A GRAND CASE PRESENTATION 2011

BSN 4F Mrs. Lacro

Introduction
Diabetes Mellitus is a group of heterogeneous disorder characterized by elevated levels of glucose in the blood, or hyperglycemia. Normally, a certain amount of glucose circulates in the blood. This glucose formed in the liver from ingested food. Insulin, a hormone produced by the pancreas , controls the level of glucose in the body by regulating the production and storage of glucose. In Diabetes, the bodys ability to respond to insulin may decrease or the pancreas may stop producing insulin entirely. This leads to hyperglycemia which may result in acute metabolic complications. Long-term Hyperglycemia may contribute to chronic microvascular complications (kidney and eye disease) and neuropathic complications (diseases of the nerves). Diabetes is also associated with an increase occurrence of macrovascular disease including myocardial infarction, strokes, and peripheral vascular disease.

Introduction
CLINICAL CHARACTERISTICS x Onset any age, Usually over 30 years x Usually Obese at diagnosis x Etiology includes Obesity Heredity Environmental Factors x No islet cell antibodies x Decrease in endogenous insulin or increased with insulin resistance x Majority can control blood glucose through weight loss if obese. x Oral hypoglycemic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful.

Introduction

RISK FACTORS

x Age ( Insulin resistance tends to increase with age of over 65) x Obesity x Family History x Ethnic group

Introduction

TRIAD OF SYMPTOMS

POLYDIPSIA

POLYPHAGIA

POLYURIA

Introduction

TRIAD OF TREATMENT

MEDICATIONS

EXERCISE

DIET

Nursing Health History

PATIENT PROFILE
NAME: D.S.M. ADDRESS: Taguig, Metro Manila AGE: 58 Y/O SEX: Female MARITAL STATUS: Married OCCUPATION: Housewife DATE OF BIRTH: December 08, 1953 PLACE OF BIRTH: Bicol NATIONALITY: Filipino RELIGION: Roman Catholic DATE OF ADMISSION: August 31, 2011 DIAGNOSIS: Uncontolled DM; Uncontrolled Hypertension; Closed Comminuted Fracture of the Distal 3rd Fibula of the Right Ankle /Foot CHIEF COMPLAINT: Right Ankle Swelling; Hypertension

Nursing Health History

HISTORY OF PRESENT ILLNESS This is a history of a 58-year-old full-time housewife, mother of 4 and a grand mother of 2 kids with a diagnosis of uncontrolled Dm. hypertension and closed complete comminuted undisplaced distal 3rd fibula fracture. Five days prior to admission, patient accidentally slipped and fell on her right ankle. Initially noting discomfort, patient took Mefenamic acid to allay the pain, did some ice compression to reduce the swelling and even consulted a manghihilot. A day after the incident, pain and swelling are still present and patient stated that she started to feel nauseated. Her blood pressure which was taken by her daughter reached up to 150/100 mmHg. Persistent swelling and pain prompted her to go for a consultation and in August 31, 2011, patient was admitted to Airforce General Hospital. Several laboratory and diagnostic exams have been made and

Nursing Health History

PAST MEDICAL HISTORY
In 2005, patient was diagnosed to have uncontrolled type II diabetes and hypertension. She stated that during her teen age years and growing up in the province, her favorite viand is always this ripe and sweet mango coming from their tree. She states that can eat consume a kilo of that in just one sitting. She is also fond of drinking Coke every meal. She was prescribed to take Metformin, Glimeperide and Amlodipine. These medications also served as her maintenance. Patient does not regularly monitor her blood pressure as well as her blood glucose despite of the fact that her previous doctor advised her to do so, due to managing all the house hold chores, according to her. Past illnesses includes measles and chicken pox during her younger years. Patient could not recall whether she had received immunizations in the past.

Nursing Health History

FAMILY GENOGRAM OF ILLNESS
FATHER (deceased)
HPN; ASTHMA MOTHER HPN; DM; SKIN PROBLEMS

ELDEST BROTHER HPN; DM: ASTHMA

D.S.M. DM; HPN

MIDDLE CHILD SKIN PROBLEM; HPN

YOUNGEST CHILD ASTHMA

Gordons Functional Assessment

HEALTH- PERCEPTION AND HEALTH MANAGEMENT PATTERN

The patient perceives herself as a shy type and a serious lady. Her daily routine of performing different household chores such as cleaning, doing the laundry, taking care of her 2 grand children and managing their mini-store served as her daily dose of exercise. According to her, maintaining a clean environment makes her feel more relaxed. She is also aware about her diagnosis and prognosis and she stated that she will try to comply with regards to her treatment regimens.

