the bowel pattern of the patient during illness before hospitalization and during illness during hospitalization. This is related to decrease fluid intake and decreased activity of the client.

E. Sleeping Pattern DURING ILLNESS Before Hospitalization During Hospitalization

BEFORE ILLNESS

She usually sleeps 9 hours every She now sleeps 7 hours to 8 When she was admitted to the day. She sleeps at 8PM and wakes hours. She still sleeps at 8PM and hospital, she also had the very same at 5:30AM. She takes her tepid wakes at 5:30AM. Yet, due to her sleeping patterns. She sleeps 9 sponge bath before she sleeps to leg pain (which she characterized to hours, she sleeps at 7PM and wakes make her feel refreshed & have a pain scale of 6/10), joint pain at 5:30AM. She is also disturbed by

comfortable, and so that she can and low back pain, she wakes up at urinary frequency and leg pain, joint

fall asleep faster. She also prays around 10PM.

She would apply pain and also with back pain (at least

before she sleeps. There are no efficacent oil at her leg and join the 2 times). She is also disturbed by the disturbances that could stop her other relatives in watching TV for a noisy and humid atmosphere at the from having a good night sleep so, while. Then she gets back to sleep at hospital. Therefore, her sleep is still she feels satisfied. She also takes a 1-hour nap at around 3PM. around 11:30PM. However, she also interrupted. Due to the disturbance wakes up at around 1 am and 4 am she encounters, she feels unsatisfied due to urinary frequency. She with the amount of sleep she gets.

urinates and then gets back to bed. It Because of this, the duration of her takes 15 minutes before she will fell nap is longer than before. She takes a asleep. She still takes her shower nap in the afternoon for a maximum before she sleeps to make her feel of 2 hours. She takes her tepid refreshed & comfortable, and so that sponge bath before she sleeps to she can fall asleep faster. She also make her feel refreshed. She also prays before she sleeps. Since she is prays before she sleeps. experiencing sleep disturbance, she feels unsatisfied with the amount of sleep she gets and feels less

energetic during the day. She also still takes a 1-hour nap at around 3PM.

ANALYSIS:

There is a change in her sleeping pattern before illness and during illness before hospitalization. She still sleeps the same time she sleeps before, but she fails to get the same amount of sleep she usually gets before. Due to this, she also feels less satisfied. The reason for all this is her leg pain/joint pain (pain scale = 6/10) and urinary frequency at night (nocturia) which disturbs her sleep. These reasons usually wake her up at around 10 pm, 1 am, and 4 am. Leg pain which includes the joints and urinary frequency are one of the manifestations of DM. There is change in the sleeping pattern of the patient during illness before hospitalization and during illness during hospitalization since there is an increased duration of sleep. However, they are both interrupted. In addition, there is a longer time for nap compensation for her interrupted sleep during illness during hospitalization.

F. Bathing Pattern BEFORE ILLNESS DURING ILLNESS Before Hospitalization During Hospitalization

She takes a bath at least 2 times a day. She still takes a bath at least 2 When she was admitted to the She takes a 1 full bath in the morning and times a day. She takes a full hospital, she only takes tepid 1 sponge bath in the evening. In taking a bath in the morning. She uses sponge bath. She washes her bath in the morning, she uses safe guard safe guard soap. She also face and perineum in the soap. She also consumes 1 pail of water consumes 1 pail of water morning and in the afternoon. and 1 sachet of sunsilk shampoo. She and 1 sachet She of also sunsilk takes

also takes a sponge bath before sleeping shampoo.

so she will be refreshed, feel more sponge bath before sleeping comfortable and so she can fall asleep for the same reason of

faster. She uses soap and consumes wanting to feel refreshed. She pail of water. She doesnt wet her hair uses soap and consumes anymore. She usually takes a bath for 15- pail of water. She doesnt wet 20 min. her hair anymore. She

consumes about 15-20 mins.

ANALYSIS: There is no change in her bathing pattern before illness and during illness before hospitalization since she still maintains her previous bathing practices. However, there is a change in the bathing pattern of the patient during illness before hospitalization and during illness during hospitalization since she couldnt endure prolonged standing brought about by leg/joint/low back pain.

VII. Levels of Competencies

Levels of Competency Physical Our

Before Illness patient

During Illness: Before Hospitalization can At home, her activities In

During Illness: During Hospitalization the hospital, she

meet her physical of daily living have spends most of the time needs perform and can been limited to dusting lying on bed, sitting on her the furniture, watering the chair, talking to her or to other

activities of daily the plants, cooking, or visitors, living. dishwashing. In short, patients. doesnt that

The patient usually she

do When shes not feeling are well, she just sits to take

wakes up at around activities 5:30 morning. in She the strenuous.

According a rest and refrain from she moving around or even to visitors. move She

is to the client,

physically well and doesnt work so much entertain is able to do the since she experienced doesnt household

around

chores. leg/joint/low back pain more often also due to

At home, she was but still sweeps the her condition. She also able to do any yard sometimes. The easily gets tired and feels

household

chores other chores left which body weakness.

such as cleaning the are the heavy ones are house, cooking, accomplished by her

washing the dishes, husband and children watering the plants however, she still helps and doing the him sometimes. She does her

laundry difficulties without assistance.

without still

and responsibilities in their any barangay but most of the time, she stays in

According to her, their barangay hall. She these activities let her barangay

Analysis: There was a change on the physical competency of the patient before illness and during illness before hospitalization. There is a decrease in the activities of our client because her family encourages her to avoid strenuous activities. There is a change also in the physical competency of the client during illness before hospitalization and during illness during hospitalization. The decrease in the activity of the client during confinement is expected due to hospital setting. Also, since there are times that she feels pain in the legs, joints, and at the low back, easy fatigability, and body weakness consequently, she has to take a rest.

Level of Competencies Emotional

During Illness: During Illness: Before During Hospitalization Hospitalization Our patient is the type She faces her In the hospital, she Before Illness of person that is easily condition pleased. She laughs and optimism. smiles at things that whenever interest her. She is the leg/joints/low with gets irritated when Yet, her leg, joints, and her lower back pains. back She tactfully herself talking to

type of person who can aches, she becomes a excuses hold her she temper little irritable. when

whenever

gets However, she can still someone, and tells them she needs rest. She still can hold her temper.

angry or irritated. She hold her temper. knows that

misunderstandings can be solved in a calm manner.

She is able to deal with the circumstances in a calm disposition. She told us that whenever they have a problem with her husband, they resolve it through a calm talk and would not pass a day without

solving it. Analysis: There is a change on the emotional competency of the patient before illness and during illness before hospitalization. Although, she faces her condition with optimism, she feels irritated whenever she is not feeling well. However, she can still hold her temper. There is no change in the emotional competency of the patient during illness before hospitalization and during illness during hospitalization, since she also feels irritated due to her condition. Her irritation is one of her coping mechanism towards the pain/discomfort. In addition, she can still grip her temper.

Level of Competency Intellectual

During Illness: During Illness: Before During Hospitalization Hospitalization The patient is a person Her illness didnt Her intellectual Before illness who easily cause any alteration. capability did not

understands/comprehends The patient can still change. However,

what is being explained comprehend well. She her or instructed to her. She can still

knowledge

follow about her disease She is increased and is

is well oriented about instructions. events, person, time, and place, able what is events to

remember more in a knowledgeable to She and

happening around her. The patient

chronological manner. manage it. can She can and remember understands

comprehend well. She places

persons follows what the advises

can follow instructions accurately. She is still doctor

precisely. She can also able to make logical her. She is still remember events in a decisions chronological manner, financial regarding oriented with the matters, things around her issues, and she answers

she can remember places, barangay

and persons accurately. family matters or even questions She is able to make personal matters that appropriately. logical regarding decisions would result to greater financial good. However, to the

matters, barangay issues, according

family matters or even patient, she had less personal matters that knowledge about her

would result to greater disease. good. Analysis:

There is no change in the intellectual capability of the client before illness and during illness before hospitalization. She remained to be mentally stable as evidenced by the fact that she is able to answer questions appropriately. She could still perform the same intellectual activities she usually does with the same level of competence. However, she has a low knowledge about her condition. There is change in the intellectual competency of the patient. She also has gained a greater knowledge about her condition. However, her intellectual capability did not change.

Level of Competency Social

Before illness

During illness during Hospitalization Our patient maintains She seldom visits their During her stay in good interpersonal neighbor but still goes to the hospital, she

During illness before Hospitalization

relationship with the mass every Sunday. She still does her best people around her. still goes to meetings in to socialize with people, health

Conflicts arise but she their town and also leads other tries to confront the the meeting in their including source of problem in a Barangay but not care

providers, nurses, fellow

calm way. Also, when joining the field works student someone asks for an anymore. advice, she was never selfish in listening and giving them advices. She is a sociable person especially because her and

patients. She said she gained friends during confinement. The only her

job requires her to be more interactive to the community people in order to know their needs and problems. She usually visits the neighborhood. Aside

hindrance to her interacting with

other people is when she is not feeling (joint/leg, well low

back pain) during which she has to excuse herself

from being a public servant, she is also active in their church and attends their mass every Sunday. She also attends gatherings birthday weddings, town barangay clean medical missions. Analysis: and and social such as

since she has to take some rest. She still

coordinates to her barangay officials through phone

parties, baptismal, fiestas or

call and also with her family.

meetings, green, dental

There is a change in her social competency before illness and during illness before hospitalization. She is now less active in socializing with her neighbors and within their

community due to her condition. There is a change in the emotional competency of the patient during illness before hospitalization and during illness during hospitalization since she cant personally involve herself with the responsibilities within their community and family because of her confinement. However, she still managed to maintain good camaraderie with the people around her.

Level of Competency Spiritual Our

Before Illness patient

During Illness: During Illness: Before During Hospitalization Hospitalization is The patients faith Her faith in the remained became

affiliated to Pentecost remained firm despite Lord church. She is a God- the crisis she is going and fearing person. She through. She

didnt deeper. She even

goes to church every blame God for the things said that her faith Sunday to worship. that are happening to was strengthened She has a strong faith. her, instead she accepted because She also prays before it wholeheartedly and condition her made

she sleeps. She also prays to God to help her her learn to trust has a positive outlook and guide her every day. in God even more. in life despite of many She still makes it a point She claimed that obstacles that comes to attend mass every she even became along lifes journey. Sunday. closer to the lord for He is in her that

strength

critical period of

her life. She also claimed that she always prays at night sleeping. wasnt able before She to

attend their church services but still didnt pray. Analysis: There is no change on his spiritual competency before illness and during illness before hospitalization since her faith to God remained firm and not altered by her condition. There is a change in the spiritual competency of the patient during illness before hospitalization and during illness during hospitalization. Despite the fact that she couldnt attend church services since she is confined, her faith became stronger as evidenced by not forgetting to pray, not blaming Him for her condition, and trusting and believing in Him even more. forget to

VIII. PHYSICAL ASSESMENT Date Performed: July 01, 2011 (Friday) General Inspection The patient is seen in a sitting position, conscious, quite irritable and conversant. She is wearing a white t-shirt, dark denim pants and slippers with on-going IV Fluid of PNSS 1liter regulated @ 40-41 gtts/min @ 350 level inserted at right metacarpal vein. She is neatly dressed

with moderate sweating. She has a mesomorph body built. She has a height of 171 cm and a weight of 69 kg. Her computed Body Mass Index (BMI) is 23.6 kg/m 2. The patients complexion is fair. She has observable scars and presence of non-healing wounds in her lower extremities. The client appears neat and well-groomed. No foul odors detected upon inspection. The client has a slumped posture manifested by sitting slightly forward bracing her arms in her knees and doesnt stand straight. She has a tense, slow gait. The patient is also not at ease when moving from standing to sitting and from sitting to lying and needs assistance. There is no presence of involuntary movements such as tremors upon inspection. The patients attitude is cooperative although she is quite irritable. She does maintain eye contact. Her speech is not so loud and not so soft. Her tone of voice is full. Anxiousness cannot be detected in her voice. She conversed appropriately, does what is instructed to her, and answers our questions intellectually. Vital Signs Blood Pressure:130/90 mmHg Respiratory Rate: 25 breaths/min (irregular, rapid and shallow breathing) Pulse Rate: 96 beats/min (irregular, strong and rapid pulse) Body Temperature: 35.3 C

Skin The patients skin complexion is fair. There are noticeable scars and presence of nonhealing wounds in her lower extremities. The patient is neatly dressed with moderate sweating. Her skin is cold and clammy and smooth to touch. She has also a good skin turgor. She is slightly pale in appearance than fair complexion. No jaundice. No cyanosis. Head to Toe Assessment

A. Head The head is normocephalic in relation to the neck and shoulders for size and shape, the skull is symmetric and is appropriately proportioned for the size of the body. The scalp of the head is intact, without lesions, redness, or flakes. The scalp is lighter in color than fair complexion. No tenderness or masses noted upon palpation The scalp is lighter in color than dark complexion. Free from lice and nits With black and oily straight hair About a waist length hair gathered into ponytail With evenly distributed hair covers the whole scalp B. Face Oval shape The facial features (eyes and eyebrows, palpebral fissures, nasolabial folds, and sides of the mouth) appear symmetrical Facial bones are symmetric and appear proportional to the size of the head

 No involuntary muscle movements noted Able to move facial muscles at will With intact cranial nerve V (trigeminal nerve) and VII (facial nerve) by asking the client to open and close his mouth, raise and lower his eyebrows, bare his teeth, smile broadly, pop out cheeks, keep mouth close while try to open it C. Eyes With good visual acuity, able to read letters from the snellen chart at 6 meters (20/20 vision) With good peripheral vision able to see objects at 180 degrees angle while looking at a fixed point Blinking is typically frequent, bilateral, involuntary movements, and with an

average of 20 blinks per minute

normal?

