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NURSING CARE IN Mrs. “S” WITH DIABETES MELLITUS AT DR.

SOETOMO GENERAL HOSPITAL


ON 11TH – 13TH NOVEMBER 2009
BY: GROUP I MIRA UTAMI NINGSIH
NINIK ENDANG S AGUS DIONISIA R.W. DJAWA IRNA SUSIATI KASHMIR WIWIN NURMALANTIKA
HUSNUL MUBAROK
(139015216)
(139015146) (139015151) (139015164) (139015219) (139015226) (139015234) (1390152
35)
FACULTY OF NURSING AIRLANGGA UNIVERSITY SURABAYA 2009
PREFACE
We really grateful to the Most Glorious and the Most Merciful Allah SWT, we can
finished this case report about “Nursing care in Mrs. ‘S’ with chronic diabetes
mellitus at RS. DR. Soetomo on 11th – 13th November 2009” ontime. This paper is
written as a part of process in studying English in nursing science and technolo
gy. Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer who has gen
erously provided us with constructive criticism and suggestions to completed thi
s paper. Special thanks to all of our colleagues in class B 12 who have particip
ated in our seminar discussion about the case in this paper. We aware that still
there are many lack in this paper so we could use some direction and we always
open to your suggestion to make it better. At last, we hope this paper may bring
s much advantages to all of us.
Surabaya, 21st November 2009
Author
2
CONTENTS
Cover...........................................................................
................................................i Preface.......................
................................................................................
................ii Contents.....................................................
...............................................................iii Nursing Care
in Mrs. “S” with Diabetes Mellitus at DR. Soetomo General Hospital, On 11th – 13
th November 2009
A. Assesment....................................................................
..................................1 B. Data Analysis and Nursing Diagnosis......
......................................................6 C. Planning.............
................................................................................
.............9 D. Implementation................................................
.............................................13 E. Evaluation / Discharge Planni
ng..................................................................18
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NURSING CARE IN Mrs.“S” WITH DIABETES MELLITUS AT DR. SOETOMO HOSPITAL, ON 11th
– 13th NOVEMBER 2009
A. ASSESMENT NURSING HISTORY Admission Date No. Reg : 11th Nov 2009 : 10177388 T
ime Medical Dx : 08.56 a.m : Diabetes mellitus + diabetic foot Date of Assesment
: 11th Nov 2009 I. Patient identity
1. Name 2. Age 3. Sex 4. Race 5. Religion 6. Education 7. Occupation 8. Address
: Mrs. “S” : 60 : female : Java, Indonesia : Islam :: Housewife : Lamongan, Kara
ng Anyar
I. History of present illness
1. Chief complain
: shortness of breath
2. Present illness history : patient has a sudden shortness of breath since
an hour before hospitalized but it’s getting better. She had cough, nausea and v
omiting a day ago. She has pain, swollen and redness at right pedis since three
days ago. Feverish a day before hospitalized. She feel faint and weakness. Patie
nt has diabetic mellitus type II since twelve years ago.
I.
Past nursing history
1. History of contagious disease : None 2. Hereditary disease 3. Allergic histor
y
: None : None
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I.
Family health history : Patient said that her family has no contagious disease o
ne of her family member, her aunt also has diabetes mellitus Genogram + +
Explanation: :+ male : female : client : stay together with client +
II.
: pass away
Observation and physical examination Vital Sign: T:37,50C 1. B1: Breathing Compl
ain RR pattern Breathing O2 adm Problem 2. B2: Blood Complain Rhythm CRT JVP Ede
ma Problem : None
5
P: 75x/mnt
RR: 20x/mnt
BP: 100/60 mmHg
: Cough (-), SOB (-), pain (-) : Frequency 20 x/mnt, Rhythm : Regular : wheezing
(-), ronchi (-), secret (-) : (-) : None
: chest pain (-), P = 72 times/minute : regular : 2 second : Normal : (-)
Heart sound : Normal