Gordons Functional Assessment

NUTRITIONAL AND METABOLIC PATTERN
Patient is currently on DM diet of 1800 kcal divided into 3 meals. She states that prior to her hospitalization, she has no control with regards to the food that she eats specifically with rice even if she is aware about her diabetes and hypertension. She eats 3 meals a day and usually takes 3 cups of coffee per day. She only eats specific vegetables and does not really care much with ampalaya or bitter melon. Her appetite was a bit affected by her hospitalization specially with her present condition. She loss 3lbs, from 163lbs to 160lbs. She is taking vitamin C and vitamin B complex for her nutritional supplement.

Gordons Functional Assessment

NUTRITIONAL AND METABOLIC PATTERN
TIME 09.08.2011 DIET

BREAKFAST ( 08:00 A.M)

Cup of Coffee, 1 Slice of Bread with Cheese, Glass of Water

Cup of Rice, Fried Fish and Vegetables, 1 Bottle of Water 1 Small of Lugaw Cup of Rice, Broiled Chicken and Soup

LUNCH ( 12:00 PM)

SNACK (04:00 PM) DINNER (08:00 PM)

Gordons Functional Assessment

ELIMINATION METABOLIC PATTERN With regards to her elimination and metabolic pattern prior to hospitalization, patient stated that waking up in the middle of the night just to urinate usually bothers her. At the moment, she is using a pad since she has difficulty with ambulating due to pain caused by post-op procedure. A yellow-orange color of urine was noted in her pad at the time of the assessment in moderate amount which was obtained thru the use of a weighing scale. As to her bowel movement, patient has no problem with defecation prior to hospitalization and stated that she usually defecate only once a day. At the moment, patient admitted that she is having trouble now with her bowel movement and she has not had any for almost 3 days, 2 days after her confinement and the day after her surgery.

Gordons Functional Assessment

ACTIVITY EXERCISE PATTERN As mentioned earlier, patient is a full-time housewife, mother of 4 and a grandmother to 2 grand kids, her daily household chores serves as her exercise but stated that on very few occassions, she and her husband would go out for an early 30-minute of walking. She believes that exercise is very important for promoting blood circulation and keeps your body healthy. SLEEP REST PATTERN

She usually has 6-7 hours of sleep per day and does not take a nap in the afternoon. She has no problem with sleeping but the only thing that bothers her is when she has to get up in the middle of the night to urinate. She usually wakes up twice usually in the wee hour. She feels very much rested after having even 6 hours of sleep only.

Gordons Functional Assessment

COGNITIVE PERCEPTUAL PATTERN
The patient has some slight visual problems but is able to read newsprint with the aid of her reading glasses. She has no problems with memory lapses. Patient is able to follow instructions all through out the assessment.

ROLE RELATIONSHIP PATTERN

Patient stated that she is very lucky to have a loving and supportive husband and they have been married for almost 34 years. She stated that her family is very close to each other to the point that their married children with their kids and spouses still lives with them. She is enjoying her role as a full-time housewife, mother and grand mother.

Gordons Functional Assessment

SEXUALITY AND REPRODUCTIVE PATTERN Patient stated that she and her husband are not that sexually active anymore. She never took any contraceptives but admitted that after her youngest child was born, she had undergone ligation. She is G4P4. COPING AND STRESS TOLERANCE PATTERN

Financial problem is one of her biggest stressor and her present health condition as well but she always tries to keep her positive outlook in life and she considers prayer as her best weapon to help her face all the endeavours coming along her way.
VALUE BELIEF PATTERN Patient and her family is a devout Roman Catholic and regularly attend Sunday mass.

Non-modifiable Factors age sex genetics

Modifiable Factors Diet Obesity Stress Lifestyle

Pathophysiology
Polyphagia Blood Clot Polydipsia

Beta cells cant keep up the increased demand for insulin Increased Insulin resistance/ Impaired insulin secretion

Occlusion of artery
Blood viscosity / Elevated BP

( DM type II develops)

Coronary artery flow

Decreased cellular uptake of glucose

Poor Circulation Poor wound healing Infection Inadequate Blood supply in the heart

Blue: Present Manifestations Red: Further complications Black: Worst possible complications

Hyperglycemia

Osmotic diuresis

Destruction of myocardial tissue (MI) DEATH

Polyuria

Wet Gangrene

Cellular Dehydration

Paresthesia

Necrosis

Coma Hyperglycemic Hyperosmolar non ketotic Syndrome

Hyponatremia

Osmolarity occurs

ICF shifts to ECF

Physical Assessment
CATEGORY
General Appearance

WHAT TO ASSESS
Body built Posture and Gait Hygiene and Grooming Body odor Signs of distress Mood Speech Temperature Pulse Rate Respiratory Rate Blood Pressure