No discharge present upon inspection With pale palpebral conjunctiva With upper eyelid partially covering the iris With puffy eyelids

 With symmetrical and evenly distributed eyebrows With equal palpebral fissure With brown iris With symmetrically aligned eyes Dark circles under eyes No irregularity noted in the external eye structures such as redness, prominence of veins No tenderness palpated in the patients eyelid and lacrimal apparatus With intact cranial nerve III (occulomotor), IV (troclear), and VI (abducens) eyes able to follow movement of finger of examiner from the six cardinal positions of gaze Pupils equal, round, and reactive to light and accommodation (pupils constricts and dilate symmetrically) D. Ears With bean shaped, symmetrical earlobes The upper connection of the earlobes are in line with the outer canthus of the eye

 No pain and tenderness noted upon palpation of the mastoid process and auricles Ear canal with minimal cerumen upon inspection No lesions noted With good hearing acuity able to repeat what the examiner said through the voice test With intact middle ear by asking the patient to stand with both feet together, close his eyes and remain in that position for at least 20 seconds E. Nose and Sinuses Nose in midline With minimal amount of thickened brown discharges No flaring of the nostrils noted upon respiration With patent nares No tenderness, mass or pain noted upon palpation Nasal septum in midline and intact With slightly pale nasal mucosa The external nose is symmetric

 No pain or mass, tenderness upon palpation of the sinuses With intact cranial nerve 1 (Olfactory) we let her close her eyes and let her smell of an alcohol, ink of the marker and let her name those things F. Mouth and Oropharynx With symmetrical lips With cracks on her lips With dry lips With slightly pale inner lips and buccal mucosa not so moist No bleeding of gums With ivory teeth With 28 number of teeth; right molar maxillary missing Tongue Midline in position Not so moist Dorsal surface slightly rough with midline groove and several fissures With smooth and slightly pale ventral surface veins visible With bony and whitish hard palate

 With muscular and slightly pale soft palate With slightly pale uvula in midline position With grade 1 tonsils With intact gag reflex G. Neck No mass/mumps noted upon palpation Trachea in midline position Proportional to body size Same complexion with the body Able to hyperextend, tilt, and turn his head to the right and then to the left (ROM) Active accessory nerve by asking the patient to turn his head on one side and we asked the patient to turn his head to the opposite side while the examiner applies pressure against the patients jaw H. Thorax and Lungs With respiratory rate of 25 breaths per minute With equal vibrations (tactile fremitus) upon saying the word 99m in length Moves symmetrically when breathing

 With straight spinal process alignment upon inspection With symmetrical lung expansion No retractions Thoracic cage rounded and symmetrical appearance with symmetrical chest movements

with bronchovesicular sounds heard over the major bronchi

cardiac rate of 97 bpm I. Breast and Axillae With brown, rounded areola With rounded nipples, same color with areola Breast of same size, contour and symmetrical No mass/lumps or tenderness noted upon palpation With fairer skin at the axilla

J. Abdomen

 Flat abdomen Bowel sounds auscultated at 12 per minute at the left lower quadrant No venous engorgement noted upon inspection No organomegaly No tenderness/mass noted upon palpation 32 inches abdominal girth Uniform in color and pigmentation K. Back straight alignment brown in color with aching and burning sensation on the lower back (6/10) L. Upper Extremities No gross deformities With irregular rhythm on his radial and brachial pulse Pulse rate of 96 bpm Right and left arms symmetrically aligned With long fingernails Slightly pale nail beds

 With capillary refill of 2 seconds With abnormal reflexes Numbness present With on-going IV Fluid of PNSS 1liter regulated @ 40-41 gtts/min @ 350 level inserted at right metacarpal vein Has a good skin turgor No scars noted Proportional to body size With trace of vaccination on the right deltoid Does not able to distinguish sharp and dull sensations; from hot to cold With cold clammy skin Motor-Function Finger to nose test Repeatedly and rhythmically touches the nose Alternate supination and pronation of hands and knees Can alternately supinate and pronate hands at normal pace Finger to nose and nurses finger Performs with coordination

Fingers to thumbs (same hand) Touches each finger to thumb with each hand at normal rate

M. Lower Extremities No gross deformities With capillary refill of 2 seconds With limited range of motion and muscle strength Right and left leg symmetrically aligned With scars noted upon inspection With presence of non-healing wounds Irregular pulses (rapid and strong) Does not able to distinguish sharp and dull sensations and from hot to cold Numbness present Proportional to body size Presence of pain on legs/joints/low back with a pain scale of 10/10 Has a good skin turgor

IX.ONGOING APPRAISAL

Day 1 (July 2, 2011) Condition She is conversant and her back pain had already ceased but experiences easy fatigability. She complained of pain in the arms and legs with a pain scale of 8/10 and experiences dizziness.

Day 2 (July 3, 2011) She is conversant and fair in appearance but still with easy fatigability. Her leg hurts which makes her feel weak. She also experienced occasional headache. At 6:00 P.M., she had bearable nape pain with a pain scale of 3/10.

Day 3 (July 4, 2011) She is fair in appearance and with improved condition.

Day 4 (July 5, 2011) She is in good condition and fair in appearance.

Day 5 (July 6, 2011) She is fair in appearance and with improved condition.

Complaint

She complained of intermittent low back pain with a pain scale of 4/10 with a 1 minute duration. She also felt pain in the knee cap and arms with a pain scale of 5/10.

Still with low back pain with a pain scale of 5/10. She also had numbness on her arms and with intermittent knee cap pain but more on the left with a pain scale of 4/10.She claimed that it is being

Her low back pain was already ceased but still complained with intermittent knee cap pain with a pain scale of 4/10.

Diet and appetite

She was on a low purine diet and didnt eat much.

Intake

Output

She was ordered with low salt low fat diet. She has a good appetite but didnt eat much. She ate 2 She ate 1 slice pieces of of bread and pandesal and drank 400 ml drunk 200 ml of water for of water for breakfast. For breakfast. For her snack, she her lunch, she ate 1 pack of ate 1 hard sky flakes in boiled egg, the morning cup of rice and 1 pack and 400 ml of also in the water. For her afternoon. For dinner, she ate her lunch, she half slice of ate cup of bangus rice and 4 (sinigang), spoons of cup of rice pinakbet and and 400 ml of 400 ml of water. And as water. And to her snack, for her dinner, she ate 1 pack she ate cup of skyflakes of rice, 3 both in the pieces(3 morning and inches each) afternoon. of She consumed munamun 1500 ml of and 400 ml of PNSS. water. She urinated She urinated 6 1120 ml and times, defecated yellowish in once. color and

aggravated during cold season. At night, she experienced dizziness. Still on low salt, She has a low fat diet, good appetite with good and also appetite but didnt eat didnt eat much. much.

Still with good appetite and still didnt eat much.

She ate bowl oatmeal with milk and 2 slices of bread for her breakfast. For her lunch, she ate 1 fried chicken and cup of rice and drunk 400 ml of water. For her dinner, she ate cup of rice, 1 serving of inabraw and 400 ml of water.

She ate cup oatmeal and 1 pack of skyflakes for her breakfast. For her lunch, she ate 5 match box sized igado, 1 serving pinakbet and cup rice and drunk 1 cup of water. For her dinner, she ate slice of banana(lakata n) , cup of rice and 1 cup of water. As to her snack, she ate 1 pack of skyflakes

She ate 2 slices of bread and 1 cup of water for breakfast, cup of rice, 1 serving inabraw,1 cup of water for lunch, cup of rice, 1 piece banana, 1 cup of water for dinner and 1 pack of skyflakes for her morning snack and another pack for the afternoon.

She urinated 6 times during the day and 6 times also at night.

She urinated 10 times during the day and 8 times

She urinated 9 times during the day and 10 times during

didnt defecate.

Gadgets attached

v/s range

manageme nt

PNSS one liter to run for 12 hours regulated at 27-28 gtts/min inserted at right hand. BP:110/80140/100mmH g PR:59-68 bpm RR:20-24 breaths/min Body Temp:35.7-36 Administratio n of medications: Trama dol 50 mg IV every 8 hours Ciprof loxaci n 300 mg IV every 12 hours Insulin glargin 10 U SQ Pregab aline 75 mg cap

NONE

She defecated once and characterized as brown and formed. NONE

during the night.She doesnt defecated. NONE

the night. She defecated once. NONE

BP: 110/80120/90 mmHg PR:68-78 bpm RR:17-23 breaths/min Body Temp:36.637.1 Trama dol 50 mg IV every 8 hours shifted to Trama dol 50 mg cap every 8 hour Ciprof loxaci n discon tinued Other meds were given

BP:120/80 mmHg PR:76 bpm RR:22 breaths/min. Body Temp:36.0 She applied efficascent oil on the knee cap and took the medications prescribed by the physician.

BP:120/80mm Hg PR:63 bpm RR:23 breaths/min. Body Temp:36.7 She continued to take the medications prescribed by the physician.

BP: 120/80mmHg PR:69 bpm RR:22 Body temp:36.9

She continued to take the medications prescribed by the physician.

every 8 hours

New Orders

start insulin 10 units every 4 hours Contin ue sodiu m salt with PNSS Follow up ultraso und Diabet ic diet Pregab aline 75 mg cap noon then every 12 hours Discon tinue Ciprof loxaci n Shift to tramad ol 50 mg 1 cap every

May go home Contin ue diabeti c diet and LSLF, full diet For follow up check up at OPD on July 13, 2011

8 hours To follow A1C result Rest and activity There is still a sleep disturbance due to leg pain. She had 6 hours of sleep and took a maximum rest. She had 5 hours of sleep and took 1 hour of siesta. She exercised for 3 minutes and she swept the floor. She had 3 hours of sleep due to frequency of urination and didnt have her siesta. She slept for 5 hours and had 1 hour siesta. At the morning she swept the floor and in the afternoon, she walked around their neighborhood as a form of her exercise.

FIRST DAY ON-GOING APPRAISAL July 2, 2011- Saturday

It was the first day of our appraisal. She is conversant and complained with pain on arms and legs with a pain scale of 8/10. Her backpain during our first assessment had already ceased. She also experienced easy fatigability and complained with dizziness. As to her diet, she was ordered with low purine diet. She doesnt eat much rice. As to her breakfast, she ate two pieces of pandesal and drank 200 ml of water. She ate one piece hardboiled egg, cup of rice and 400 ml of water for her lunch and for her dinner, she ate half slice of bangus(sinigang), cup of rice and drank 400 ml of water. And as to her snack, she ate 1 pack of skyflakes. She consumed 1500 ml of PNSS. She urinated 1120 ml and she

defecated once because of the suppository that was given to her prior to the ultrasound. She had an IVFluid of PNSS one liter to run for 12 hours regulated at 27-28 gtts/min inserted at her right hand. She was given the medications, Tramadol 50 mg IV every 8 hours, Ciprofloxacin 300 mg IV every 12 hours, Insulin glargin 10 U SQ, and Pregabaline 75 mg cap every 8 hours. She was examined by Dr. Bigornia and gave new orders such as to start insulin 10 units every 4 hours, continue sodium salt with PNSS, follow up ultrasound, to be on diabetic diet, Pregabaline 75 mg cap noon then every 12 hours, discontinue

Ciprofloxacin, shift to Tramadol 50 mg 1 cap every 8 hours and to follow ALC result. As to her rest and activity, there is sleep disturbance due to her leg pain. RBS Monitoring TID + HS July 2, 2011 Pre-Breakfast Pre-Lunch Pre-Dinner HS VALUE 156 mg/dL 224 mg/dL 238 mg/dL 199 mg/dL

Her vital signs were taken as follows: BP: 110/80-140/100mmHg PR: 59-68 bpm RR: 20-24 breaths/min Body Temp: 35.7-36 SECOND DAY ON-GOING APPRAISAL July 3, 2011- Sunday It was the second day of our appraisal. She is fair in appearance, conversant, and still with easy fatigability. She complained of weakness when her leg hurts and also had occasional headache. At 6:00 P.M., she experienced bearable nape pain with a pain scale of 3/10. As to her diet, she was ordered with low salt, low fat diet. On this day, she was in good

appetite however she didnt eat much. She ate 1 slice of bread and drank 400 ml of water for breakfast. For her snack, she ate 1 pack of sky flakes in the morning and 1 pack also in the afternoon. For her lunch, she ate cup of rice and 4 spoons of pinakbet and 400 ml of water. And for her dinner, she ate cup of rice, 3 pieces (3 inches each) of munamun and 400 ml of water. There were changes in her medications such as Tramadol 50 mg IV every 8 hours was shifted to Tramadol 50 mg cap every 8 hours, Ciprofloxacin was discontinued. The other medications were given the same frequency and dosage. On this day, she was examined by Dr. Bigornia and advised to go home and to have a follow check up at OPD on July 13, 2011, instructed her to follow diabetic diet and LSLF, full diet, and prescribed medications such as Pregabaline 75 mg cap, Insulin glargin 10 U SQ, and Tramadol 50 mg cap. She was discharged at 11:05 A.M and took maximum rest at their house and had slept for 6 hours.

