NURSING CARE STUDY: DIABETES MELLITUS

NAME: NORFAZILAH BINTI AHMAD IBRAHIM I/C NUMBER: 841029-01-6222 POST BASIC GERONTOLOGY

ACKNOWLEDGEMENTS

I would like to take this opportunity to express my appreciation and thanks to my lecturers, Puan Rodhiah binti Mohd Yasin for the guidance and cooperation given for me to complete the study Diabetes Mellitus. I also would like to thanks to Pengarah Kolej Kejururawatan, Melaka, and the librarian for permitting me to use the facilities in finishing the case of my study. My appreciation and sincere thanks to all of those individuals at 2B (Hospital Jasin, Melaka) who were very helpful and supportive. Besides that, I would like to give my special thanks to all my course mates, who always motivate and help me to do some references together and sharing their knowledge and ideas.

LITERATURE REVIEW
Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia).

Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) is characterized by a lack of insulin production.

Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) is caused by

the bodys ineffective use of insulin. It often results from excess body weight and physical inactivity.

(WHO) http://www.who.int/topics/diabetes_mellitus/en/

Diabetes is a disease in which the body doesn't produce or properly use insulin. Insulin is a

hormone produced in the pancreas, an organ near the stomach. Insulin is needed to turn sugar

and other food into energy. When you have diabetes, your body either doesnt make enough

insulin or cant use its own insulin as well as it should, or both. This causes sugars to build up

too high in your blood.

Diabetes mellitus is defined as a fasting blood glucose of 126 milligrams per deciliter (mg/dL)

or more. Pre-diabetes is a condition in which blood glucose levels are higher than normal

but not yet diabetic. People with pre-diabetes are at increased risk for developing type 2

diabetes, heart disease and stroke, and have one of these conditions:

y y y

impaired fasting glucose (100 to 125 mg/dL) impaired glucose tolerance (fasting glucose less than 126 mg/dL and a glucose level between 140 and 199 mg/dL two hours after taking an oral glucose tolerance test)

AMERICAN HEART ASSOCIATION http://www.americanheart.org/presenter.jhtml?identifier=4546

Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin to meet its needs.
THE MERCK MANUALS ONLINE MEDICAL LIBRARY (http://www.merckmanuals.com/home/sec13/ch165/ch165a.html)

Diabetes is a chronic disease that has no cure. Diabetes is a disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy needed for daily life. The cause of diabetes is a mystery, although both genetics and environment appear to play roles.
MALAYSIAN DIABETES ASSOCIATION (http://www.diabetes.org.my/article.php?aid=5)

CONTENT

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TOPIC

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1.TOPIC

1.1. WHAT IS DIABETES MELLITUS? DIABETES MELLITUS (DM) is metabolic syndrome characterized by hyperglycaemia that results from an impairment of insulin action and/or secretion. Type I or Insulin-Dependent Diabetes Mellitus Is the result of pancreatic islet cell destruction and a total deficit of circulating insulin. When beta cells are destroyed, insulin is no longer produced This disorder is characterized by hyperglycaemia (elevated blood glucose levels), a breakdown of body fats and proteins, and the development of ketosis (an accumulation of ketone bodies produced during the oxidation of fatty acids) Type II or Non-Insulin-Dependent Diabetes Is the result from insulin resistance with a defect in compensatory insulin secretion. Is a condition of fasting hyperglycaemia that occurs despite the availability of endogenous insulin (Porth, 2002). It can occur at any age, but it is usually seen in middle age and older people.

1.2. WHAT CAUSES OF DIABETES MELLITUS? DM

1.3. RISK FACTORS? 1.4. SIGN AND SYMPTOMS OF DM? Type I - symptomatic hyperglycemia or DKA. y oplasma glucose glucosuria osmotic diuresis (Polyuria) dehydration

(polydipsia /weight loss). y y blurred vision, fatigue, nausea fungal and bacterial - vaginal candidiasis

Type II frequency routine medical examination - asymptomatic y Glucose molecules accumulate in the circulating blood, resulting in hyperglycaemia.