ACTUAL FINDINGS
Obese Coordinated, slouched Clean and neat No unpleasant odor No signs of distress Cooperative Understandable 36.5C 88 bpm 19cpm 150/100mmHg

Vital Signs

Physical Assessment

Skin

Color Symmetry Edema Skin lesion Moisture Temperature Skin turgor

Nail curvature Texture Nailbed color Surrounding tissue Capillary refill time

Brown Uniform No Edema Abrasions, flat nevi Dry Uniform Good

Convex 160 Smooth Pallor Intact Less than 3 seconds

Nails

Physical Assessment

Nose Pharynx

External nose Nasal cavity Uvula Oropharynx Tonsils Gag reflex Lips Teeth Gums Tongue Palate

Symmetric, uniform in color Patent, septum in midline In midline Pinkish Pinkish Intact Symmetrical, movable With dentures Pinkish, moist Pinkish, midline, movable Light pink, smooth

Mouth

Physical Assessment
Neck Muscles Movement Range of motion Muscle strength Lymph nodes Trachea Thyroid gland Carotid pulse Jugular veins Breathing pattern Coastal angle Shape and symmetry Spinal alignment Skin Respiratory excursion Breath sounds Percussion Equal in size Coordinated Full Equal Not palpable In midline Not visible Symmetric pulse Not visible Effortless Less than 90 degrees Symmetrical Aligned Smooth Full Clear Resonant

Chest and lungs

Physical Assessment
Heart Abdomen Precordium Heart sounds Skin integrity Contour Symmetry Bowel sounds Percussion Palpation Muscle size Muscle tone Muscle strength Bones Joints Range of motion Pulsations S1 louder than S2 in apex Visible scars Rounded Symmetrical Normoctive Tympanic Relaxed Unequal (noted on lower extremities) Atony R foot Unequal (noted on lower extremities) Tenderness, swelling R foot Tenderness, swelling R foot Limited (noted on lower extremities)

Back and extremities

Laboratory and Diagnostic Studies

Diagnostic Test And Description A urinalysis is a group of manual and/or automated qualitative and semi-quantitative tests performed on a urine sample. A routine urinalysis usually includes the following tests: color, transparency, specific gravity, pH, protein, glucose, ketones, blood, bilirubin, nitrite, urobilinogen, and leukocyte esterase. Some laboratories include a microscopic of urinary sediment with all routine urinalysis tests. If not, it is customary to perform the microscopic exam, if transparency, glucose, protein, blood, nitrite, or leukocyte esteraseis abnormal. Indication and Contraindication * For General health screening to detect renal and metabolic diseases For diagnosis of diseases or disorders of the kidneys or urinary tract For monitoring of patients with diabetes In addition, quantita-tive urinalysis tests may be performed to help diagnose many specific disorders, such as endocrine diseases, bladder cancer, osteoporosis, and porphyrias (a group of disorders caused by chemical imbalance). Quantitative analysis often requires the use of a timed urine sample. The urinary microalbumin test measures the rate of albumin excretion in the urine using laboratory tests. This test is used to monitor the kidney function of persons with diabetes mellitus. In diabetics, the excretion of greater than 200 g/mL albumin is predictive of impending kidney disease. Client Preparation And Post Procedure Instruction
Pretest: * Identify the patient before providing services. * Ask the patient if he/she had intense athletic training or heavy physical work before the test, as these activities may cause small amounts of blood to appear in the urine. * Women who require a urinalysis during menstruation should insert a fresh tampon before providing a urine sample. * Ask the patient if he/she has taken any drugs prior to the test. Over two dozen drugs are known to interfere with various chemical urinalysis tests. These include ascorbic acid, chlorpromazine,L-dopa, nitrofurantoin (Macrodantin, Furadantin),penicillin, phenazopyridine (Pyridium) ,rifampin (Rifadin) and tolbutamide * Patient should not take any preservatives prior to the test.There are preservatives that are used to prevent loss of glucose and cells may affect biochemical test results. Midstream clean collection is acceptable in most situations, but the specimen should be examined within two hours of collection. To collect a sample using the clean-catch method: Females should use a clean cotton ball moistened with lukewarm water (or antiseptic wipes provided with collection kits) to cleanse the external genital area before collecting a urine sample. To prevent contamination with menstrual blood, vaginal discharge, or germs from the external genitalia, they should release some urine before beginning to collect the sample. Males should use a piece of clean cotton moistened with lukewarm water or antiseptic wipes to cleanse the head of the penis and the urethral meatus (opening). Uncircumcised males should draw back the foreskin. After the area has been thoroughly cleansed, they should use the midstream void method to collect the sample. For infants, a parent or health care worker should cleanse the baby's outer genitalia and surrounding skin. A sterile collection bag should be attached to the child's genital area and left in place until he or she has urinated. It is important to not touch the inside of the bag, and to remove it as soon as a specimen has been obtained. If urine for culture is to be collected from an indwelling catheter, it should be aspirated (removed by suction) from the line using a syringe and not removed from the bag in order to avoid contamination. Post-test: The patient may return to normal activities after collecting the sample and may start taking any medications that were discontinued before the test.