July 3, 2011

RBS Monitoring Pre-Breakfast

VALUE 240 mg/dL

Her vital signs were taken as follows: BP: 110/80-120/90 mmHg PR: 68-78 bpm RR: 17-23 breaths/min Body Temp: 36.6-37.1 THIRD DAY ON-GOING APPRAISAL July 04, 2011-Monday On this day, she has improved condition and fair in appearance.

She complained of intermittent low back pain with a pain scale of 4/10 with a 1 minute duration. She also felt pain in the knee cap and arms with a pain scale of 5/10. She is still on a low salt, low fat diet. She had good appetite but doesnt eat much. She ate bowl oatmeal with milk and 2 slices of bread for her breakfast. For her lunch, she ate 1 fried chicken and cup of rice and drank 400 ml of water. For her dinner, she ate cup of rice, 1 serving of inabraw and 400 ml of water. During the day, she urinated 6 times and at night time, she defecated once and characterized as brown and formed. Upon assessment, her IVFluid had already removed since she had been discharged on this day. As to the management, she took the medications prescribed by Dr. Bigornia and she applied efficascent oil on the knee cap to alleviate the pain. She had 5 hours of sleep and took 1 hour of siesta. For 3 minutes, she had her exercised early in the morning and then she swept on the floor. Her vital signs were taken as follows: BP:120/80 mmHg PR:76 bpm RR:22 breaths/min. Body Temp:36.0

FOURTH DAY ON-GOING APPRAISAL July 05,2011-Tuesday

Upon visiting at their house, she is in good condition and fair in appearance. However, she still complained of low back pain with a pain scale of 5/10. She also had numbness on her arms and with intermittent knee cap pain but more on the left with a pain scale of 4/10. She noticed that the pain was being aggravated during cold season. At night, she felt dizziness that lasted for 2 hours. She had good appetite on this day but she doesnt ate much. She ate cup oatmeal and 1 pack of skyflakes for her breakfast. For her lunch, she ate 5 pieces match box sized igado, 1 serving pinakbet and cup rice and drunk 1 cup of water. For her dinner, she ate slice of banana (lakatan) , cup of rice and 1 cup of water. As to her snack, she ate 1 pack of skyflakes. During the day, she urinated ten times and eight times during nighttime. She didnt defecate. She continued to take the medications that were prescribed by Dr. Bigornia. At night, she had 3 hours of sleep due to frequency of urination and didnt have her siesta because she had her duty at their Brgy. Hall. Her vital signs were taken as follows: BP:120/80mmHg PR:63 bpm RR:23 breaths/min. Body Temp:36.7

FIFTH DAY ON-GOING APPRAISAL July 06, 2011-Wednesday

She is fair in appearance and with improved condition since her low back pain was already ceased. However, she complained with intermittent knee cap pain with a pain scale of 4/10. She still had good appetite and still didnt eat much. She ate 2 slices of bread and 1 cup of water for breakfast, cup of rice, 1 serving inabraw, 1 cup of water for lunch, cup of rice, 1 piece banana, 1 cup of water for dinner and 1 pack of skyflakes for her morning snack and another pack for the afternoon. As to her output, she urinated 9 times during the day and 10 times during the night and defecated once and characterized the stool as formed, brown in color. She continued to take the medications prescribed by the physician. She slept for 5 hours and had 1 hour siesta. At the morning she swept the floor and in the afternoon, she walked around their neighborhood as a form of her exercise. Her vital signs were taken as follows: BP: 120/80mmHg PR:69 bpm RR:22 breaths/min Body temp:36.9

X. LABORATORY STUDIES AND DIAGNOSTIC PROCEDURES A. LABORATORY STUDIES

1. Complete Blood Count 2. Blood Chemistry 3. Urinalysis 4. CM Microalbumin 5. Hemoglobin A1C

HEMATOLOGY The concerns of hematology are: (1) the concentration of different types of cells in the blood, (2) the status and proliferation behavior of their precursors cells in the hematopoietic organs, (3) the structure, chemical content, and functional activity of blood cells, (4) certain chemical constituent of plasma or serum which are intimately linked with blood cell structure and function, (5) the role of blood coagulation in maintaining vascular integrity.

1. COMPLETE BLOOD COUNT (CBC) a. Description: CBC is a screening test, is one of the most frequently ordered laboratory procedures. It is a group of tests that usually includes the hemoglobin, hematocrit, red blood cell count, white blood cell count, differential white cell count, red cell indices and stained red cell examination. A platelet count may also be included in the CBC.

 Hemoglobin (Hgb) - is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues to the lungs. Hematocrit (Hct) is a blood test that tells us what proportion, by volume, of total blood cells is made up of red blood cells. Hematocrit is given as a percentage. Red Blood Cells are pale red in color and shaped like a donut with a thinner section in the middle instead of a hole. They have hemoglobin inside them, a protein that transports oxygen throughout the body. Mean Corpuscular Volume (MCV) reflects the size of red blood cells by expressing the volume occupied by a single red blood cell. Increased values may indicate macrocytic anemia or vitamin B6 or Folic Acid deficiency and decreased values may indicate microcytic anemia, possibly caused by iron deficiency. Mean Corpuscular Hemoglobin (MCH) gives the average weight of hemoglobin in the red blood cell. Due to its use of red blood cells in its calculation, MCH is not as accurate as MCHC in its diagnosis of severe anemias. Decreased MCH is associated with microcytic anemia and increased MCH is associated with macrocytic anemia. Mean Corpuscular Hemoglobin Concentration (MCHC) this test measures the average concentration of hemoglobin in red blood cells. It is most valuable in evaluating therapy for anemia because Hemoglobin and Hematocrit are used, not R.B.C. in the calculation. Low MCHC means that a unit of packed R.B.C.s

contain less hemoglobin than normal and a high MCHC means that there is more hemoglobin in a unit of R.B.C.s. Increased MCHC is seen in spherocytosis, and not seen in pernicious anemia whereas decreased levels may indicate iron deficiency, blood loss, B6 deficiency, or thalassemia. White Blood Cells the total WBC is the absolute number of WBC circulating in a cubic millimeter of blood. White cells are produced in the red bone marrow and lymphatic tissues. After they are formed the enter the blood which transports them to the parts of the body where they are needed to defend against invading organisms through phagocytosis and produce or transport and distribute antibodies to help maintain immunity. Segmenters during infection, neutrophils are the predominant phagocytes removing debris, foreign bodies and toxic accumulation of waste products. Neutrophils are mature cells that are incapable of division and sensitive to acidic environments. Lymphocytes leukocyte (white blood cell) that normally makes up about 25% of the total white blood cell count but can vary widely. Lymphocytes occur in two forms: B cells, which produce antibodies, and T cells, which recognize foreign substances and process them for removal. Monocytes leukocytes (white blood cells) function in the ingestion of bacteria and other foreign particles. Monocytes make up 5-10% of the total white blood cell count. Monocytes are immature macrophages which are formed and released by bone marrow in the bloodstream.

 Eosinophils these are leukocytes (white blood cell) with granules that are stained by the dye, eosin. Eosinophils, normally about 1-3% of the total white blood cell count, are believed to function in allergic responses and in resisting some infections. Basophils it is a type of white blood cell (leukocyte), with coarse granules that stain blue when exposed to a basic dye. Basophils normally constitute 1% or less of the total white blood cell count but may increase or decrease in certain diseases. Platelet count platelets, also called thrombocytes, are large, non-nucleated cells derived from megakaryotes produced in the bone marrow. Two-thirds are found in the blood and one-third in the spleen. One-tenth of the platelets found in the blood maintain endothelial integrity and the rest are available for hemostasis. The adhesive or sticky quality of platelets allows them to clump together or aggregate and adhere to injured surfaces. They release a substance that begins the coagulation process. Platelets plugs form and occlude breaks in the integrity of the small vessels. Along with fibrin, they form the network for a clot to form. This test is used to evaluate platelet production. ABO blood type ABO blood groups are inherited characteristics that consists of the presence or absence of either A or B antigens. It is usually referred to as agglutinogens. Blood typing maybe done for a variety of reasons which includes when a person plans to donate blood, need a blood transfusion, or is pregnant.

 Rh blood type the blood group (approximately 85% of people) whose red cells have the Rh factor (Rh antigen) b. Purpose: This was done to our patient to determine the quantity of each type of blood cell and each component and how they are affected, and how they respond to the disease.
Requesting Physician: Date Requested: Date Processed: Annalyn Urbano M.D July 1, 2011 July 1, 2011

c. Result: Result 120.00 0.36 3.930 92.10 30.50 33.10 5.54 0.50 0.32 0.12 0.06 0.00 272 Unit g/L 10^12/L fL Pg g/dl 10^9g/L Reference ranges 123-153 0.35-0.44 4.5-5.1 80-100 27-32 31-35 4.50-11.00 0.50-0.70 0.20-0.40 0.02-0.08 0.01-0.04 0.00-0.01 150-450 Interpretation N N N N N N N N N N N

Hgb Hematocrit RBC Mean cell volume Mean cell Hgb MCHC Concentration WBC Differential Count: Segmenters Lymphocytes Monocytes Eosinophils Basophils Platelet Count Analysis:

10^g/L

NURSING RESPONSIBILITIES 1. Verify doctors order. 2.

RATIONALE To avoid error and to determine the

desired laboratory studies to be done. Explain the procedure and the To gain cooperation and to minimize

purpose to the patient. anxiety. 3. Fill up the laboratory request form To notify the medical technologist and

properly and forward it to the laboratory process the CBC as soon as possible. immediately. 4. When the results are obtained, notify So that appropriate orders can be made. the physician and attach it to the patients chart. 5. Document the procedure For legal purposes.

2. BLOOD CHEMISTRY a. Description it tests measure levels of certain substances such as electrolytes, enzymes and proteins in the blood that can tell whether or not various organs are healthy and functioning properly. Glucose The blood glucose test is ordered to measure the amount of glucose in the blood right at the time of sample collection. It is used to detect both hyperglycemia and hypoglycemia, to help diagnose diabetes, and to monitor glucose levels in persons with diabetes. High levels of glucose can indicate the presence of diabetes or another endocrine disorder. Considerations include keeping in mind that some medications and the timing of the test in relation to meals can radically alter the results and avoid assuming that the results indicate a problem until consultation with the physician is done.

Blood Urea Nitrogen (BUN) - Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure. It may also be due to a condition that results in decreased blood flow to the

kidneys, such as congestive heart failure, shock, stress, recent heart attack, or severe burns, to conditions that cause obstruction of urine flow, or to dehydration. BUN concentrations may be elevated when there is excessive protein breakdown (catabolism), significantly increased protein in the diet, or gastrointestinal bleeding (because of the proteins present in the blood). Creatinine is a nitrogenous waste product produced during protein metabolism in muscle tissue. The amount produced each day, which is related to the muscle mass, seldom changes rapidly. It is eliminated from the body by the kidneys. Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. These can include: -Damage to or swelling of blood vessels in the kidneys

(glomerulonephritis) caused by, for example, infection or autoimmune diseases -Bacterial infection of the kidneys (pyelonephritis) -Death of cells in the kidneys small tubes (acute tubular necrosis) caused, for example, by drugs or toxins -Prostate disease, kidney stone, or other causes of urinary tract obstruction -Reduced blood flow to the kidney due to shock, dehydration, congestive heart failure, atherosclerosis, or complications of diabetes Creatinine blood levels can also increase temporarily as a result of muscle injury and are generally slightly lower during pregnancy.