1.5. WHAT ARE THE EFFECTS OF DM? Progressive complications  Hyperglycaemia   Diabetic ketoasidosis Hyperglycaemic hyperosmolar nonketotic coma

 Hypoglycaemia Late complications y Neurologic

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 Somatic neuropathies  Paresthesias, pain, loss of cutaneous sensation, loss of fine motor control.  Visceral neuropathies  Sweating dysfunction, pupillary constriction, fixed heard rate, constipation, diarrhoea, incomplete bladder emptying, sexuality dysfunction y Sensory  Diabetic retinopathy, cataracts, glaucoma y Cardiovascular  Orthostatic hypotension,  Accelerated atherosclerosis  Coronary artery disease  Cerebrovascular disease (stroke)  Peripheral vascular disease  Blood viscosity and platelet disorder y Renal  Hypertension, albuminuria, oedema, chronic renal failure y Musculoskeletal  Joint contractures y Integumentary  Foot ulcers, gangrene of the feet, atrophic changes. y Immune system  Impaired healing, chronic skin infections, periodontal disease, urinary tract infections, lung infections, vaginitis
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1.6. HOW IS A DIABETIC DIAGNOSE? Oral Glucose Tolerance Test(OGTT)- the client is given a specified amount of glucose (either 75g or 100g) as a lemon flavour or glucola liquid after fasting blood and urine samples are taking. Fasting Blood Sugar(FBS)- this test often ordered, especially if the client is experiencing symptoms of hyperglycaemia and hypoglycaemia. Glycosylated haemoglobin(c) HbA1C- this test determines the average blood glucose level over approximately the previous 2-3months. When the glucose is elevated or control of glucose is erratic, glucose attaches to the haemoglobin molecule and remains attached for the life of the haemoglobin, which is about 120 days. Urine glucose and ketone levels- these are not as accurate in monitoring changes in blood glucose as blood levels. The presence of glucose in the urine indicates hyperglycaemia. Ketonuria (the presence of ketones in the urine) occur with the breakdown of fats and is an indicator of DKA; however, fat breakdown and ketonuria also occur in stages of less than normal nutrition. Serum cholesterol and triglyceride levels- these are indicator of artherosclerosis and an increased risk of cardiovascular impairments. Serum electrolytes- levels are measured in clients who have DKA or HHs to determine imbalances.

1.7. MANAGEMENT?

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ABSTRACT
This nursing care study is about a male patient Mohd Salleh @Yahya bin Nikmat who is 69 years old he lives in Taman Damai, Bemban, Jasin, Melaka. He was admitted to the Jasin Hospital on 04 Mei 2011 after he was complaining of dizziness and abdominal discomfort.

He retired as a Post Officer, and was very active and hardworking but he was so depressed after the death of his wife on the 7th Mac 2011. He was hospitalised for eleven days. Since diabetes is a chronic disease which occurs when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycemia) and no cure to this.

The insulin theraphy was introduced to him in order to stabilized his blood sugar level and later when he was discharged he currently be treated as an outpatient. A frequent routine medical examination is recommended.

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ASSESSMENT

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2.0 ASSESSMENT 2.1. BIOGRAPHIC DATA

NAME: MOHD SALLEH @ YAHYA BIN NIKMAT I/C NUMBER: 421121-04-5113 AGE: 69 YEARS OLD SEX: MALE RACE: MALAY RELIGION: ISLAM ADDRESS: 4957, JALAN RIA, TMN DAMAI, BEMBAN, 70000 TEL.NUMBER: 017-2054944 MARITIAL STATUS: WIDOW