Normal Findings *Color: Pale yellow to amber

Actual Findings Dark yellow orange Hazy

Clinical Significance Abnormal color are due to the medications that the patient are presently taking and maybe due to lack of hydration. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. Elevation in specific gravity also occurs with glycosuria (e.g. diabetes mellitus or IV glucose administration), proteinuria, IV contrast, urine contamination, LMW dextran solutions (colloid) The most common cause of acidic urine is a lack of hydration. When the body does not have enough water, it will pass urine that has a higher concentration of waste materials and a lower concentration of water. This causes the urine to be darker in color. Indicates absence of hematuria. Indicates absence of pyuria. Squamous epithelial cells from the skin surface or from the outer urethra can appear in urine. They represent possible contamination of the specimen with skin bacteria. Bacteria are sometimes common in urine specimens because of the abundant normal microbial flora of the vagina in the female and the the external urethral meatus in both sexes and because of their ability to rapidly multiply in urine standing at room temperature. Common crystals are sometime seen even in healthy patients include calcium oxalate, triple phosphate crystals and amorphous phosphates. Mucus threads have no clinical significance since they come from the terminal urethra or vagina This is a common finding in urine since the entire urine system is filled with mucus.

*Turbidity:Clear to slightly hazy *Specific Gravity 1.015-1.025 *pH 4.5-8.0 *Red Blood Cells: Negative or rare *White Blood Cells: Negative or Rare *Epithelial Cells:Few *Bacteria: Negative

1.030

8.2 (acidic) 0 1 / hpf

2-3 / hpf

Few

None

*Crystals: None
*Mucous Threads: Few *Albumin: None *Amorphous Urate: None to Rare

None
Many

Negative Rare

Normal kidney function. Amorphous urates (Na, K, Mg, or Ca salts) tend to form in acidic urine.

Laboratory and Diagnostic Studies

Diagnostic Test And Description
Hematology tests = the diagnostic tests of the blood and its constituent parts. Complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute. A major portion of the complete blood count is the measure of the concentration of white blood cells, red blood cells, and platelets in the blood.
Indication and Contraindication

Client Preparation and Post Procedure Instruction

Pretest: Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Patient Teaching: Inform the patient this test can assist in evaluating theamount of hemoglobin in the blood to assist in diagnosis and monitor therapy. Obtain a history of the patient's complaints, including a list of knownallergens, especially allergies or sensitivities to latex. Obtain a history of the patient's cardiovascular, gastrointestinal, hematopoietic, hepatobiliary, immune, and respiratory systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures. Note any recent procedures that can interfere with test results. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals Review the procedure with the patient. Address concerns about pain and explain that there may be some discomfort during the venipuncture. Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. There are no food, fluid, or medication restrictions unless by medical direction.
Post-test: A report of the results will be sent to the requesting HCP, who will discuss the results with the patient. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed.

Normal Findiings
Hemoglobin: Female: 123157g/L

Actual Findings

Clinical Significance
Patient has normal level of hemoglobin and hematocrit which indicates functional transportation of 02 from the lungs to body Tissues

Used to diagnose and manage numerous diseases. It can reflect problems with fluid volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood cells. It can reflect acute or chronic infection, allergies, and problems with clotting.

147g/L

Hematocrit: 0.35-0.47

0.45x109 /L

Leukocyte:4.5 -11 x 109/L

12.5 x 109/L

Normal value of leukocyte indicates no infection present.

Neutrophils:0. 55-0.65

0.58

Normal value of neutrophils indicates no infection present.

Lymphocytes: 0.25-0.35

0.35

Normal value of lymphocytes indicates no infection or anemia.

Thrombocytes : 130-400 X 109/L .

209x109/L

Normal value of lymphocytes indicates no infection or anemia.