Low blood levels of creatinine are not common, but they are also not usually a cause for concern. They can be seen with conditions that result in decreased muscle mass. Sodium is the most abundant cation in the blood and its chief base. It functions in the body to maintain osmotic pressure, acid-base balance, and to transmit nerve impulses. Changes in the serum sodium level occur during any change in body cations. The sodium pump moves sodium out of the cells. Due to the intricate relationship between sodium and water, sodium has a primary role in the distribution of body water. Decrease in sodium is seen in states characterized by intake of free water or hypotonic solutions, as may occur in fluid replacement following sweating, diarrhea, vomiting, and diuretic abuse. Dilutional hyponatremia may occur in cardiac failure, liver failure, nephrotic syndrome, malnutrition, and SIADH. There are many other causes of hyponatremia, mostly related to corticosteroid metabolic defects or renal tubular abnormalities. Drugs other than diuretics may cause hyponatremia, including ammonium chloride, chlorpropamide, heparin,

aminoglutethimide, vasopressin, cyclophosphamide, and vincristine.

Potassium is the major intracellular cation in the blood. It, along with sodium, helps to maintain osmotic balance and is also involved in acid-base balance. It is needed for proper nerve and muscle action.

Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in vomiting, diarrhea, villous adenoma of the colorectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, carbenoxolone, corticosteroids, diuretics, licorice, salicylates, and ticarcillin

Blood Uric Acid The uric acid blood test is used to detect high levels of this uric acid in the blood in order to help diagnose gout. People with gout suffer from joint pain, most often in their toes, but in other joints as well. Higher than normal uric acid levels in the blood is called hyperuricemia and can be caused by the over-production of uric acid in the body or the inability of the kidneys to clear out enough uric acid. Increased concentrations of uric acid can cause crystals to form in the joints, which can lead to the joint inflammation and pain characteristic of gout. Uric acid can also form crystals or kidney stones that can damage the kidneys. Low levels of uric acid in the blood are seen much less commonly than high levels and are seldom considered cause for concern. Although low values can be associated with some kinds of liver or kidney diseases. b. Purpose blood chemistry is done to our patient to determine the loss of electrolytes that are needed to maintain electrolyte and water imbalance since the patient is diagnosed also

with mild dehydration. Furthermore, blood glucose test is also a part to determine the presence of hypoglycemia or hyperglycemia.

Requesting Physician: Date Requested: Date Processed:

Annalyn Urbano M.D July 1, 2011 July 1, 2011

c. Result: Result 13.81 1.90 48.41 130.00 4.00 210.11 Unit mmol/L mmol/L umol/L mmol/L mmol/L mmol/L Reference ranges 4.2-6.4 1.7-8.3 40.00-68.00 136-150 3.4-5.3 140-320 Interpretation N N N N

Glucose, FBS BUN Creatinine Sodium Potassium Blood Uric Acid Analysis:

The glucose, FBS of the patient is high because the pancreas can not sufficiently produce insulin. Her sodium is low because of the frequent dieresis of the patient.

NURSING RESPONSIBILITIES 1) Check the doctors order.

RATIONALE To determine the exact procedure to be

done 2) Explain the purpose of the procedure to In order for the patient to know what to the patient, how the specimen is to be anticipate as well as to gain cooperation collected and the stinging sensation that may be felt. 3) Fill up the laboratory request properly To notify the medical technician and forward it to laboratory. 4) Upon the arrival of the result, refer it to For the physician to determine the the physician and then attach it to the appropriate management to be given to the patients chart. 5) Administer blood transfusion as ordered patient To replace the loss RBC of the body

3. URINALYSIS (CM and Bacteriology) a. Description urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. Color dark yellow urine indicates concentrated urine and the excretion of waste products in a smaller quantity of water, such as is seen with the first morning urine, with dehydration, and during a fever. Clarity urine clarity refers to how clear the urine is. Usually, laboratories report the clarity of the urine using one of the following term: clear, slightly cloudy, cloudy, or turbid. Normal urine can be clear or cloudy. Substances that cause cloudiness but that are not considered unhealthy include mucus, sperm and prostatic fluid, cells from the skin, normal urine crystals, and contaminants such as body lotions and powders. Other substances that can make urine cloudy, like red blood cells, white blood cells, or bacteria, indicate a condition that requires attention. Urine Specific Gravity specific gravity, is actually a physical characteristic of the urine, a measure of urine concentration. There are no abnormal specific gravity values. This test simply indicates how concentrated the urine is. Specific gravity is the estimation of the concentration of urine relative to water; reflects concentrating ability of the kidneys. If there were no solutes present, the SG of urine would be 1.000- the same as pure water. Since all urine has some solutes a urine SG of 1.000 is not possible. If a person drinks excessive quantities of water in a

short period of time or gets an IV infusion of large volumes of fluid, then the urine SG may be as low as1.002. As the concentration of minerals, salts and compounds in urine increases, the specific gravity increases. Urine pH - is defined as the hydrogen ion concentration of the urine. It is a

measurement of the acid or alkaline status of urine. The secretion by the kidney of acidic or alkaline urine is one of the mechanisms by which the normal acid-base balance of the body is maintained. A high-protein diet or consuming cranberries will make the urine more acidic. A vegetarian diet, a low-carbohydrate diet, or the ingestion of citrus fruits will tend to make the urine more alkaline. Urine Protein Protein found in the urine is albumin, a serum protein that normally does not leak into the glomerular filtrate. Normally, there will not be detectable quantities. When urine protein is elevated, it signifies a condition called proteinuria. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Urine Glucose glucose is normally not present in urine. When glucose is present, the condition is called glucosuria. It results either because there is an excessively high glucose concentration in the blood, such as may be seen with people who have uncontrolled diabetes mellitus and/or reduction in the renal threshold. When the blood glucose level exceeds the renal threshold for the reabsorption of glucose, some glucose spills into the urine. Normal individuals who have eaten a meal very high concentrated carbohydrate can have transient glucosuria.

 Urine Hemoglobin this test is used to detect hemoglobin in the urine (hemoglobinuria). Hemoglobin is an oxygen-transporting protein found inside red blood cells (RBCs). Its presence in the urine indicates blood in the urine (known as hematuria). The small number of RBCs normally present in urine (see microscopic examination) usually result in a "negative" test. However, when the number of RBCs increases, they are detected as a "positive" test result. Even small increases in the amount of RBCs in urine can be significant. Numerous diseases of the kidney and urinary tract, as well as trauma, medications, smoking, or strenuous exercise can cause hematuria or hemoglobinuria. Urine Ketones this test cannot determine the severity of disease nor be used to identify where the blood is coming from. Ketones are not normally found in the urine. They are intermediate products of fat metabolism. They can form when a person does not eat enough carbohydrates (for example, in cases of starvation or high-protein diets) or when a person's body cannot use carbohydrates properly. When carbohydrates are not available, the body metabolizes fat instead to get the energy it needs to keep functioning. Ketones in urine can give an early indication of insufficient insulin in a person who has diabetes. Severe exercise, exposure to cold, and loss of carbohydrates, such as with frequent vomiting, can also increase fat metabolism, resulting in ketonuria. Nitrite this test detects nitrite and is based upon the fact that many bacteria can convert nitrate to nitrite in your urine. Normally the urinary tract and urine are free of bacteria. When bacteria find their way into the urinary tract, they can cause a urinary tract infection (UTI). A positive nitrite test result can indicate a UTI.

 Bilirubin bilirubin is not present in the urine of normal, healthy individuals. Bilirubin is a waste product that is produced by the liver from the hemoglobin of RBCs that are removed from circulation. It becomes a component of bile, a fluid that is secreted into the intestines to aid in food digestion. The presence of bilirubin in urine is an early indicator of liver disease and can occur before clinical symptoms such as jaundice develop. Urobilinogen urobilinogen is normally present in urine in low concentrations. It is formed in the intestine from bilirubin, and a portion of it is absorbed back into the bloodstream. Positive test results help detect liver diseases such as hepatitis and cirrhosis and conditions associated with increased RBC destruction (hemolytic anemia). When urine urobilinogen is low or absent in a patient with urine bilirubin and/or signs of liver dysfunction, it can indicate the presence of hepatic or biliary obstruction. Leuko Esterase (an enzyme found in certain white blood cells) leukocyte esterase is an enzyme present in most white blood cells (WBCs). Normally, a few white blood cells are present in urine and this test is negative. When the number of WBCs in urine increases significantly, this screening test will become positive. When the WBC count in urine is high, it means that there is inflammation in the urinary tract or kidneys, and other abnormalities associated with infection. Urine Blood normally, a few RBCs are present in urine sediment. Inflammation, injury, or disease in the kidneys or elsewhere in the urinary tract can cause RBCs to leak out of the blood vessels into the urine.

 Epithelial Cells normally, a few epithelial cells from the bladder (transitional epithelial cells) or from the external urethra (squamous epithelial cells) can be found in the urine sediment. Cells from the kidney (kidney cells) are less common. In urinary tract conditions such as infections, inflammation, and malignancies, more epithelial cells are present. Epithelial cells are usually reported as "few," "moderate," or "many" present per low power field (LPF). Squamous Cells - Cells are produced in the distal urethra, prepuce, vagina, and vulva. They are large, angular and irregular in shape. They stain purple, depending upon the amount of keratinization. Usually squamous epithelial cells are contaminants. Transitional Cells - They are produced in the proximal urethra, bladder, ureters and renal pelvis. Because these are "stretchy" cells, they vary in size and shape. They are less angular than squamous epithelial cells, with a larger nucleus. They are larger and often more granular than leukocytes. Transitional cells may be normal, especially if it was catheterized. However, large rafts (clumps) of cells are not normal and should be recorded. They may indicate infection or a transitional cell carcinoma. Renal Tubular Cells - They should be less visible. These come from the renal tubules and, when seen intact in urine, indicate renal tubular disease. Renal tubular cells from normal exfoliation have disintegrated by the time urine exits the body.

 Bacteria - normal urine is sterile until it reaches mid-urethra, and then bacterial contaminants are picked up, so that urine collected by natural void will always contain bacteria. Mucus Threads mucus threads are long, narrow, wavy shreds from mucus surface. Normal in small numbers or amount, but greatly increased in amount is seen in irritation in any kind. They also appear often with split ends. These are long strands and ribbon-like. Yeast Cells the presence of yeast in the urine sediment may indicate an infection Casts casts are cylindrical particles sometimes found in urine that are formed from coagulated protein secreted by kidney cells. They are formed in the long, thin, hollow tubes of the kidneys known as tubules and usually take the shape of the tubule (hence the name). Under the microscope, they often look like the shape of a "hot dog" and in healthy people they appear nearly clear. This type of cast is called a "hyaline" cast. When a disease process is present in the kidney, other things such as RBCs or WBCs can become trapped in the protein as the cast is formed. When this happens, the cast is identified by the substances inside it, for example, as a red blood cell cast or white. blood cell cast. Different types of casts are associated with different kidney diseases, and the type of casts found in the urine may give clues as to which disorder is affecting the kidney. Some other examples of types of casts include granular casts, fatty casts, and waxy casts. Normally, healthy people may have a few (05) hyaline casts per low power field (LPF). After strenuous exercise, more hyaline casts may be detected. Cellular

casts, such as RBC and WBC casts, indicate a kidney disorder. When they are present in the urine is called cylinduria. Hyaline cast - are often non-pathogenic. They are increased when protein leaks through the glomerulus causing proteinuria. Granular cast contain degenerative tubule cells in the hyaline matrix. Granules maybe coarse, fine or mixed. Many granular casts are nonpathogenic. Tubular degeneration increases the number of granular cast present, and is an early indicator of renal disease. Waxy cast are present with advance nephritis and renal disease. They are dull and opaque in appearance with clefts and broken ends. Waxy cast are usually pathogenic. Crystals - crystals are frequently seen in urine. Crystal formation is affected by mineral composition, water and pH of urine during formation. Crystals are identified by their shape, color, and by the urine pH. They may be small, sand-like particles with no specific shape (amorphous) or have specific shapes, such as needle-like. Crystals are considered "normal" if they are from solutes that are typically found in the urine. Amorphorous Urate crystals are seen in acidic to slightly alkaline urine. They form a granular precipitate which maybe normal or associated with liver disease. Calcium Oxalate Crystals form in acidic to neutral urine. They are also colorless and have an envelop or dumbbell shape. They maybe normal or associated with urolithiasis or ethylene glycoltoxicity.

 Triple Phosphate (Calcium magnesium ammonium phosphate) these are are usually associated with urine infected by urea splitting bacteria which cause "infection", or "triple phosphate" infection, or triple phosphate stones.

Uric Acid - High uric acid levels in the urine are seen with gout, multiple myeloma, metastatic cancer, leukemia and a diet high in purines. Those at risk of kidney stones who have high uric acid levels in their urine may be given medication to prevent stone formation. Low urine uric acid levels may be seen with kidney disease and chronic alcohol use. b. Purpose: This test was performed to our patient to assess the effects of the disease on renal function and the existence of concurrent renal or systemic diseases.