2.2. INTRODUCTION: MR S
Mr S is a 3rd son in the sibling of 6th. His parents passed away due to old age disease. All siblings are still alive accept the eldest brother, Mr I, was died at the age 70 years old due
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to diabetes mellitus. His eldest sister Mrs H was in KL, 72 years old. His two sisters, Mrs J, 67 years old and Mrs K, 62 years old were staying in Melaka and his brother Mr L, 60 years old was at Johor Bahru. His sister Mrs J had a hypertension and diabetes and now she is under treatment. Mr S was studying until primary six. Worked as a Post Officer about 30 years and he had retired at the age 55 years old. Married with Mrs B and have seven children, four daughters and three sons. Their eldest daughter is 49 years old, married and as a housewife. She had three children. Second son is 44 years old, married and had four children. Work as a teacher and he had diabetes. Their third son 42 years old, married and had five children. Work as Postmen. Fourth daughter 39 years old, married and had two children. Work as Staff Nurse and had a hypertension. Fifth son is 37 years old, married and had three children. Work as a Clerk. Sixth daughter is 28years old, married and had two children. Work as Project Manager. Lastly, their seventh son is 27years old and not married yet. Work as Lorry Driver. (see Figure 1: Mr S family tree). According to his daughter Mrs A, Mr S is an active and hardworking person. After retired he always do some chores and likes to do gardening and farming. He always said to his daughter that he felt he was in healthy and energetic; no need to go to clinic for check-up. According to his daughter, since 3 month ago, he looked very sad and unhappy because his wife passed away at 07.03.2011 due to DM. He always be pensive and become quite, sometimes he cried when he remember his wife and felt lonely and lost. He is very secretive with his children but sometimes he shared his sadness with his friends.

2.3. SOCIAL AND ENVIRONMENT ASSESSMENT

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Currently, Mr S lives in his single storey house,four bedrooms, and two bathroom with a squatting and sitting toilet. There is no hand railing in his home. His house is near the mosque and grocery shop. Mr S stayed with his eldest daughter who is housewife and look after him. Besides that, he also shared the home with his son-in-law and three grandchildren. His economic is stable. He got some money from his children about RM500 per month. He also got pension money about RM800 per month. Mr S has a good social interaction with neighbour and friend. Always go to the mosque for prayig and attended religious activities.

2.4. COMMUNICATION ASSESSMENT

Mr S can only understand and communicate in Bahasa Melayu and simple English. He was good in communication and answer the entire question relevant and appropriately. However, his eyesight has developed some changes about 4-5years ago because he claimed having problems when reading newspapers. He wore spectacle when he was reading.

2.5. DIETARY ASSESSMENT

Mr S likes to eat all types of food. He did not like to eat outside food but he always eats his wife cook. He does not have a problem with swallowing. Breakfast roti canai/nasi lemak/fried bihun/rice/bread/coffee. Lunch rice/chicken curry/seafood/meat/vegetable. Tea tea/milo/coffee/nescafe/local cakes/fried banana/biscuit. Dinner rice/chicken curry/seafood/meat/vegetable. Supper coffee/milk/biscuit.

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2.6. HABIT ASSESSMENT

2.6.1 CIGARETTE SMOKING : Mr S used to smoke 1pack of cigarette per day. He smokes since he was 20 years old until now. Lately, he has stopped smoking because he was hospitalized. 2.6.2 ALCOHOLIC BEVERAGES CONSUMPTION: He does not drink alcoholic beverages.

2.7. SLEEP AND REST ASSESSMENT

Mr S has a good sleep and have enough rest. He used to sleep at 11.00pm till 6.00am in the morning. After that he was going to the mosque for Subuh prayer. However, since he was admitted in the hospital he sleeping was disturbed.

2.8. INCONTINENCE ASSESSMENT

Mr S dont have a urinary or bowel problem.

2.9. PAST ILLNESS HISTORY

In 2006, Mr S has done for haji screening. Since then he was diagnosed DM and Hypertension. He was under treatment for a few months only and he missed the TCA and the
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treatment for almost 5 years. He always said to his daughter that he felt he was in healthy and energetic condition and no need to go to clinic for check-up. On the other hand, he has never undergone any forms of surgical intervention and hospital admission till now. He also does not have any known allergies to neither drug nor food.