Laboratory and Diagnostic Studies

Drug Study
Generic Name GLIMEPE RIDE Classificatio n Antidiabetic Agent DOSAGE: 20mg/tab OD BB Brand Name Arya Action Blood glucose Lowering Through stimulation of insulin release from pancreas and insulin sensitivity at receptor sites; reduction of basal hepatic Glucose secreation; ineffective if patient lacks Functioning beta cells. Indication Adjunct to diet and exercise in type II Diabetics whose Hyperglycemi a cannot be controlled by diet and exercise alone; in combination with insulin for type II diabetics withsecondary failure to oral Sulfonylureas Contraindication Type I diabetesmellitus, Diabetic ketoacidosis With or without coma, treat this conditions with insulin. History of hypersensitivity reactions to glimepiride Or other sulfonylureas. Serious renal or hepatic dysfunction; dialysis patients; pregnancy and lactation. Adverse Reaction Oral sulfonyl as may have increased risk Of Cardiovascular Morbidity When compared with patients treated with diet alone, dizziness, allergic Skin reactions, porphyria, cutanea tarda, photosensitivity and blurred vision. Nursing Consideration Assess for allergies prior to start of therapy. Assess for potential interactions with other prescriptions, OTC medications, or herbal products that the patient may be taking. Assess for hypoglycemic reactions that can occur soon after meals; hypoglycemic reactions; hyperglycemic reactions. Assess the results of laboratory test, therapeutic effectiveness and adverse Response at regular intervals during the course of therapy. Patients Teachings Instruct patient to check for symptoms of cholestatic jaundice; dark urine. Yellow sclera, pruritus, physician should be notified if these occurs. >Teach patient to use capillary blood glucose test or chemstrip 3x a day. Inform patient thatsymptom of hypo/hyper glycemia and what to do each. >Instruct patient that drug must be taken daily: Caution patient To avoid OTC medications unless approved by a physician. Instruct patient That all food included in diet plan must be eaten to prevent hypoglycemia.

Drug Study
Generic Name Mefenamic Acid Classification: Nonsteroidal Antiinflamma tory drug (NSAID) Dosage: 500mg/tab PR Brand Name Biostan Action Aspirin like drug that has analgesic, antipyretic and Antiinflammat ory activities. These Activities appear to be due to its ability to Inhibit Cyclooxygen se and also Antagonize certain effects Of prostaglandins. Indication Relief of pain Including muscular, rheumatic, traumatic, dental or post operative and Postpartum pain, headache, migraine, fever And dysmenorrheal, pain from Rheumatoid arthritis. Contraindication Hypersensitivity, active ulceration or chronic inflammation of either the upper or lower gastrointestinal tract. Of diarrhea or skin rash appears, the drug should be stopped at once. Blood disorders, poor platelet function. Kidney or liver impairment. Adverse Reaction Gastrointestinal discomfort, diarrhea or constipation, gas pain, nausea, vomiting, drowsiness and dizziness have been observed. Peptic ulceration, nervousness, Visual disturbances, skin rash, urticaria, Occasional Allergic Glomeruloneph ritis. Nursing Consideration Assess patients pain before therapy: location, duration, precipitating and alleviating factors. Monitor for possible drug induced adverse reactions, Gastrointestinal discomfort, diarrhea, constipation, gas pain, nausea, and vomiting, peptic ulceration. Patients Teachings Instruct patient Not to take drug For more than 7 days. Advice patient To immediately report persistence failure to relieve pain. Tell patient to report occurrences of drug induced adverse reactions.

Drug Study
Generic Name ATORVAS TATIN Classificatio n: (Antilipidem ic) DOSAGE: 20mg/tab OD HS Brand Name Lipitor Action Selectively inhibits HMGCoA reductase, which converts HMGCoA to Mevalonat e, a precursor of steroids. Lowers cholesterol and lipoprotein levels. Indication Hypercholest erolemia: Adjunct to diet to reduce elevated total cholesterol, LDL, CHOLESTE ROLApoliproprotein B. and Triglycerides levels. Contraindication Hypersensitivity to any component of this medication. Active liver disease or unexplained persistent elevations of serum transaminases exceeding 3x the upper linit normal. Or who are breastfeeding, or of childbearing potential who are not using adequate contraceptive measures. Adverse Reaction GI disturbances, headache, maylgia, asthenia, insomnia, angioneuritic edema, muscle cramps, myositis, myopathy, cholestatic jaundice. Nursing Consideration Document Indications for theraphy, onset and duration od illness, other medications taken. Monitor cholesterol, tgrigylcerides and liver function tests before theraphy and reassess regularly. LDL and VLDL should be watched closely; if increased drug should be discontinued. Assess nutrition and dietary habits: weight, exercise habits, lifestyle and complete nutritional analysis. Assess for muscle pain, tenderness, obtain CPKif these occur, drug may need to be discontinued. Patients Teachings Inform patient that compliance is needed for positive results to occur. Do not double the dose. Treatment may take several years. Teach patient that risk factors should be decreased: high fat diet, smoking, alcohol consumption, sedentary lifestyle. Advise patient to report adverse reaction. Diarrhea, abdominal or epigastric pain, nausea, vomiting, chills, fever, sore throat, muscle pain and weakness. Advice patient that follow up laboratory monitoring will be necessary during treatment.