Requesting Physician: Date Requested: Date Processed:

Butch Bigornia, M.D July 1, 2011 July 1, 2011

c. Result: Result Physical Exam: Urine color Clarity Specific Gravity pH Chemical Exam: Protein Glucose Hemoglobin Ketone Nitrite Light yellow Clear 1.010 7.0 Negative Normal Negative Negative Negative Unit Reference ranges Straw, amber, transparent, clear yellow Clear 1.005-1.035 4.6-8.0

Bilirubin Urobilinogen Leuko Esterase Urinary Cells: WBC RBC Epithelial cells Bacteria Mucus threads Renal cells Yeast cells Urinary casts: Hyaline cast Fine Granular cast Course Granular cast Waxy cast Urinary crystals: Amorphous

Negative Normal Negative 0-5 0-1 0-1 Occasional Occasional Occasional /HPF /HPF 0-5

/LPF /LPF /LPF /LPF

0-1

Urate/ Occasional -

phosphates Calcium Oxalates Triple Phosphate Uric acid

Analysis: The values in the urinalysis is normal because her problem in UTI was already solved and that this procedure is only done because it`s a part of routine procedures,

NURSING RESPONSIBILITIES 1. Check doctors order.

RATIONALE To determine the procedure to be done to

the patient and for legal purposes. 2. Inform & explain to the patient & To gain cooperation. significant other/s the reason why the

specimen was ordered. 3. Instruct the patient to wash and dry the To reduce the number of transient bacteria perineum first before taking the urine in the skin that may contaminate the urine specimen. specimen

4. Provide a specimen bottle with proper So that the patient and the significant other instructions. will know what to do and to be able to a proper specimen for the

a. Urine should be collected on the obtain first void in the

morning, laboratory procedure. a. It has more uniform

midstream. (after the urine has flowed for several seconds, place the collection cup into the stream and collect about 2 fl oz (60 mL) of this "midstream" urine without interrupting the flow. b. Put the lid tightly on the container.

concentration and more acidic pH specimen later in the day. b. To prevent spillage of the specimen.

5. Label with patients name, ward and For proper identification. room number. 6. Fill up laboratory request properly and So that the medical technologist will know completely. the specific test to be done to the specimen

once forwarded. 7. When the specimen is available, send it To avoid delay in examining the urine and immediately to the laboratory according to hospital protocol. to avoid sedimentation and for a more accurate analysis.

8. Refer the result to the physician once So that the physician will be able to available and attach it to the patients chart determine the problems occurring in the afterwards. 9. Document. 10. Monitor I & O every hour. patient and determine the appropriate management to be done to the patient. For legal purposes To assess the patients renal ability to

function. 11. Teach the patient on proper perineal To prevent ascending infection. hygiene.

4. CM MICROALBUMIN a. Description the microalbumin urine test is mostly ordered in case of people suffering from medical conditions that make them susceptible to kidney damage. This test helps in ascertaining the levels of albumin in urine. Albumin is a water-soluble protein that plays a vital role in the regulation of osmotic pressure of the blood. Albumin is an important component of the blood plasma, and is filtered by the kidneys into the blood. Like other proteins, albumin is large-sized, and doesn't pass through the glomeruli or the small filters of the kidney. This is why, traces of albumin are not found in urine. Traces of albumin in urine, indicate that the filters may have been damaged. This can help in early detection of kidney diseases. In this article, we will look into the circumstances under which albumin may be found in urine along with details on the normal range of albumin.

b. Purpose This test was done to check for the presence of albumin in the urine and to check for possible kidney disorder or involvement secondary to Diabetes.

Requesting Physician: Date Requested: Date Processed:

Butch Bigornia, M.D July 2, 2011 July 2, 2011

c. Result TEST Urine Microalbumin RESULT 0.00 UNIT REFERENCE RANGES mg/L 0-19
INTERPRETATION

Analysis: The result of this test that was done to our patient shows that there is no presence of albumin in the urine. Hence, her kidney function is normal. NURSING RESPONSIBILITIES NURSING RESPONSIBILITIES 1. Check doctors order. RATIONALE To determine the procedure to be done to

the patient and for legal purposes. 2. Inform & explain to the patient & To gain cooperation. significant other/s the reason why the specimen was ordered. 3. Instruct the patient to wash and dry the To reduce the number of transient bacteria perineum first before taking the urine in the skin that may contaminate the urine specimen. specimen

4. Provide a specimen bottle with proper So that the patient and the significant other instructions. will know what to do and to be able to

a. Urine should be collected on obtain

proper

specimen

for

the

the first void in the morning, laboratory procedure. midstream. (after the urine has flowed for several a. It has more uniform concentration and more acidic pH specimen later in the day. b. To prevent spillage of the specimen.

seconds, place the collection cup into the stream and collect about 2 fl oz (60 mL) of this "midstream"

urine without interrupting the flow. b. Put the lid tightly on the container. 5. Label with patients name, ward and For proper identification. room number. 6. Fill up laboratory request properly and So that the medical technologist will know completely. the specific test to be done to the specimen

once forwarded. 7. When the specimen is available, send it To avoid delay in examining the urine and immediately to the laboratory according to hospital protocol. 8. Refer the result to the physician once So that the physician will be able to available and attach it to the patients chart determine the problems occurring in the afterwards. 9. Document. patient and determine the appropriate management to be done to the patient. For legal purposes to avoid sedimentation and for a more accurate analysis.

10. Monitor I & O every hour.

To assess the patients renal ability to

function. 11. Teach the patient on proper perineal To prevent ascending infection. hygiene. 5. HEMOGLOBIN A1C a. Description - the A1c test evaluates the average amount of glucose in the blood over the last 2 to 3 months. This test is used to monitor diabetes treatment in someone who has been diagnosed with diabetes. It helps to evaluate how well their glucose levels have been controlled by treatment over time. It does this by measuring the concentration of glycated hemoglobin A1c. Hemoglobin is an oxygen-transporting protein found inside red blood cells (RBCs). There are several types of normal hemoglobin and many identified hemoglobin variants, but the predominant form about 95-98% is hemoglobin A. Hemoglobin A can be further subdivided, with one of the subcomponents known as hemoglobin A1c. As glucose circulates in the blood, some of it spontaneously binds to hemoglobin A. The glucose-hemoglobin molecules formed are said to be glycated. The higher the concentration of glucose in the blood, the more glycated hemoglobin is formed. Once the glucose binds to the hemoglobin, it remains there for the life of the red blood cell - normally about 120 days. The combination of glucose and hemoglobin A is referred to as HbA1c or A1c. b. Purpose To determine the extent of controllability of our patients DM
Requesting Physician: Date Requested: Butch Bigornia, M.D July 2, 2011

Date Processed:

July 2, 2011

c. Result CHEMISTRY Significance

Value Hemoglobin A1C Analysis:

Reference Range

The patient hemoglobin A1C level is slightly higher than the reference range which means that the high glucose of the patient can still be controlled.

NURSING INTERVENTION 1. Check for doctors order 2. Explain to the patient about the test that will be done to her and the

Rationale Basis what test will be done to the patient to avoid mistakes To promote compliance

purpose of the test 3. Fill up the laboratory request form To notify the medical technologist and properly and forward it to the process the CBC as soon as possible. laboratory immediately. 4. When the results are obtained, notify So that appropriate orders can be made. the physician and attach it to the patients chart. 5. Encourage the client to eat a balance diet. 6. Teach patient on how to properly administer insulin. 7. Encourage patient to drink fluids frequently. 8. Document. To help manage her condition. To potentiate the drug and to prevent lipodystrophy To prevent problems on fluids and electrolyte imbalance To have a legal basis and basis for

future interventions.

B. DIAGNOSTIC PROCEDURES
1. Abdomino-Pelvic X-Ray 2. Abdominal Ultrasonography (UTZ) 3. Electrocardiography (ECG) 4. RBS Monitoring

1.

X-RAY AND ULTRASOUND ABDOMINO-PELVIC X-RAY a. Description X-rays are waves that have a relatively high frequency along the electromagnetic spectrum. They are absorbed or transmitted by different body tissues in varying amounts, producing different shades of black and white on an xray image. X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body tissues onto specially treated plates (similar to camera film) and a "negative" type picture is made (the more solid a structure is, the whiter it appears on the film). It is a non-invasive procedure that visualizes all solid organs of the upper and lower abdomen. This study is valuable in detecting a variety of pathologies, including fluid collections, masses, infections, and obstructions. b. Purpose To detect if there are abnormalities in the abdominal areas/organs. It was also done to determine presence of fat depositions in the organs.

NURSING RESPONSIBILITIES FOR X-RAY NURSING RESPONSIBILITIES 1. Check doctors order. 2. RATIONALE To determine the procedure to be done to

the patient. Inform & explain to the patient & To gain cooperation. significant other/s the reasons why the specimen was ordered, how it is to be collected and the stinging sensation that

may be felt. 3. Fill up laboratory request properly To notify the medical technologist. & forward it to the laboratory. 4. Upon the arrival of the result, refer For the physician to determine the it to the physician & then attach it to appropriate management to be applied to the patients chart. the patient.

ABDOMINAL ULTRASONOGRAPHY (UTZ) a. Description Ultrasound waves have a frequency just beyond that of audible sound. These waves are emitted and bounce back once they strike an object. As a clinical tool, ultrasound imaging (ultrasonography) can detect differences between solid and liquid material in the body. Ultrasound studies use a portable machine with a computer and transducer probe. The probe is placed on the region of the patient's body to be visualized. A gel is placed between the probe and patient's body to maximize clarity of the image. The computer takes ultrasonic data and coverts it into visual form. An abdominal ultrasound can evaluate the:

Abdominal aorta, which is the large blood vessel (artery) that passes down the back of the chest and abdomen. The aorta supplies blood to the lower part of the body and the legs.

Liver, which is a large dome-shaped organ that lies under the rib cage on the right side of the abdomen. The liver produces bile (a substance that helps digest fat), stores sugars, and breaks down many of the body's waste products.

Gallbladder, which is a small sac-shaped organ beneath the liver that stores bile. When food is eaten, the gallbladder contracts, sending bile into the intestines to help in digesting food and absorbing fat-soluble vitamins.

Spleen, which is the soft, round organ that helps fight infection and filters old red blood cells. The spleen is located to the left of the stomach, just behind the lower left ribs.

Pancreas, which is the gland located in the upper abdomen that producesenzymes that help digest food. The digestive enzymes are then released into the intestines. The pancreas also releases insulin into the bloodstream. Insulin helps the body use sugars for energy.

Kidneys, which are the pair of bean-shaped organs located behind the upper abdominal cavity. The kidneys remove wastes from the blood and produce urine.

b. Purpose This was done to our patient to determine abnormalities or involvement of the organs of the upper abdomen secondary to Diabetes.

NURSING RESPONSIBILITIES FOR UTZ

NURSING INTERVENTIONS 1. Check the Doctors order 2. Fill up a request form. 3. Explain the procedure and drink

RATIONALE To confirm the diagnostic procedure and to protect self from any illegal actions. To inform the x-ray unit about the test its To gain cooperation and allay anxiety 1 To full his bladder prior to the procedure

importance to the client 4. Instruct patient to

quart(1000mL) and not to urinate for more accurate results prior to the procedure 5. Place the patient in supine position. For better visualization of the abdominal

parts 6. After the procedure wipe off the To prevent possible irritation and to clear gel that is applied to the maintain a clean and ungreased abdomen abdomen. 7. When the examination is complete To inform the client about the things to do tell the patient that she may be asked next to dress and wait while the

ultrasound images are reviewed. Then the patient can be released immediately. 8. Refer results to the physician if it is To have a baseline data already available and attach to chart.

c. Result
Name: SIMPLICIANO, ZENAIDA CULANNAY Age/Sex: 41/Female

Address: San Marcos (Payas), SAN NICOLAS, ILOCOS NORTE

Ward/Room/Dept: 4th Floor Med-Female-SV/Medicine

Examination Desired: Abdomino-Pelvic

Requested by: Annalyn Urbano, M.D

Admitting Diagnosis: Low back pain R/O Nephrolithiasis, Osteoarthritis, R/O Hyperglycemia

-------------------------------------------------------------------------------------------------------------X-RAY / ULTRASOUND REPORT The liver is not enlarged with smooth borders. Parenchyma is diffusely echogenic. No fecal solid or cystic mass noted. The intra and extra-hepatic bile ducts are not dilated. The portal venous radicles are not ecstatic. Hepatorenal space is devoid of fluid. The gallbladder is undilated with thin walls wich measures 6.2x 2.2x 2.0 cm. No intraluminal echoes, pericholecystic fluid or transducer tenderness. The common bile duct is not dilated. The pancreas and spleen are unremarkable. Abdominal aorta is normal in course and caliber with no focal dilatation. The right kidney, measures 11.34 x 3.9 cm. The left kidney measures 10.3 x 4.7 cm. Both kidneys are normal in size with distinct borders and seen in their usual location. The renal cortical thickness is adequate. Renal parenchyma is also normal with delineable corticomedullary junctions. Both central renal echocomplexes are intact. No nephrolithiasis or focal lesion noted. Perinepheric regions are unremakarble. The urinary bladder is transonic and adequately filled with thin walls. No intraluminal pathology noted. Uterus is not enlarged. Retroverted which measures 6.2x 4.6 x4.0 cm. Parenchyma appears homogenous with no definite myoma or bulging lesions within. Endometrial stripe echogenic, midline with 0.95 cm. thickness. No uterine cavity fluid noted. Adnexal areas are clear. Both ovaries are unremarkable. Posterior cul-de-sac is devoid of fluid. No ascites or mass detected.