2.10. HISTORY OF PRESENT ILLNESS

2.10.1 ADMISSION HISTORY:On 04/05/2011 at 9.00am, Mr S was complaint of dizziness, on and off abdominal discomfort at home and bilateral lower limb edema. He went to Klinik Kesihatan Daerah Jasin for check-up. B/P: 135/71mmhg, RBS: 21.4mmol/L, urine for ketone: 1+. Doctor gave the instruction, if possible for admission and for further management. At 02.52pm, Mr S went to OPD of Jasin Hospital. G/M was HI. Inj Actrapid 12 stat was given. Mr S was informed to be admitted to Wad 2B.

2.10.3 MR S PROGRESS IN WARD? 04/05/2011 In ward, Mr S look alert and comfortable. He still has mild pedal oedema bilaterally. Vital sign was taken, B/P: 121/82mmHg, Pulse: 64/min, SPO: 98% R/A, Temperature: 37C, G/M: 18.9mmol/L. Dr Zawani planned to give S/C Humulin R 10 TDS,
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S/C Humulin N 10 ON, continue anti-hypertension drug: T. Captopril 12.5mg TDS, T. Amlodipine 5mg OD, withhold T. Metformin, G/M QID, vital sign monitoring every 4hourly. 05/05/2011@9.50am: Mr S was seen by Dr Amudra. She planned an asked pharmacist to collect back all metformin which he consumed from other sources, advised family

members to buy G/M, S/C Humulin R 12 TDS, if G/M >10 to add 2 and if G/M >14 to add 4, S/C Humulin N 14 ON. At 12.00pm: Seen by Diabetic Nurse (M/A M. Hafiz bin Sulaiman). Diabetic counselling was given to Mr S. Then he was referred to Counsellor about complication of diabetic, blood glucose control, insulin injection, and self-monitoring blood glucose. At 4.00pm: Mr S was conscious but have mild lethargic. RIB. He complained of giddiness, cold and clammy. He took one glass of sweet drink and two pieces of bread. Vital sign was taken, B/P: 93/51mmHg, Pulse: 42/min, SPO: 95% R/A, G/M: 3.1mmol/L. Dr Zawani was noted and ordered to give I/V Dextrose 5%/24hrs. At 4.45pm: B/P 119/65mmHg, Pulse: 51/min, SPO:98% R/A, G/M: 13.2mmol/L. At 05.45pm: Seen by Pharmacist, Miss Fan Siew Kim. She was consulted Mr Ss daughter about hypoglycaemia attack. Mr Ss daughter claimed that shell buy glucometer herself. All the medications was taken by pharmacist and plans for switch the dosage of insulin to BD once Mr S discharge. 06/05/2011@4.10pm: Seen by Dietician. Mr S claimed giddiness and not feeling well. Planned to review Mr S Tuesday or as outpatient if discharge and ward staff to indent low soft diabetic diet for Mr S. 07/05/2011@8.00pm: Mr S still had lethargic and giddiness. His condition was very labile during the first three days. His temperature fluctuates ranging 39.1C 37.5C. T.PCM 1gm was given and IVD 3 Normal Saline in progress. Besides that, his blood sugar level was not

controlled, ranging from 14.0 23.8mmol/L. G/M QID and insulin therapy was introduced in order to stabilize Mr Ss blood sugar level. (Refer appendix: Blood Sugar Chart). However,