Drug Study
Generic Name CEFOTA XIME Classificati On: Cephalosp Orin antibiotic DOSAGE: 1gn/IVP q8 Brand Name Ceptax Action Inhibits cell wall sybthesis, rendering cell wall Osmotivall y unstable, leading to cell death. Indication Treatment of infections caused by susceptible Microorganis ms especially serious and life threatening infections. Brain abscess, gonorrhea, intensive care, lyme diasease, meningitis, peritonitis, pneumonia, septicemia, surgical infection and typhoid fever. Contraindication Hypersensitivity to cephalosporins. Possibility of cross sensitivity in patients who have shown allergy to penicillin. Intramuscular administration in conditions with impaired homeostasis and severe sepsis. Adverse Reaction GI effects: Anorexia,diarrhe a, nausea, vomiting,abdomi nal cramps, and colitis. Hematologic changes: Transient neutropenia, Granulocytopeni a, leucopenia, andAgranulocyto penia.
Nursing Consideration Assess patients previous sensitivity reaction to penicillin or other cephalosporin is common. Assess patient for signs and symptoms of infections before and during treatment: fever, earache, characteristics, of wounds, sputum, urine and stool. Assess for allergic reaction and anaphylaxis: rash, urticaria, pruritis and chills. Assess for renal function before and drug therapy: urine output, BUN and creatinine. Monitor hematologic, electrolyte and hepatic status, if patient is on long term therapy Hematologic bleeding: ecchymosis, bleeding gums, hematuria, stool guaiac. Assess for possible superinfection: perineal itching, fever, malaise, redness, pain, swelling, drainage and rash.

Patients Teachings Instruct patient To take medication as prescribed by length of time ordered even if he feels better. teach patient to report sore throat, bruising, bleeding and joint pain, this may indicate blood dyscrasias. Advise patient to watch out for perineal itching fever, malaise, redness, pain, swelling, drainage, rash, diarrhea and change of cough. Advice patient to reports bloody mucoid diarrhea which may indicate pseudo membranous colitis.

Drug Study
Generic Name METFOR MIN Classificati on: Antidiabet ic agent DOSAGE: 500mg/tab BID PC Brand Name Diafat Action Decreases intestinal absorption of glucose and hepatic glucose production. It alsoimproves insulin sensitivity. Indication Non insulin dependent Diabetes mellitus, particularly overweight patients of blood sugar levels cannot be controlled adequately nu diet, physical exercise and weight reduction alone. And in cases where there is primary or secondary resistance to sulfonylurea. Contraindication Renal impairment, cardiac failure, diabetic coma, severe liver disorder, pancreatitis, alcoholisms, those on slimming diets, shock, severe lung disorders, very poor blood circulation Adverse Reaction Urinary Tract infection, headache, back pain, Hyperglycemi a, fatigue, sinusitis, diarrhea, viral infection, and weight gain. Nursing Consideration
Assess for hyperglycemic and hypoglycemic reactions. Monitor glucose and glycosylated Hgb levels before therapy and regularly during therapy to monitor drug effectiveness. > Assess renal status before therapy and reassess at least annually. monitor for possible drug interactions. > closely monitor patients in times of stress such as infection, surgery and trauma. Assess for lactic acidosis: malaise, myalgia, and abdominal distress.. Assess for liver function.

Patients Teachings
Educate patient on signs and symptoms of \ hypo/hyperglycemi a and proper action regarding each condition. Remind patient that diabetes is a lifelong illness: drugs may control symptoms but will not cure the condition. Teach patient to use capillary blood glucose test or chemstrip regularly. Advice patient to take drug in the morning to prevent hypoglycemia at night. >Tell patient to consume all the food included in the plan to prevent hypoglycemia.

Drug Study
Generic Name SILYMARIN Classification: Antioxidant DOSAGE: 1tab TID Brand Name Milk thistle Action Milk thistle provides hepatocellular protection by stabilizing hepatic cell membranes. It alters the structure of the outer cell membrane of thehepatocytes in such a way as to prevent the penetration of the liver toxins into interior of the cell. The stimulation effect on nucleolar polymerase A results in an increase in ribosomal protein synthesis, and thus increase the regenerative ability of the liver and the formation of new hepatocytes. Other actions include interruption of enterohepatic recirculation of toxins and regeneration of damaged hepatocytes. Indication Silymarin is primarily indicated in conditions like Hepatitis, Hepatitis A infection, Jaundice, and can also be given in adjunctive therapy as an alternative drug of choice in Cirrhosis. Contraindication People with allergies to plants in the aster family. Primary biliary cirrhosis, Hypersensitivity to any component of product. Adverse Reaction Some adverse reactions are stomach upset, headache, and itching. Nursing Consideration Monitor consistency and frequency of bowel movements Emphasiz e the need for blood tests to monitor liver function tests Patients Teaching Avoid alcohol and follow diet consistent with the liver or gall bladder diseasebeing Treated.