IMPRESSION: DIFFUSE FATTY LIVER INFILTRATION SONOGRAPHICALLY NORMAL GALLBLADDER, PANCREAS, SPLEEN, ABDOMINAL AORTA, KIDNEYS, URINARY BLADDER AND PELVIS

Analysis: According to the patient she noticed that her waist line decrease from 36 cm to 32 cm as reflected in the physical assessment. When she was younger, she loved to eat sweet foods specially those high in carbohydrates and fats. Because of this excessive amount of carbohydrates and fats which were not used by the body, they were transformed into adipose deposits in different organs. In the case of our client, those fats were deposited in the liver.

2.

ELECTROCARDIOGRAPHY (ECG) a. Description The ECG is a visual representation of the electrical activity of the heart as reflected from various angles to the skin surface. The ECG is recorder as a tracing on a strip of paper or appears on the screen of an oscilloscope. This is the electric observation of the conductivity patterns of the heart by the use of skin electrodes and a monitoring device; the hearts electric activity is conducted to the surface of the skin by the salty fluids bathing the cells and tissues. The ECG produces a graphic recording of the hearts electrical activity, detecting transmission of impulses and the electrical position of the heart. b. Purpose

Requesting Physician: Date Requested: Date Processed:

Butch Bigornia, M.D July 1, 2011 July 1, 2011

c. Result

MEASUREMENTS Durations PR: 0.12 sec QRS: 0.08 sec QTa: -----QTc: -----Rhythm Morphologies P wave Upright Biphastic in _____ Inverted in ______ Not discernible Sinus

Rates Atrial: 70/min Ventricular: 70/min Axis Normal

QRS Complexes:

good R waveprogression poor R wave progression Significant Q in ______ S V1 or V2 + V5 or V6> 35

Widened/notched in__________

S v1+ R V5>53 in ages 16-25

Tall prominent in ___________

___________________

ST segment :

Isoelectric Depressed in:_________ Elevated in

T Wave:

Upright Inverted in

Others:________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ __ Interpretation:

Regular Sinus

Within Normal Limits

Normal Heart_________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ __ Read By: Dr. Butch B. Bigornia Interpretation: ECG tracing: within normal limits and regular sinus rhythm Analysis: The ECG interpretation was within normal limits which were interpreted by the physician who requested/ordered the said procedure.

NURSING RESPONSIBILITIES a.Check the doctors order. b.

RATIONALE To determine the specific procedure to be

done to the patient. Inform and explain to To alleviate anxiety and gain cooperation. the patient and significant others about the procedure, including where it will

take place and its expected duration. c.Fill-up request properly and completely To notify the cardiologist. then forward it to the cardiology department. d. Refer to the physician So that the physician will be able to the ECG result once available and then determine the appropriate management to attach it to the clients chart. be applied to the patient. e.Position the patient in a high back rest This will help the patient breathe properly position as prescribed. and as well as to provide comfort to the

f. Regulate oxygen inhalation properly. g. Administer

patient. To relieve the DOB of the patient while preventing respiratory overload. loop To excrete the excessive amount of fluid in

diuretics as prescribed by the physician. the body. h. Administer antibiotics as To treat infection. prescribed. i. Monitor the v/s especially the blood To assess the effect/s of the drug and to pressure of the patient every hour. j. Monitor I & O every hour. k. Report monitor the condition of the patient. To assess the amount of fluid being excreted. any To make an immediate intervention to

abnormalities in the v/s and urine prevent complication. output to the physician.

3. RBS MONITORING tid + HS a. Description Blood glucose monitoring refers to the ongoing measurement of blood sugar (glucose). Monitoring can be done at any time using a portable device called a glucometer. It is done to detect hyperglycemia or hypoglycemia. This test must be performed frequently in patients with newly diagnosed diabetes mellitus to assist in monitoring and adjusting the insulin dose. b. Purpose: This was ordered to monitor the uptake of glucose by the neurons. Another purpose is to provide the patient as well as the health care providers with current blood glucose levels. Monitoring blood glucose allows the patient to alter diet, insulin or activity to maintain good glycemic control.

Requesting Physician: Date Requested: Date Processed:

Butch Bigornia, M.D July 1, 2011 July 1, 2011

c. Results RBS MONITORING, TID + HS July 1, 2011 Pre-Lunch Pre-Dinner HS July 2, 2011 Pre-Breakfast Pre-Lunch Pre-Dinner HS July 3, 2011 Pre-Breakfast VALUE 254 mg/dL 298 mg/dL 241 mg/dL 156 mg/dL 224 mg/dL 238 mg/dL 199 mg/dL i. /dL

Analysis: As observed, the glucose level of the patient are above the average which mainly caused by the insufficient amount of insulin in the body. NURSING RESPONSIBILITIES 1. Check the doctors order and identify the client 2. Wash hands properly. 3. Assemble the equipments ( lancet or needle, glucometer dry and wet alcohol, )at the bedside 4. Remove the strip from its cover and insert it at the glucometer.Turn on the meter. 5. Select appropriate puncture site and wipe it with a cotton ball with To activate the meter that will be used for testing. To eliminate possible microorganisms found in the RATIONALE To avoid errors and prevents performing an invasive procedure on the wrong client To reduce transmission of microorganisms Allows for a smooth procedure

alcohol. 6. Select the side of the finger pad as puncture site. 7. Hold hand in a relaxed

clients finger It is usually less uncomfortable to pierce the side of the finger than the end of the finger. It is easier to obtain a drop of blood if the finger is relaxed.

position to collect a drop of blood on the test strip. 7. Perform skin puncture. 8. Wipe away the first drop of blood from the site with a dry cotton ball 9. Gently squeeze the site to produce a large droplet of blood 10. Transfer the drop of blood to the strip 11. Wait for the result of the test and record the result. 12. Apply pressure to the puncture site 13. After the procedure, turn off the meter and properly dispose the test strip, cotton balls and lancet 14. Wash hands 15. Record and notify the health care provider of the test results

To collect blood necessary for the test This drop may impede accurate results because it may contain a large amount of serous fluid Large droplet of blood covers the test pad on the strip So that the blood will be absorbed thus producing the result To know the right amount of patients blood sugar To stop the bleeding at the site To reduce contamination by blood to other individuals To reduce transmission of microorganisms Results will be used to determine the clients treatment plan

X. MEDICAL MANAGEMENT
1. Intake and Output Monitoring 2. Diet Therapy (Low-Purine, Diabetic Diet, LSLF_ 3. Intravenous Therapy (PNSS)

1. INPUT AND OUTPUT MONITORING every shift a. Description Fluid intake and output (I and O) is the measurement and recording of all fluid intake and the output during a 24-hour period/every shift. Accuracy of total input and output from all sources is necessary in the determination of the clients response and reactions towards the drugs given. This is also essential for planning the patients care because it will serve as a baseline data for the nurse to determine any abnormality/ies that needs to be immediately referred to the physician. b. Purpose I & O was ordered upon admission to determine fluid imbalances. It provides important data about the clients fluid and electrolyte balance. And also, it is use to indicate the presence of renal failure. Generally, I and O are measured for hospitalized at-risk clients.

Ordered by: Date ordered:

Maximo Callangan, M.D July 1, 2011

Intake and Output Monitoring (July 1, 2011) Shift 7-3 3-11 11-7 Total Clysis Oral Urine

Intake and Output Monitoring (July 2, 2011) Shift 7-3 Clysis Oral Urine

3-11 11-7 Total NURSING RESPONSIBILITIES 1. Check doctors order 2. about Inform the patient and watcher the purpose of this For accurate measurements. RATIONALE To verify the management to be done and to avoid error To gain cooperation.

management. 3. Provide

calibrated

glass/dextrose bottle for the intake and a receptacle for the urine output. 4. Record all the intake and output of the patient. 5. Indicate whether the patient had episodes of vomiting, excessive sweating, and diarrhea. 6. Record all oral fluid intake, clysis, and urine output of the patient on his I & 0 sheet accurately For legal purposes, and could be a basis for carrying out further necessary actions. To properly monitor the balance between intake and output. To identify other sources of fluid loss.

2. DIET THERAPY LOW-PURINE DIET a. Description

b. Purpose A low-purine diet was recommended for our patient because of her history of kidney stones. Purine is a compound found primarily in foods of animal origin. It is specially high in organ meats, anchovies, mackerel, and sardines.
Ordered by: Date ordered: Butch Bigornia, M.D July 1, 2011

NURSING RESPONSIBILITIES 1. Check the Doctors order 2. Inform the patient and the watcher about the diet. Avoid consuming fish such as anchovies,

RATIONALE To avoid errors To gain cooperation.

mackerel, sardines, and scallops. Also avoid gravies,

meat extracts and sweet breads. 3. Encourage active participation of the watchers to the diet of the patient. 4. Tell the client as well as the family that full diet includes mostly vegetables (except cauliflower) like spinach, asparagus, peas, fruit juices, The watchers are the ones assisting the patient, and are the ones who keep their eyes on the patient. So that they will have an idea on whether what foods the client may have.

eggs, cottage cheese, except cauliflower. 5. Write the diet of the patient in the diet list. 6. Endorse patient to other HCPs with an emphasis on his diet. DIABETIC DIET a. Description consists of 65% CHO, 15% Fat, 20% CHON. 1600 kcal is recommended which is composed of 3 meals and 2 snacks. Animal fat and juices are to be avoided but fruits after eating are allowed. A diabetic diet is an attempt to manage diabetes by the use of diet, considering individual nutritional needs, maintenance of ideal weight, calories, and situational adaptations; a planned follow-up program according to need. b. Purpose this was ordered to our patient to prevent wide daily fluctuations in her blood glucose levels.
Ordered by: Date ordered: Butch Bigornia, M.D July 2, 2011

To inform the diet section, preventing serving of restricted foods for the patient. To ensure that the prescribed diet is followed.

NURSING RESPONSIBILITIES 1. Check the Doctors order 2. Assist the patient and the family in understanding the disease process. 3. Encourage active participation of the watchers to the diet of

RATIONALE To confirm the prescribed diet for the patient. To gain cooperation and compliance.

The watchers are the ones assisting the patient, and are the ones who keep their

the patient. 4. Assist

the

client

to

eyes on the patient. To gain patients cooperation.

recognize the need for continuing supervision. 5. Write the diet of the patient in the diet list. 6. Endorse patient to other HCPs with an emphasis on his diet. To inform the diet section, preventing serving of restricted foods for the patient. To ensure that the prescribed diet is followed. health

LOW-SALT, LOW-FAT, FULL DIET a. Purpose Low salt diet was ordered for the patient due to the affectation of the kidneys brought about by the disease process. This was also ordered so as to prevent the potential recurrence of her previous condition, nephrolithiasis. Low fat diet was ordered due to the patients ultrasound report impression, which is diffuse fatty liver infiltration. Full diet was ordered because the patient is able to tolerate solid food but still should be low salt, low fat as well.
Ordered by: Date ordered: Butch Bigornia, M.D July 3, 2011

NURSING RESPONSIBILITIES 1. Check the Doctors order 2. Inform the patient and the watcher about the diet. Avoid processed/salty

RATIONALE To avoid errors To gain cooperation.

foods. Avoid the use of salty condiments (soy sauce, fish sauce, and spices) 3. Encourage active participation of the watchers to the diet of the patient. 4. Tell the client as well as the family that full diet includes all kinds of foods but it is low salt and low fat in nature. 5. Write the diet of the patient in the diet list. 6. Endorse patient to other HCPs with an emphasis on his diet. INTRAVENOUS THERAPY a. Description Intravenous fluids aims to maintain homeostatic functioning or maintain and replace body stores of water, electrolytes, vitamins, proteins, fats and calories in the patient who cant maintain an adequate intake by mouth; provide avenue for the administration of IV medications and monitor central nervous pressure; restore acid-base balance; and restore volume of blood components. b. Purpose To provide necessary nutrient to meet daily requirements and also for supplementation and also served as passage of medications. To inform the diet section, preventing serving of restricted foods for the patient. To ensure that the prescribed diet is followed. The watchers are the ones assisting the patient, and are the ones who keep their eyes on the patient. So that they will have an idea on whether what foods the client may have.

c. Type of solution used PNSS X 12 hours-27-28 gtts/min it replaces NaCL deficit and restore extra cellular fluid volume it contains 154 mEq/L of sodium and chloride, it has slightly higher degree of osmolality compared to blood of about 300 mOsm/L. It was ordered to our patient to replace electrolyte loss and as an avenue for drug administration.
Ordered by: Date ordered: Butch Bigornia, M.D July 1, 2011

NURSING RESPONSIBILITIES

RATIONALE

1. Verify the doctors order and calculate the To determine the right IVF to be infused desired infusion flow rate. and its appropriate regulation as well as

to avoid error. 2. Inform as well as explain the procedure to To gain cooperation. the patient. 3. Observe aseptic technique when handling To prevent further infection. IVFs. Use gloves in inserting the IVF. 4. Check for IV solutions and needles for To prevent infiltration and phlebitis. patency. 5. Verify that the fluid container is not Detection of possible contamination or cracked or leaking and that the solution is clear decomposition of the solution protects and does not contain crystals. Holding the patient. container up to the light facilitates checking for cracks, cloudiness, and crystals. Squeeze

the plastic bag gently to check for leaks 6. Attach tubing to fluid container, hang it, and Priming removes air from the system. prime the tubing while maintaining sterility. If Sterility is necessary to prevent infection. using pump or controller, follow

manufacturers directions for set-up and priming. 7. Regulate IV flow properly. To maintain proper hydration. 8. Assess for signs of infiltration on the IV site To prevent complication. such as swelling, heat and pain around the vein at the infusion site or proximal to it. 9. Change the solution container before it is To prevent embolism. completely emptied. 10. Advice the client not to manipulate the To prevent infiltration. IVF. 11. Change IV line every 72 hours. To prevent phlebitis.