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there were two incidents, where Mr S had hypoglycaemia episode. This related to loss of appetite. 09/05/2011: Mr S still complained of headache on and off and redness at right hand, cough, nausea and vomiting for four times. Dr Zawani was diagnosed as thrombophlebitis at dorsum right hand. She was ordered I/V Cloxacillin 1mg QID, T. PCM 1gm QID, T. Maxalon 10mg BD and off IVD. 11/05/2011@9.30am: Mr S still having cough. He claimed that he had chest pain and SOB. During the examination by Dr Amudha, he had crepts at lower site of lung and the implication: Carers for hospitalization due to pneumonia TRO pulmonary embolism. She planned to give I/V Tazosin 4.5gm stat & TDS, repeat FBC/BUSE/ESR, chest X-ray, D-dimer and off OHA. At 01.25pm: D-dimer result was positive 1.8. Dr Amudha planned for urgent CTPA at Malacca General Hospital: if positive finding to admit Malacca General Hospital but if normal finding to send back to Jasin. Dr Amudha was spoken to Dr Roza (Radiologist specialist) and planned to refer Mr S to Malacca General Hospital. 03.30pm: Mr S gone to Malacca General Hospital accompanied by SN Norazean and PPK Walid.

2.11. PHYSICAL EXAMINATION

1. GENERAL CONDITION: Mr S was alert and conscious but mild lethargic. Can do his activities daily by himself. 2. VITAL PARAMETERS 3. HAIR: Grey, clean and tidy 4. EYES :USED A GLASSES, hypermetropia 5. EARS : no discharge and no hearing problem 6. MOUTH AND THROAT: clean, used a dentures, no cough and sputum 7. NECK: no lymph nodes enlargement/tender 8. SKIN :redness at right hand 9. NAILS:clean and short 10. CHEST&HEART: C/O chest pain& SOB
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11. LUNGS : Crept+ 12. ABDOMEN: soft and tender 13. GENITALIA :no enlarged prostate/hernias 14. PERIPHERAL VASCULAR 15. NEUROLOGICAL

2.12. FUNCTIONAL ASSESSMENT

1. SELF-CARE ASSESSMENT
This nursing care study adopted from Barthel Index in assessing how well Mr S was able to care for himself. (Refer appendix: Barthel Index). After a session of interview with Mr S, Barthel Index revealed that Mr Ss ADL was mid dependent.

2. PSYCHOLOGICAL ASSESSMENT
a) COGNITIVE FUNCTIONING Cognitive assessment such as the ECAQ and the Mini-mental State Examination shows that(Refer appendix: ECAQ & MMSE) b) AFFECTIVE FUNCTIONING Mr S has demonstrated sign and symptoms of depression such as loss of interest to do. Depression scale show that (Refer appendix: Depression scale)

3. SOCIAL ASSESSMENT
In this context, Mr S is taken care by his daughter. It is essential to assess his daughter for carer assessment (Refer appendix: The Caregiver Strain Index)

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NURSING CARE PLAN

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3.NURSING CARE PLAN: NURSING PROCESS APPROACH

1) NURSING DIAGNOSA#1: Risk for impaired skin integrity related to diabetic process GOAL: Patient will experience intact skin status, and skin will be free of irritation or trauma especially at feet and lower extremities INTERVENTION: 1) Conduct baselines and on-going assessment on the feet including: - Musculoskeletal assessment that includes foot and ankle joint range of motion, bone abnormalities (bunions, hammertoes, overlapping digits), gait patterns, and abnormal wear patterns on shoes. - Neurologic assessment that includes sensations of touch and position, pain and temperature. - Vascular examination that includes assessment of lower extremity pulses, capillary refill, colour and temperature of skin, lesions and oedema. - Hydration status, including dryness or excessive perspiration. - Lesions, fissures between toes, corns, calluses, cracks in the skin, plantar warts, ingrown or overgrown toenails, redness, blisters, cellulitis or gangrene. : Identifies potential circulatory insufficiency that may lead to skin breakdown as perfusion of oxygen and nutrients are reduced
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2) Teach foot hygiene. Wash the foot daily with lukewarm water and mild hand soap; pat dry, and dry well between the toes. Apply a very thin coat of lubricating cream if dryness is present (but not between the toes) : proper hygiene decreases the chance of infection. Temperature receptors may be impaired, so the water should always be tested before use. 3) Conduct foot care teaching sessions as often as necessary. - Use proper shoes y Shoe that allow to inch of toe room are best; there should be room for toes to spread out and wiggle. The lining and inside stitching should be smooth and the insole soft. y Do not wear open-toed shoes, sandals, high heels, or thongs; they increase the risk of trauma. y Buy shoes late in the afternoon, when feet are at their largest; always buy shoes that feel comfortable and do not need to be broken in. y Check the shoes before each wearing for foreign objects, wrinkled insoles and cracks that might cause lesions. - Care of toenails y Cut the toenails after washing, when they are softer and easier to trim. y Cut the nails straight across with a clipper and smooth edges and corners with and emery board. y Do not use razor blades to trim the toenails. - Check the feet daily for red areas, cuts, blisters, corns, calluses, or cracks in the skin. Check between the toes for cracks or reddened area. - Check the skin of the feet for dry or damp areas. - Use a mirror to check each sole and the back of each heel. - If you unable to inspect the feet daily, be sure that someone else does so. - Do not sit with the legs crossed at the knees or ankles. 4) Instruct patient/family to avoid use of over-the-counter products for calluses and corns. : Some commercial products contain harsh chemicals that may injure alreadycompromised skin. 5) Discuss the importance of maintaining blood glucose levels through prescribed diet, medication and exercise. : Hyperglycaemia promotes the growth of microorganisms.