Drug Study
Generic Name TELMISAR TAN Classificatio n: Angiotensin II receptor antagonist DOSAGE: 80mg/tab OD in AM Brand Name Micardis Action Blocks the Vasoconstricti ve and aldosterone secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues. Indication Treatment of HPN. Contraindication Hypersensitivity, pregnancy and lactation. Biliary obstructive disorders, severe hepatic or renal impairment. Adverse Reaction Diarrhea and angioedema , sinusitis, pharyngitis, upper respiratory tract infection and back pain. Nursing Consideration Assess patients condition before therapy and regularly thereafter to monitor drug effectiveness. Assess for heart failure because in patients whose renal function depends on rennin angiotensin aldosterone system, use of ACE inhibitors and Angiotensin receptor antagonist. Obtain baseline renal and liver status before therapy. Assess for obstructive jaundice because drug level may elevate due to inability to excrete drug, Monitor serum electrolyte levels. Patients Teaching Instruct patient to comply with dosage schedule even if feeling better. Tell patient that drug may cause light headedness, dizziness and fainting. > Instruct patient with heart failure to report decreased urine output. Teach patient he importance of diet control, exercise, smoking cessation and stress reduction in the management of hypertension. Advice patient to use contraceptive while taking this drug.

Problem Prioritization
Problem 1.Acute pain related to post operative surgery (ORIF) as evidenced by pain scale of 8/10. 2. Ineffective Tissue Perfusion related to increased blood viscosity asevidenced By verbalization of headache by the pt. 3. Ineffective therapeutic regimen management related to excessive demands made by the family and knowledge deficits 4. Risk for Infection Priority HIGH (Life Threatening) Explanation Pain is an unpleasant sensation ranging from mild to discomfort to agonized distress. Any alteration in clients comfort should be highly prioritized since this could hinder clients performance of daily activities and daily tasks. Un managed pain may lead to clients anxiety which can be a barrier for a nurse to establish cooperation from the client.

MEDIUM (Health Threatening)

Sufficient tissue perfusion and oxygenation are vital for all metabolic processes in cells and the major influencing factor of tissue repair and resistance to infectious organisms. The concept of tissue perfusion has been alike with blood flow, oxygen delivery or a combination of flow and nutritional supply including that of oxygen. Ineffective tissue perfusion is one of the priorities of a nurse to her patient. Tissue perfusion belongs to the category circulation. A good circulation of blood in the human body helps to delivered nutrients and oxygen to the capillaries. Effective therapeutic regimen management is essential for attaining health goals that are aimed at treating present infirmities and sustain body at a functional level. Integrating healthy lifestyle and prescribed therapy to daily living is essential in attaining this goal.

LOW (Needs Minimal Attention)

LOW (Needs Minimal Attention) LOW (Needs Minimal Attention)

Infection is the invasion of the body by harmful microorganism that causes different infirmities. Knowing that the client is at risk, the nurse should focus on preventing occurrences of infection by promoting a safe environment for the client. The nurse should also eliminate modifiable factors that increase risk for infection.

5. Risk for self care deficits.

It is vital to stress to the client the importance of self care to manage the present medical condition and be able to mange symptoms of the disease. Self acre deficit is a factor that could precipitate development of illnesses.

Actual Diagnoses

Acute pain R/T to post operative surgery (ORIF) as evidenced by pain scale of 8/10. Ineffective Tissue Perfusion related to increased blood viscosity as evidenced by verbalization of headache by the client. Ineffective therapeutic regimen management related to excessive demands made by the family and knowledge deficits

Actual Diagnoses
Cues S: Namamaga at masakit pa rin tong paa ko as stated by the patient O: *(+)Facial Grimace when attempting to move in bed *(+)Guarding behavior *(+)Restlesness *(+)Protective gestures *Redness of the skin on the affected side and swelling *Right foot secured with elastic bandage, elevated with 2 Pillows *Pain scale of 8/10 Nursing Diagnosis Acute pain R/T to post operative Surgery (ORIF) as Evidenced by pain scale of 8/10. Scientific Explanation Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damaged or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a Duration of less than 6 months. Planning Selected Intervention Independent: *Establish Rapport with the patient *Monitor and record V/S *Monitor and record I&O *Document location And intensity of pain *Keep the affected part elevated by using a pillow *Provide general comfort measures like Stress management (therapeutic communication with the patient, diversional activities) *Help with ambulation and positioning in bed *Perform ROM if indicated *Encourage adequate rest periods. Dependent: *Administer analgesics As prescribed.