XII. DRUG STUDY

1. Tramadol (IV and Cap) 2. Ciprofloxacin 3. Pregabaline 4. Insulin Glargine

1. TRAMADOL Intravenous Date Ordered: July 01, 2011 Generic Name: Tramadol Brand Name: Classification: Analgesic (centrally-acting) Dosage, Route and Frequency: 50 mg IV every 8 hours

Mode of Action: A centrally acting synthetic analgesic compound not chemically related to opiates. Drug is thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin in the CNS. Desired Effect: This was given to the patient to relieve her leg pain without a significant alteration in level of consciousness. NURSING RESPONSIBILITIES Check the doctors order. RATIONALE To know the dose, route and frequency of the drug in order to Monitor U/S avoid mistakes. To assess bowel and bladder function since the drug can cause constipation Increase fluid intake and provide small frequent feeding. Caution ambulatory patient to be careful when rising and walking. Warn to avoid activities that require mental alertness until drug's CNS effects are known. Advise patient to change positions slowly. Encourage divertional activity. Advice patient to report adverse effect such as dizziness. seizures, headache, confusion, constipation and nausea. To minimize orthostatic hypotension. and urinary retention. - To decrease the bulk of the stool and prevent nausea. To avoid the risk for fall or other accidents since the drug can cause dizziness and confusion.

To decrease the pain To notify physician and to have immediate management.

2. TRAMADOL PO B. Date Ordered: July 03, 2011 Generic Name: Tramadol Brand Name: Classifications: Analgesic (centrally-acting) Dosage, Route, Frequency: 50 mg cap q 8 hours PRN Mode of Action: A centrally acting synthetic analgesic compound not chemically related to opiates. Drug is thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin in the CNS. Desired Effect: This was given to the patient to relieve pain. NURSING RESPONSIBILITIES Check the doctors order. RATIONALE To know the dose, route and frequency of the drug in order to Monitor U/S avoid mistakes. To assess bowel and bladder function since the drug can cause constipation Increase fluid intake and provide small frequent feeding. Caution ambulatory patient to be careful when rising and walking. and urinary retention. - To decrease the bulk of the stool and prevent nausea. To avoid the risk for fall or other accidents since the drug can cause

Warn to avoid activities that require mental alertness until drug's CNS effects are known. Advise patient to change positions slowly. Encourage divertional activity. Advice patient to report adverse effect such as dizziness. seizures, headache, confusion, constipation and nausea.

dizziness and confusion.

To minimize orthostatic hypotension.

To decrease the pain To notify physician and to have immediate management.

2. CIPROFLOXACIN Date Ordered: July 01, 2011 Generic Name: Ciprofloxacin Brand Name: Cipro Classification: Urinary Anti-infectives, broad-spectrum Dosage, Route, Frequency: 300 mg IV every 12 hours Mode of action: Interferes with conversion of intermediate DNA fragments into high-molecularweight DNA bacteria by inhibiting DNA gyrase which leads to death of susceptible bacteria. Desired Effect: This drug was given to the patient to treat her urinary tract infection (UTI) NURSING RESPONSIBILITIES RATIONALE

Check for doctors order

To know the dose, route and frequency of the drug in order to avoid mistakes. To identify the causative agent for the initiation of the appropriate treatment. To enhance patient knowledge about drug therapy and to promote compliance.

Obtain C&S before beginning the therapy. Ensure that the client receives instructions about the appropriate dosage schedule and possible adverse

effects. Inform S/O to report immediately if the patient has feelings of dizziness, drowsiness, headache, abdominal pain,

These are adverse effects and must be monitored so that immediate interventions can be done.

and nausea. Provide small and frequent meals as tolerated. Monitor for hypersensitivity reactions. Maintain proper personal hygiene.

To relieve discomfort and provide nutrition. Basis for discontinuing the drug To prevent further infection

3. PREGABALIN Date Ordered: July 02, 2011 Generic Name: Pregabalin Brand Name: Lyrica Classification: Analgesic Dosage, Route, Frequency: 75mg/cap now then every 12 hours oral

Mode of Action: Binds to calcium channels in CNS tissues which regulate neurotransmitter release; does not bind to opioid receptors. Desired Effect: It was given to the patient to decrease her neuropathic pain. NURSING RESPONSIBILITIES Check for doctors order. Instruct the patient to take medications as directed; not to d/c abruptly. Ensure that the client receives instructions about the appropriate dosage schedule and possible adverse effects. Instruct patient to promptly report unexplained muscle pain, tenderness, or weakness especially if accompanied by malaise or fever. Inform the patient that the drug may cause edema and weight gain Offer support and encouragement. 4. INSULIN GLARGINE Date Ordered: July 03, 2011 Generic Name: Insulin glargine Brand Name: To alleviate anxiety RATIONALE To know the dose, route and frequency of the drug in order to avoid mistakes. Discontinuing the drug abruptly, may cause insomnia, nausea, headache or diarrhea. To enhance patient knowledge about drug therapy and to promote compliance. To identify if the patient have a hypersensitivity to the drug.

Help the patient cope with the drug regimen.

Classification: Anti-diabetic agent Dosage, Route, Frequency: 10 u SQ OD Mode of Action: Insulin glargine is a recombinant human insulin analog that is a long-acting (up to 24-hour duration of action), parenteral blood-glucose-lowering agent. Lantus is produced by recombinant DNA technology utilizing a non-pathogenic laboratory strain of Escherichia coli as the production organism. The primary activity of insulin is regulation of glucose metabolism. Insulin and its analogs lower blood glucose levels by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production. Insulin inhibits lipolysis in the adipocyte, inhibits proteolysis, and enhances protein synthesis. Desired Effect: This was prescribed to the patient to decrease and normalize the increased blood glucose level of the patient. NURSING RESPONSIBILITIES Check for doctors order. RATIONALE To know the dose, route and frequency of the drug in order to Ensure uniform dispersion of insulin suspensions by rolling the vial gently between hands; avoid vigorous shaking. Give maintenance doses SC, rotating injection sites regularly Monitor patients receiving insulin IV carefully. Dosage delivered to the To decrease incidence of lipodystrophy plastic IV infusion sets have been reported to remove 20%80% of the avoid mistakes. To ensure proper distribution of suspensions of insulin

patient will vary Do not give insulin injection concentrated IV

insulin severe anaphylactic reactions can occur.

Ask client to avoid drinking alcohol.

Alcohol is known to affect the the blood sugar levels.

Document interventions done.

Basis for future interventions to be made.

XIII. NURSING CARE PLAN

1. Deficient Fluid Volume r/t intracellular dehydration secondary to DM II 2. Imbalanced nutrition: less than body requirement r/t insulin deficiency 3. Fatigue r/t decreased muscular strength 4. Risk for infection r/t disease condition 5. Disturbed sleep pattern related to urinary urgency and leg pain 6. Acute pain related to injuring agents 7. Activity Intolerance related to insufficient physiologic energy to endure required or desired daily activities

1. NURSING DIAGNOSIS Deficient Fluid Volume related to intracellular dehydration secondary to DM II as manifested by increased urine output, increased pulse rate (96bpm), sweating of the skin,

exhaustion, dry skin and mucous membrane, and a verbalization of Agkakapsut nak, naglaka nak nga mabannug, ken maka-in-inumen nak kanayun (I feel weak, I get tired easily, and I always am thirsty.)

NURSING INFERENCE Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.

NURSING GOAL Short Term: After 3 of NI, patient shall have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications. Long Term: After 2 days of NI, the patient shall have maintained fluid volume at a functional level as evidenced by individually adequate urinary output, moist mucous membrane and stable vital signs.

NURSING INTERVENTIONS 1. Establish rapport. Friendly relationship with patient and to be able to each others concern 2. Take and record vital signs especially the blood pressure (lying/sitting/standing)

To obtain baseline data and to evaluate degree of fluid deficit because postural hypotension is one objective sign of dehydration. 3. Monitor the temperature To monitor changes in temperature 4. Assess skin turgor and mucous membranes for signs of dehydration Dry skin and mucous membranes are signs of dehydration 5. Monitor accurate intake and output, and weigh daily. To determine the extent of dehydration. 6. Encourage the patient to increase fluid intake To replace fluid loss and prevent dehydration 7. Administer IVF as ordered by the Doctor To replace electrolytes and fluid loss 8. Administer anti-pyretic once body temperature is 38.0 C as prescribed by the Doctor. Dehydration may cause an elevation in the body temperature. 9. Bathe using mild soap/cleanser and provide optimal skin care with suitable emollients To maintain skin integrity and prevent excessive dryness.

NURSING EVALUATION Short Term: After 3 of NI, patient will have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications. Long Term:

After 2 days of NI, the patient will have maintained fluid volume at a functional level as evidenced by individually adequate urinary output, moist mucous membrane and stable vital signs.

2. NURSING DIAGNOSIS Imbalanced nutrition: less than body requirement related to insulin deficiency as manifested by poor muscle tone, generalized weakness, increased thirst, increased urination, and polyphagia.

NURSING INFERENCE Due to decrease of lack of insulin in the body, the glucose level continuously rises because glucose cant be utilized without the presence of insulin. Glucose is the source of energy, while insulin is the vehicle to transport glucose to the body tissues. Because of decrease insulin level in the blood stream, the cells starved, leading to alteration of metabolism. The body needs glucose for metabolism; there will be a breakdown of energy reserved from adipose tissue, muscles and liver (glucagons). This will result to weight loss. But the energy breaks down, the glucose level continuously increase because there is less amount of insulin. The body tissues need to be fed, this will lead to polyphagia and polydipsia because the tissue are not being fed and need glucose for metabolism.

NURSING GOAL Short Term:

After 3 of NI, patient shall have verbalized understanding of causative factorswhen known and necessary interventions and identified diabetic client. Long Term: After 1-4 months of NI, the patient shall have demonstrated weight gain toward goal.

NURSING INTERVENTIONS 1. Establish rapport Friendly relationship with patient and to be able to each others concern 2. Ascertain understanding of individual nutritional needs To determine what information to be provided to client/SO 3. Discuss eating habits and encourage diabetic diet as prescribed by the Doctor To achieve health needs of the patient with the proper food diet for is/her disease 4. Document actual weight, do not estimate. Patient may be un aware of their actual weight or weight loss due to estimating weight. 5. Note total daily intake including patterns and time of eating. To reveal changes that should be made in clients dietary intake 6. Consult dietician/physician for further assessment and recommendation regarding food preferences and nutritional support For greater understanding and further assessment of specific foods.

NURSING EVALUATION Short Term:

After 3 of NI, patient will have verbalized understanding of causative factors when known and necessary interventions and identified diabetic client. Long Term: After 1-4 months of NI, the patient will have demonstrated weight gain toward goal.

3. NURSING DIAGNOSIS

Fatigue related to decreased muscular strength as manifested by generalized weakness, increased respiratory rate of 25cpm, presence of non-healing wound on both feet, body weakness, weight loss, limited ROM, and inability to perform ADL.

NURSING INFERENCE Diabetes Mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood resulting from defects in insulin secretion, insulin action, or both. In type 2 diabetes, people have decreased sensitivity to insulin and impaired beta cell functioning resulting in decreased insulin production. Glucose derived from food cannot be stored in the liver thereby remaining into the bloodstream. The beta cells of the islets of Langerhans release glucagon which stimulates the liver to release the stored glucose. After 8 12 hours, the liver forms glucose from the breakdown of non-carbohydrate substances, including amino acids resulting to muscle wasting which results to weakness.