EVALUATIONS

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1) Patient will have intact skin that is free from redness, irritation, bruises and rashes.

1) NURSING DIAGNOSA#2: Deficient knowledge related to self-administration of insulin GOAL: patient will obtain appropriate knowledge and able to maintain safety of selfadministration of insulin. INTERVENTION: 1) Instruct patient the importance to take insulin 2) Instruct patient in administration of insulin; name, action, peak, levels, dosage, how to store, preparation and filling syringe, rotation sites, and procedure to inject insulin. EVALUATIONS:

1) NURSING DIAGNOSA#3: Risk for injury related to decreased temperature sensation, decreased tactile sensation and lack of awareness of environmental dangers. GOAL: i) Patient will experience no injury, trauma or fall. ii) Patient will avoid injury to extremities from environmental hazards INTERVENTION: 1) Assess patients mobility and stability status, muscular weakness, cognitive limitations, balance, or gait difficulties, and factors related to disease process. : Provides information for baseline data to establish plan care. Falls are common in elderly patient and may result from muscle weakness and skeletal support dysfunction, as well as decreased tactile and sensory status. Claudication may result at difference times dependent on the weather, incline of walking, or rapidity with which the patient ambulates. 2) Assess patients sensory deficits of visual, tactile, perceptual, and kinaesthetic changes. : May contribute to falls and other trauma because of insensitivity to pain, temperature extremities or visual acuity. 3) Asses patients mentation, changes, in mental status, vertigo, syncope, and penchant for wandering. : Provide information regarding potential for falls and trauma. 4) Assess environment for safety hazards. Ensure lighting, pathways are cleared, beds are in lowest position and locked, hazardous object out of reach, and ability to summon help, within reach. : Safety hazard predispose patient to falls or serious injury. By ensuring that hazardous objects are removed, patients environment is made safer.
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5) Provide night light as needed and ensure that pathways are clear, and floor is dry and not slippery. : Prevents bumping into objects or stumbling and falling. 6) Assist with ambulation as needed. : Promotes safety and prevents falls if patient is too weak or impaired to ambulate alone. 7) Stay with patient if complaints of faintness or dizziness. : Reduces anxiety and potential injury from fall if patient dose faint 8) Apply alarm system to bed or chair to alert caregivers that patient has wandered outside of safe limitations. : provide patient the opportunity to ambulate and wander about a safe distance rather than use restrains or other confinement method, yet maintaining a safe environment 9) Instruct patient regarding need for extreme caution when caring for wounds or burns cause by disease process complications. : Diabetic patient have poor wound healing that may take much longer than normal. Elderly patient usually have fragile skin that can easily be traumatized 10) Instruct patient/family regarding medication effects and side effects of medications currently being taken, and regarding potential for causing injury. : Promotes understanding of effect that medication have on well-being or that medications can predispose patient to injury or trauma. EVALUATIONS: 1) 2) 3) 4) Patient will have safe environment maintained with absence of safety hazards. Patient will have no incident of falls or injury from dangerous objects. Patient will be able to ambulate and wander about in a safe environment. Patient/family will be able to maintain safety with medication administration and home environmental safety 5) Patient/family will be able to accurately verbalize understanding of disease process as to how it affects safety within the environment.