3. B3: Brain Orientation Awareness GCS Eye Sclera Problem 4. B4: Bladder Complai
n Urine output Others Problem : polyuri : 1000 cc/day smell: normal : + 3000 cc/
day : cateter adm (-) : Altered urinary elimination pattern Risk for deficit flu
id volume 5. B5: Bowel Mouth Abdomen Diit Alvi elimination Peristaltic Others Pr
oblem 6. B6: Bone Joint Activity : Free Back Injury Integuments Turgor Others Pr
oblem : None : pale, acral warm : good : right pedis: wound, swollen, redness, p
ain. Post amputated falanx digit 1 pedis, osteomilitis. : impaired skin integrit
y
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: Person, Time and Place normal : Composmentis : E4 V5 M 6 : Pupil Isochors, Lig
ht reflex (+), eye lens: snoring (+/+). : anemis : Disturbed sensory perception;
visual. Risk for Injury
Conjunctiva : hiperemi (-/-), sub conjunctiva bleeding (-/-) Nerves disturbance:
sensory perceptual; visual
Fluid intake : Oral + 2500cc/day, Parenteral
color: light yellow
: normal : normal : Diit B1 2100 kkal : frequency once a day, consistency: soft
: 15 x/mnt : none : none
7. Endocrine system Complain Prolem : CBS: 288, polyuria, polydipsi : hyperglyce
mia
I. Psychosocial assessment
1. Client perception about his disease : God-struggle 2. Client expression towar
d his/her disease : Quite 3. Year reaction: cooperative 4. Self concept disturba
nce : none
I. Diagnosis test and medical treatment
1. Laboratory:
Hematology 11th Nov 2009 Hb : 10,3 Leukosit: 17.800 Plt: 221.000 BG: 288 BUN: 19
,5 Creatinin: 1,5 SGOT/SGPT: 10/8 2. Radiology: Thorax photo (PA): cardiomegali
Pedis photo: osteomilitis amputated phalanx digit 1 pedis dextra. 3. Therapy IVF
D Pz 14 drops/minute Humolin R 3x4 IU SC Humolin N 4 IU SC malam Ceftazidine 3 x
1gr IV Metronidazole 3 x 500 mg IV Metformin 3 x 500 per oral Wound care
4. Additional data:
Ca: 9 Cl: 101 K: 4,5 Na: 140 Globulin: 4,98 Albumin: 2,8 Bilirubin direct: 0,26
Consult internist: unregulated DM and selulitis pedis (D), osteomilitis Consult
ophthalmologist: OD cataract mature, OS cataract immature
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WEB OF CAUTION DIABETES MELLITUS
Decrease of insulin production (auto immune) Ineffective glucose movement to the
Increase blood glucose Hyperglycem ia Resists the flourishing of WBC Low immune
system Risk for Insulin resistance by liver fat and muscle cell Metabolize fat
&protein to gain energy Uses more energy
Imbalanced nutrition; less than body
Lead to loss of weight Negative calorie effect
Body tries to get rid of the extra sugar in blood Excreting sugar through urine
Prompt urinate
Glucose + amino protein Accumulation of AGE (advance glicosilasi end
Decrease of capability for attacking foreign particles and blood Poor wounding h
ealing Impaired skin integrity Altered urine eliminatio n pattern
Induce unwanted biological
Excess fluid excretion Risk for deficit fluid
Glucose metabolize
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A. DATA ANALYSIS AND NURSING DIAGNOSIS No 1 Data Etiology Decrease of insulin pr
oduction (auto – Patient said that she has had Diabetes mellitus since 12 years
ago. O: – BG: 288 mg/dl Ineffective glucose movement to the cell Increase blood
glucose level Hyperglycemia 2 S:
– Neuron, blood vessel, Kidney, eye lens Causes damage of blood vessel within th
e
Problem hyperglikemi
Fatig ue
S:
Activity intoleranc
immune) Or Insulin resistance by liver, fat and muscle cell
Hyperglycemia Sorbitol + Impaired skin patient said that her redness and pain si
nce three days ago.
fructose
integrity
Osmotic load
Risk for has swollen, foot
resists the flourishing Decrease
fosfoinosida of white blood cells metabolism and signal
Lead blood and fluid into the surrounding tissue Affects the ability of lenses t
o
O: –
Impaired sensory there is a wound at perception;
low immune system
Neuropathy, retinopathy decrease ofnephropathy, capability
right pedis that seems swollen, redness – Leukocyte : 17.800 – Photo pedis: oste
omilitis and
for attacking foreign particles (microorganism etc.) and blood vessel repair
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shows amputated phalanx digit 1 pedis dextra – BG: 288 mg/dl 3 S: – Patient comp
lains about urinate frequently O:

poor wound healing
Hyperglycemia Body tries to get rid of the extra sugar in the blood by excreting
it Polyuria Urine output: + 3000 cc/day through urine Prompt urinate frequently
Excess fluid excretion (carries a large amount of water out of the body along w
ith it) – BG : 288 mg/dl

Risk for deficit fluid volume
4
S: – Patient said that she has blurry vision O: – Eye lens: snoring (+/ +) – Oph
thalmologist examina-tion: OD cataract mature, and OS cataract immature
Hyperglikemia Causes damage of blood vessel within the eye leak blood and fluid
into the surrounding tissues affects the ability of lenses to focus
Disturbed sensory perception; visual
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causes vision problems (blurry vision)
5
S: – Patient said that she has blurry vision O: – Eye lens: snoring (+/ +)

Eye lens snoring Affect the ability of lenses to focus Causes vision problem Ris
k for injury
Risk for Injury
Ophthalmologist examination: OD cataract mature, and OS cataract immature
Nursing Diagnostic
1. Hyperglycemia due to decrease of insulin production (auto immune) or insulin
resistance, signed by BG: 288 mg/dl.
2. Impaired skin integrity due to poor wound healing secondary to hyperglycemia,
signed by patient said that her foot has swollen, redness and pain since three d
ays ago, there is a wound at right pedis that seems swollen, redness, photo pedi
s shows osteomyelitis and amputated phalanx digit 1 pedis dextra.
3. Risk for deficit fluid volume due to excess fluid excretion secondary to
hyperglycemia, signed by patient complains about urinate frequently, polyuri, BG
: 288 mg/dl, urine output: + 3000 cc/day.
4. Disturbed sensory perception; visual due to the decline of lenses ability to
focus,
signed by patient said that she has blurry vision, eye lens: snoring (+/+), OD c
ataract mature, and OS cataract immature.
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5. Risk for injury due to vision problem, signed by patient said that she has bl
urry
vision, eye lens: snoring (+/+), OD cataract mature, and OS cataract immature
12
A. PLANNING Nursing Diagnosis Goal and Objective Nursing Orders
Hyperglycemia due to the decrease of insulin production (auto immune) or insulin
resistance
Goal: After 3 hours of nursing interventions, blood glucose level will be decrea
se and controlled Outcome criteria:

1. Administer insulin therapy regularly as ordered
2. Consult nutritionist to
develop diet planning 3. Administer IVFD
4. Monitor laboratory results:
CBS, aseton, pH, HCO3
5. Teach client about the
BG within normal limit: 120 – 160 mg/dl
importance of keeping diet therapy as it programmed
6. Promote comfortable
– Patient follow the diet therapy
environment to minimize stressor that can induce increase blood glucose level
Impaired skin integrity due to poor wound healing secondary to hyperglycemia
Goal: after 3 days of nursing intervention, shows improvement of skin integrity
Outcome criteria; – Shows skin tissue regeneration – Wound healing
1. Assess wound site for signs of infection such as swelling, redness, pain.
2. Review laboratory results
(Hb/Hct, blood glucose blood and /or wound culture, albumin) to evaluate causati
ve factors or ability to heal 3. Cleanse or irrigate wounds using physiological
solution (e.g. isotonic saline) with
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shows progression – Blood glucose within normal limit – Free of infection sign
syringe or gauze square, avoiding cotton balls or other product that shed fibers
4. Use appropriate barrier
dressing or wound covering to protect wound and surrounding tissue from excoriat
ing secretion/ drainage and to promote wound healing
5. Carefully dress wounds and
stimulate circulation to surrounding areas to assist body’s natural process of r
epair. 6. Maintain a moist environment for wound 7. Practice and instruct client
in scrupulous hand washing clean or sterile technique to reduce incidence of co
ntamination or infection
8. Provide optimum nutrition
appropriate to diet planning (including adequate protein, lipids, calories, trac
e minerals and multivitamins [e.g., A, C, D, E]) to promote skin health/healing
and to maintain general good health
9. Administer/monitor
medication regimen (e.g.,
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antimicrobials, drip infusion into osteomyelitis, subeschar clysis, topical anti
biotics)
Risk for deficit fluid Goal: volume due to excess fluid excretion secondary to h
yperglikemia After 3 days nursing intervention, risk for deficit fluid volume av
oided and demonstrate adequate hydration Outcome criteria:

1. Monitor input and output.
Note urine specific gravity 2. Monitor orthostatic blood pressure changes 3. Wei
gh daily
4. Maintain fluid intake at least
3000 ml / day within cardiac tolerance with oral intake is resumed.
5. Promote comfortable
Vital sign WNL
– CRT 2 second – Balance intake and output – Electrolyte WNL
environment. Cover patient with light sheets to reduce/ replenish trans epiderma
l water loss. Collaborative:
6. Administer fluids as
indicated (e.g normal saline with or without dekstrose) 7. Monitor electrolyte r
esults
Disturbed sensory perception; visual due to the decline of lenses ability to foc
us And
Goal After 3 hours nursing intervention, patient can recognize/compensate for se
nsory impairments Outcome criteria:
1. Note particular vision
problem (e.g., loss of visual field, change in depth perception, double vision,
blindness) that affects client’s ability to perceive
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Risk for injury due to vision problem

Patient demonstrate using resources effectively and appropriately
environment and learn/relearn motor skills
2. Speak to visually impaired
client frequently, especially when entering room/client’s presence to provide au
ditory stimulation and prevent startle reflex.
3. Position objects to take

Patient can Identify/ modify external factors that contribute to alterations in
sensory/perceptu al abilities
advantage of intact visual field, and use eye patch, when needed, to decrease se
nsory confusion when client has loss of vision or, field of vision in one eye. 4
. Supply adequate lighting for reading and activities.
5. Place glasses/contacts
– Be free of injury
where they can be easily found and encourage client to wear corrective lenses du
ring waking hours. 6. Arrange bed, personal articles, and food trays to take adv
antage of functional vision. 7. Maintain bed/chair in lowest position with wheel
s locked 8. properly placing alarms/fire extinguishers
9. Place assistive devices
(e.g., walker, cane, glasses, hearing aid) within reach, make sure call light is
within
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reach and client knows how to operate it.
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A. IMPLEMENTATION Date Time 11-11-09 Number Dx I Implementation Evaluation
– Maintain IVFD PZ 14 drops/minute – Monitoring laboratory: blood glucose, elect
rolyte, Hb, Hct, Albumin, BUN, Creatinin – Teaching client about the importance
of keeping diet as it programmed – Observing vital sign

S: client said that they understand and will keep her diet as it programmed O:

Blood glucose: 264 mg/dl Hb: 10,3 gr% albumin: 2,8
– Client finish her meal appropriate to her diet

Vital sign: T: 36,50C, RR: 20x/mnt, BP: 110/70 mmHg, P: 72x/mnt
Injecting Humolin R 4 IU per SC t.d.s (0712-15)
A: Goal met partially P: Continuing intervention
– Helping and ensuring patient eat her meal appropriate to her II

diet (B1 2100 kal) Injecting Humolin N 4 IU per SC od (0-0-1)

Administering antibiotic : ceftazidine 1gr t.d.s and metronidazole 500 mg IV t.d
.s S: – Client complain about pain, redness and swelling in his right pedis
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– Cleansing and irrigating wound using normal saline,
smearing Garamicyn cream then dressing it with gauze and Bactigras. Keeping asep
tic and sterile technique

– Client said that they will keep sterile technique O:

Vital sign: T: 36,50C, RR: 20x/mnt, BP: 110/70 mmHg, P: 72x/mnt
Teaching client about scrupulous hand washing clean or sterile technique to redu
ce incidence of contamination or infection

III
Leukocyte: 17.800 dressing well, there is no skin regeneration yet
– Wound clean and
– Observing vital sign – Monitoring laboratory result :leukocyte output – Sugges
ting clients to drink at least 2500cc/ day
A: goal not met yet
– Monitoring intake and P: continuing intervention
– Monitoring electrolyte, S: client complain about BUN, creatinin, blood IV,V gl
ucose O: – Intake per oral: 2500 cc, parenteral: 1000 cc – Output urine: 3000 cc
– Vital sign WNL – CRT 2 second

urinate frequently
Blood glucose: 264 mg/dl
– BUN: 19,5, creatinin: 1,5
19

Electrolyte WNL: Ca: 9
Cl: 101, K: 4.5, Na: 140 – Placing alarm near patient and teaching her how to op
erate it – Suggesting client to place glasses or any assistive device within rea
ch where she can easily found. – Ensuring the light is adequate for clients sigh
t

A: Goal met partially P: continuing intervention S: client said that they unders
tand how to compensate the impaired of vision O: – Patient demonstrate using res
ources effectively and appropriately – Patient free of injury A: goal met P: int
ervention stopped
Maintaining client’s bed and chair in lowest position with wheels locked
11-12-09
I
– Injecting Humolin R 4 S: IU per SC t.d.s (0712-15) – Monitoring laboratory: bl
ood glucose, electrolyte, Hb, Hct, Albumin, BUN, Creatinin – Observing vital sig
n – Helping and ensuring patient eat her meal appropriate to her diet (B1 2100 k
al)