NURSING GOAL Short Term:

After 2-3 of nursing interventions, the patient will be able to identify measures to conserve and increase body energy. Long Term: After 3-5 days of nursing interventions, the patient will be free from signs of fatigue

NURSING INTERVENTIONS 1. Assess response to activity Response to an activity can be evaluated to achieve desired level of tolerance 2. Asses muscle strength of patient and functional level of activity. To determine the level of activity 3. Discuss with patient the need for activity Education may provide motivation to increase activity level even though patient may feel too weak initially 4. Alternate activity with periods of rest/ uninterrupted sleep. Prevents excessive fatigue 5. Monitor pulse, respiration rate and blood pressure before/after activity Indicates physiological levels of tolerance 6. Perform activity slowly with frequent rest periods Tolerance develops by adjusting frequency, duration and intensity until desired activity level is achieved 7. Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and so on.

Interventions should be directed at delaying the onset of fatigue and optimizing muscle efficiency. Symptoms of fatigue are alleviated with rest. Also, patient will be able to accomplish more with a decreased expenditure of energy. 8. Provide adequate ventilation For proper oxygenation 9. Provide comfort and safety To be free from injury 10. Instruct patient to perform deep breathing exercises Promotes relaxation 11. Instruct client to increase Vitamins A, C and D and protein in her diet. For muscle strength and tissue repair 12. Instruct also patient to increase iron in diet To prevent weakness and paleness 13. Administer oxygen as ordered. To provide proper ventilation

NURSING EVALUATION Short-Term: After 2-3 of nursing interventions, the patient shall have been able to identify measures to conserve and increase body energy Long-Term: After 3-5 days of nursing interventions, the patient shall have been free from signs of fatigue

4. NURSING DIAGNOSIS Risk for infection related to disease condition as manifested by inadequate secondary defences e.g decreased haemoglobin of 120 g/dl, decreased RBC of 3.93, and presence of peripheral neuropathy.

NURSING INFERENCE Risk for infection is an increased probability of invasion of pathogenic organisms for a pt. with DM wound is possible in the future. Clients with diabetes are susceptible to infections because of polymorphonuclear leukocyte function, diabetic neuropathies, and vascular insufficiency as a result is a poor glycemic control; thus making a wound to heal slowly because the damaged of the vascular system cannot carry sufficient oxygen, WBC, nutrients, and antibodies to the injured site. Thereby infections increase and enhance possibility of further complications.

NURSING GOAL Short Term: After 4 hours of NPI the risks factors of occurrence of infection will be reduce or control to a manageable level by a clean bed and maintain skin intact. Long Term: After 1-2 weeks of NPI, pt will be free of purulent drainage or erythema and be afebrile

NURSING INTERVENTIONS 1. Establish rapport to obtain patients trust and cooperation 2. Take and record vital signs To obtain baseline data 3. Encourage expression of feelings and anxieties facilitates grieving the loss 4. Observe non verbal cues non verbal cues is more accurate than verbal cues 5. Encourage client to look at/touch affected body part to begin to incorporate changes into body image 6. Encourage verbalization of and role play anticipated conflicts to enhance handling of potential problems 7. encourage to increase fluid intake to prevent dehydration 8. increase Vit. C in the diet to boost immune system and promote collagen formation 9. increase CHON intake for tissue repair 10. provide a safe and quiet environment to promote pts comfort 11. Take Due meds on time To meet the bodys requirements

NURSING EVALUATION Short Term: -After 4 hours of NPI, the pt. shall have identified risks factors of occurrence of infection shall have reduced or controlled to a manageable level by a clean bed and skin intact. Long Term: -After 1-2 weeks of NPI, the patient shall be free of purulent damage or erythema and be febrile

5. NURSING DIAGNOSIS Disturbed sleep pattern related to urinary urgency and leg pain as manifested by three or more nighttime awakenings, frequent urge to urinate at night, dark circles under eyes, aching and burning sensation in the lower extremities with a pain scale of 6/10, and verbalization of Mandyak unay makontento ti turug ko ah, ata makariing nak met ti sakit tuy sakak ken nu mapan nak agkara-isbu. (Im not content with my sleep pattern because I keep on waking up due to pain in my legs and urinary frequency.)

NURSING INFERENCE Polyuria, polydypsia, and pain that radiates to the leg muscles are common manifestations of Diabetes Mellitus. Polydyspia, together with polyuria, leads to the urge to urinate every now and then even at night. Excessive thirst is brought about by cellular dehydration caused by polyuria; while frequent urination is brought about by the inability of

water to be reabsorbed from the renal tubules because of osmotic activity of glucose in the tubules. Also, our patients leg pain recurs several times during the day and even at night. This causes her to feel uncomfortable during the duration of her sleep, thus, her sleeping pattern is disturbed.

NURSING GOAL Short-Term Goal: After 30 min of rendering appropriate nursing interventions, the patient will know, understand, and verbalize willingness to apply interventions to improve sleep pattern and that will promote sense of well-being and feeling rested. Long-Term Goal: After 1-2 weeks of rendering appropriate nursing interventions, the patient will no more experience leg pain.

NURSING INTERVENTIONS 1. Provide a quiet and conducive environment for bedtime (Eg. use of electric fan for better air ventilation, use of comfortable bed sheets and pillows.) To promote comfort and increase quality of sleep. 2. Limit fluid intake in the evening. To reduce need to urinate at nighttime. 3. Administer pain medications (Tramadol) 1 hour before bedtime. To relieve discomfort and take maximum advantage of sedative effect. 4. Encourage participation in regular exercise during the day.

To aid in stress control/release of energy. 5. Recommend midmorning nap. To cope up with sleep disturbance at night. It is preferred to take naps at midmorning because afternoon nap may further disrupt sleep pattern. 6. Advice husband/child of patient to massage or do backrub to the patient at night. This will serve as a bedtime ritual that will promote sleep to the patient.

NURSING EVALUATION Short-Term Goal: After 30 min of rendering appropriate nursing interventions, the patient shall know, understand, and verbalize willingness to apply interventions to improve sleep pattern and that will promote sense of well-being and feeling rested. Long-Term Goal: After 1-2 weeks of rendering appropriate nursing interventions, the patient shall no more experience frequent awakenings during the night and leg pain.

6. NURSING DIAGNOSIS Acute pain related to injuring agents as manifested by verbal report of pain scale of 8/10, altered ability to continue previous activities, changes in sleep patterns, fatigue, and observed behaviors.

NURSING INFERENCE

The patient is experiencing pain because there is decrease uptake of glucose in the muscles, therefore, there will be no fuel of the cells of the affected muscles. The decrease of the glucose was caused by the insulin deficiency. Because of the lack of glucose uptake, lactic acid was use as compensatory mechanism. And lactic acid is known to cause pain.

NURSING GOAL Short-Term Goal After 6-8 hrs of rendering nursing interventions, the patient will verbalize and demonstrate relief or demonstrate appropriate use of therapeutic interventions. Long-Term Goal After 1

NURSING INTERVENTIONS 1. Note gender and age of client current literature suggests that there maybe differences between women and men as to how they perceive or respond to pain and sensitivity is likely to decline as one gets older. 2. Discuss use of nicotine, sugar, caffeine as appropriate because some holistic practitioners believe these items need to be eliminated for the clients diet. 3. Determine issues of secondary gain for the client such as financial, family and work issues because these may interfere the progress in pain management or resolution of situation. 4. Evaluate pain behavior because patient maybe exaggerated on the perception of pain and they believe that caregivers are discounting reports of pain.

5. Ascertain duration of pain problem and the intensity by using pain rating scale to determine the extent of the pain felt. 6. Encourage use of non-pharmacological methods of pain control such as massage on the affected area to relieve pain. 7. Establish pattern of discussing pain for specified length of time to limit focusing on pain. 8. Encourage right brain stimulation with activities such as love, laughter and music to release emotions, enhancing sense of well being. 9. Encourage adequate rest periods to prevent fatigue.

NURSING EVALUATION After 8 hrs. of rendering nursing interventions, the patient verbalized and demonstrated relief or demonstrated appropriate use of therapeutic interventions.

7. NURSING DIAGNOSIS Activity Intolerance related to insufficient physiologic energy to endure or complete required or desired daily activities as manifested by verbal report of weakness or fatigue and altered range of motion

NURSING INFERENCE In Diabetes, glucose is not utilized by the body causing insufficient physiology energy. Because of this, the patient can not tolerate her normal ADL and that working too can cause her fatigue.

NURSING GOAL Short-Term Goal After 3-6 hours of nursing interventions, the patient will regain maximum joint ROM, perform self care activity to tolerance level, patient will state understanding of and willingness to cooperate in maximizing activity level, and perform isometric exercises

Long-Term Goal After 2 days of nursing interventions, the patient shall have acquired sufficient physiologic energy to endure or complete required or desired daily activities.

NURSING INTERVENTIONS 1. Perform active or passive ROM exercises to all extremities every 2 to 4 hours. These exercises foster muscle and joint mobility, and prevent contractures. 2. Encourage active exercise and teach isometric exercises. To help patient maintain or increase muscle tone and joint 3. Provide emotional support and encouragement. To improve patients self concept and motivate patient to perform ADLs. 4. Involve patient in planning and decision making To encourage greater compliance with activity plan. 5. Monitor physiologic responses to increased activity level, including respirations and heart rate. To ensure they return to normal within 2 to 5 minutes after stopping exercise

6. Teach caregivers to assist patient with self care activities in a way that maximizes patients potential. This enables caregivers to participate in patients care and encourages them support patients independence.

NURSING EVALUATION Short-Term Goal After 3-6 hours of nursing interventions, the patient will regain maximum joint ROM, perform self care activity to tolerance level, patient will state understanding of and willingness to cooperate in maximizing activity level, and perform isometric exercises

Long-Term Goal After 2 days of nursing interventions, the patient shall have acquired sufficient physiologic energy to endure or complete required or desired daily activities.

XIV. GENERAL EVALUATION The client was admitted at Mariano Marcos Memorial Hospital and Medical Center on July 1, 2011 with the chief complaints of low back pain and pain in the calf.

Physical assessment of the admitting physician reveals the confirmed presence of puffy eyelids, visible carotid artery pulsations, numbness on both arms, and presence of calf with a pain scale of 8/10. Laboratory procedures done on the patient includes: Complete Blood Count, Blood Chemistry, Urinalysis, CM Microalbumin, and Hemoglobin A1C. Diagnostic procedures were also done to the patient which include: Abdomino-Pelvic X-Ray, Abdominal Ultrasonography, Electrocardiography, and RBS Monitoring. Medical management done on the patient includes Intake and Output Monitoring, Diet therapy (Low Purine Diet, Low salt, low fat, full diet, and Diabetic Diet), and Intravenous therapy (PNSS x 12 hrs for 27-28 gtts/min). Medications were also given to the patient which include: Tramadol, Ciprofloxacin, Pregabalin, and Insulin Glargine. During the assessment, the following problems were identified. (1) Deficient Fluid Volume, (2) Imbalanced nutrition less than body requirements , (3) Fatigue, (4) Risk for infection, (5) Disturbed sleep pattern, (6) Acute pain, and (7) Activity intolerance. Nursing goals were formulated and interventions were applied to the patient. Fortunately, the clients condition was improved upon discharge. The client was discharged on July 3, 2011; 11:05 AM, with the final diagnosis of DM2 Insulin Required Non-Obese Fairly Controlled Peripheral Neuropathy. Treatment procedure and managements were done to her while in the hospital for 2 days. The client went home with an improved health status. Chief complaints upon admission, which are the clients low back pain and calf pain, were corrected. She was prescribed with take home medications, which include the following: Tramadol, Insulin Glargine, and Pregabaline.

On July 4, the client was visited at home. The client is still complaining of calf pain with a pain scale of 4/10. The signs and symptoms of the disease is much less evident. Her activity intolerance is not seen. The client, same is through with her family, is very thankful for the presence of student nurses who looked after her condition. The family of the client is very much happy because even though we do not have any familial connection with them, wherein we can be considered as strangers to them, we are still showing concern for the client and the family as a whole.

TABLE OF CONTENTS PAGE

I. II. III. IV.

Personal Data ----------------------------------------------------------------Anatomy and Physiology of the Endocrine-------------------------------Family Background ----------------------------------------------------------Health History A. Family Health History ---------------------------------------------------B. Past Health History -------------------------------------------------------C. Present Health History ----------------------------------------------------

V.

Developmental Data A. Erick Erickson -------------------------------------------------------------B. Robert Havighurst ----------------------------------------------------------

VI. VII. VIII. IX. X. XI. XII. XIII.

Patterns of Functioning -------------------------------------------------------Levels of Competencies ------------------------------------------------------Physical Assessment -----------------------------------------------------------On-Going Appraisal -----------------------------------------------------------Laboratory Studies and Diagnostic Procedures ----------------------------Medical Management ----------------------------------------------------------Drug Study ----------------------------------------------------------------------Nursing Care Plan ---------------------------------------------------------------

XIV. General Evaluation --------------------------------------------------------------