1) NURSING DIAGNOSA#1: a) b) OBJ: INTERVENTION: EVALUATIONS:

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CONCLUSION

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REFERENCING

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APPENDIX

1) FAMILY TREE

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Mr Ss father

Mr Ss mother

Mr I Died at the age of 70yrs DM

Mrs H 72yrs

Mrs J 67yrs HPT & DM

Mrs K 62yrs

Mr L 60yrs

Mr. S 69yrs Patient Uncontrolled DM

Mrs. N 62yrs Died on 07.03.2011 DM-amputation both leg since 5years ago & all Right finger since Feb 2011.

Mrs. A 49yrs Housewife Married 3 child

Mr. B 44yrs Teacher Married 4 child DM

Mr. C 42yrs Postman Married 5child

Mrs. D 39yrs Staff nurse Married 2child HPT

Mr. E 37yrs Clerk Married 3child

Mrs. F Mr. G 28yrs 27yrs Project manager Driver Married Married 2child

2) INVESTIGATIONS & FINDINGS (X-RAY) - Diperihilar Haziness

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ECG

3) LABORATORY INVESTIGATION FINDINGS DATE FBC: - HB - TW - PLATELET BUSE: - UREA - SODIUM - POTASSIUM - CHLORIDE - CREATININE FBS URINALYSIS: - GLUCOSE - KETONES - SG - PH LIPID PROFILE - CHOL - LDL - HDL - TRIGLYCERIDES URINE ACETONE ABG: - PH - PCO - PO D-DIMER CE: - AST - LDH - CK ESR 04/05/11 15.2mmol/L 7.61mmol/L 201mmol/L 8.3mmol/L 132.8mmol/L 4.770mmol/L 92.8mmol/L 117mmol/L 9.0mmol/L 56mmol/L Negative 1.015mmol/L 5 4.75mmol/L 3.21mmol/L 1.11mmol/L Negative 7.332mmhg 46.1mmhg 34.6mmhg Positive 1.8ug/ml 26.08ul/L 555ul/L 178ul/L 64mm fall 1st hour

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4) BLOOD SUGAR PROFILE DATE/TIME BLOOD SUGAR PRE-BF BLOOD SUGAR PRELUNCH BLOOD SUGAR POST LUNCH BLOOD SUGAR PRE DINNER BLOOD SUGAR PRE BED REMARKS/ SIGNATURE

5) I/O CHART 6) INTRAVENOUS FLUID THERAPY REGIMENT DATE/TIME TYPE OF I/V SOLUTION

AMOUNT

7) FEEDING REGIMENT ENTERAL FEEDING CHART DATE/TIME TYPES OF FEEDING

AMOUNT

ORAL FEEDING CHART DATE/TIME

TYPES OF FEEDING

AMOUNT

8) ELDERLY COGNITIVE ASSESSMENT QUESTIONNAIRE-ECAQ 9) MMSE 10) BARTHEL INDEX 11) THE CAREGIVE STRAIN INDEX www.hartfordign.org 12) NORTON SCALE 13) ROM EXERCISE 14) TECHNIQUES OF TRANSFERRING & LIFTING 15) DRUG REFFERENCES NAME OF ACTIONS OF INDICATIONS SIDE NURSING DRUG DRUG EFFECT/ INTERVENTION
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ADVERSE REACTION

16) DRUG CHART NAME OF MEDICINE

INSTRUCTION & INDICATION OF MEDICINE

SIDE EFFECTS

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