O:

Blood glucose: 252 mg/dl
– Client finish her meal appropriate to her diet Vital sign: T: 36,50C, RR: 20x/
mnt, BP: 110/60 mmHg, P: 76x/mnt A: Goal met partially P: Continuing interventio
n
II
– Injecting Humolin N 4
20
IU per SC od (0-0-1)

Administering antibiotic : ceftazidine 1gr t.d.s and metronidazole 500 mg IV t.d
.s S: – Client complain about pain, redness and swelling in his right pedis – Cl
ient said that they will keep sterile technique O:

– Cleansing and irrigating wound using normal saline, smearing Garamicyn cream t
hen dressing it with gauze and Bactigras. Keeping aseptic and sterile technique
– Observing vital sign III
Vital sign: T: 36,50C, RR: 20x/mnt, BP: 110/60 mmHg, P: 76x/mnt
– Wound clean and dressing well, there is no skin regeneration yet

Blood glucose: 252 mg/dl
– Monitoring intake and output – Suggesting clients to drink at least 2500cc/ da
y – Maintaining IVFD 14 drops /minute S: O:
A: goal not met yet P: continuing intervention
– Intake per oral: 2500 cc, parenteral: 1000 cc
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– Output urine: 3000 cc – Vital sign WNL – CRT 2 second

Blood glucose: 252 mg/dl
A: Goal met partially P: continuing intervention 11-13-09 I

Injecting Humolin R 4 S: IU per SC t.d.s (0712-17) O:

Blood glucose: 330 mg/dl
– Monitoring laboratory: blood glucose, electrolyte, Hb, Hct, Albumin, BUN, Crea
tinin – Observing vital sign – Helping and ensuring patient eat her meal appropr
iate to her diet (B1 2100 kal) II – Injecting Humolin N 4 IU per SC od (0-0-1)
– –
– Client finish her meal appropriate to her diet Vital sign: T: 36,50C, RR: 20x/
mnt, BP: 100/60 mmHg, P: 72x/mnt A: Goal not met P: modify intervention. I: admi
nister Humolin R 8 IU per SC t.d.s (07-12-17)
Administering antibiotic : ceftazidine 1gr t.d.s and metronidazole 500 mg IV t.d
.s
S: – Client complain about pain, redness and swelling in his right pedis – Clien
t said that they will keep sterile
22

Cleansing and irrigating wound using normal saline, smearing Garamicyn cream the
n dressing
it with gauze and Bactigras. Keeping aseptic and sterile III technique – Observi
ng vital sign

technique Vital sign: T: 36,50C, RR: 20x/mnt, BP: 100/60 mmHg, P: 72x/mnt – Woun
d clean and dressing well, there is no skin regeneration
– Monitoring intake and output – Suggesting clients to drink at least 2500cc/ da
y – Maintaining IVFD 14 drops /minute O:
yet A: goal not met yet P: continuing intervention S: client complain about urin
ate frequently – Intake per oral: 2500 cc, parenteral: 1000 cc – Output urine: 3
000 cc

T: 36,50C, RR: 20x/mnt, BP: 100/60 mmHg, P: 72x/mnt
– CRT 2 second

Blood glucose: 330 mg/dl
A: Goal met partially P: continuing intervention
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A. EVALUATION / DISCHARGE PLANNING
Item Control
Messages – Control to Policlinic Ophthalmology, cataract division – Control to P
oliclinic DM and Rehabilitation
Medicine
Insulin 4 IU t.d.s before meals Metformin 500 mg t.d.s
Dressing
Cleansing and irrigating wound using normal saline, smearing Garamicyn cream the
n dressing it with gauze and Bactigras. Keeping aseptic and sterile technique. D
one by nurse in homecare
Diet Nutrition
B1 2100 kal At 06.00 : 4 spoon rice + side dishes At 10.00 : 1 boiled potatoes A
t 12.00 : rice + fruit (apple, papaya) At 17.00 : 4 spoon rice + fruit At 20.00
: 2 slice of bread Water at least 3000 cc/day
Others
Wearing suitable pad Exercise appropriate to client’s ablity Keeping the diet th
erapy
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