Implemented Intervention
Independent: *Established rapport with the patient *Monitored & Recorded V/S *Monitored & recorded I& O *Documented location & intensity of pain *Kept the affected part elevated with the use of 2 pillows *Provided general comfort measures like stress management thru therapeutic communication & promotion of divertional activities *Assisted patient in positioning in bed *Encouraged adequate rest periods Dependent: *Administered analgesics as prescribed

Rationale
*To gain patients trust and cooperation *Serves as indicators of circulatory status and adequacy of perfusion *To monitor pt. hydration status & check if the pt has nutritional imbalance and elimination problems *Aids in evaluating the need for & effectiveness of interventions. *Lessens edema formative by enhancing venous return, reduces muscle fatigue & skin pressures. *Refocuses attention & promotes relaxation *To provide comfort & helps to promote skin integrity *Reduces muscle spasms *To prevent fatigue *To allay pain and reduces discomfort

Evaluation GOAL: Met The patients pain level decreases from pain scale of 8/10 to 6/10

After 8 hours of nursing intervent ions, the patient will verbalize decreased or relieved of pain.

Actual Diagnoses
Cues S: Masakit ang ulo ko, pati na din sa batok, as verbalized by the patient. O: > CBG: 252 mg/dl BP: 150/100 mm hg Skin moist & pale in color (+) facial grimace Increase Sweating noted Complaints of headache Nursing Diagnosis Ineffective Tissue Perfusion related to increased blood viscosity as evidenced by verbalization of headache by the client. Scientific Explanation It is defined as the adequacy of blood flow through the small vessels of the extremities to maintain tissue. Planning After 8 hours of thorough nursing intervention -The patients CBG and blood pressure will be within normal range. -Pt. will demonstrate behaviors or Lifestyle changes to improve circulation. Selected Intervention Establish rapport. Evaluate CBG & vital signs, Noting changes in bloodpressure, heart rate, and respiratoryrate Measure capillary refill. Monitor & record I&0 Position the client. Evaluate the head of bed to at least 45 degrees. Encourage relaxation techniques. Dependent: Administer medication as ordered Implemented Intervention Established rapport. Evaluated and monitored CBC and vital signs, especially BP. Measured capillary refill. Monitored & recorded I& 0. Assisted Pt. and elevated head of the bed to 45. Encourage Relaxation techniques. Due medications given as ordered. (amlodipine) Rationale To gain Pts trust & cooperation. To monitor & provide comparison with current findings. To assess blood circulation in the peripheral areas. To monitor patients hydration status. To promote circulation and venous drainage. To decrease oxygen demand. To normalize blood pressure & blood glucose level with the aid of pharmacological regimen. Evaluation Goal: Partially Met Pts latest CBG result is 225 mg/ dl & BP of 140/90.

Actual Diagnoses
Cues S: Kung minsan nakakalimutan kong uminom ng gamot sa dami ng trabho sa bahay as verbalized by the patient O: V/S taken upon admission: BP = 150/100mmHg CBG = 232 mg/dl (+) Weakness Nursing Diagnosis Ineffective therapeutic regimen management related to excessive demands made by the family and knowledge deficits Scientific Explanation Pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactor y for meeting specific health goals Planning After 8 hours of nursing interventions , the patient will verbalized and demonstrate willingness to participate in problem solving of factors interfering with integration of therapeutic regimens. Selected Intervention *Establish rapport with patient *Assess patients knowledge and understanding of condition and treatment needs *Review complexity of treatment regimen such as number of expected tasks like taking medications, blood pressure monitoring, CBG monitoring, and doctors appointment *Use of therapeutic communication skills *Encourage patient to make a list of activities and make a schedule for all of it *Encourage patient and S/O to verbalize concerns Implemented Intervention *Established rapport with the patient *Assessed the patients knowledge and understanding of conditions and treatment needs *Reviewed complexity of treatment regimen such as number of expected tasks regarding medications, blood pressure, CBG monitoring, and doctors appointment *Used therapeutic communication skills *Encouraged patient to make a list of activities and make a schedule for all of it Rationale *To gain patients trust and cooperation *The patient can make informed decisions about managing selfcare * These factors are often involved in lack of participation of the treatment plan *To assist patient with regards to problem solving and decision making *In order for the patient not to forget treatment regimens and to monitor and compare the results to the previous one Evaluation Goal: Partially met After 8 hours of nursing interventions, the patient verbalized willingness & demonstrated participation in the treatment regimen

Potential Diagnoses

Risk for infection related to presence of surgical incision secondary to uncontrolled DM type 2 Risk for self-care deficit r/t pain secondary to post-op surgery

Potential Diagnoses
Cues O: *Right ankle swelling post op surgery *With Jshaped incision along the posterior border of the R fibula, with surrounding skin intact *Blood glucose level: 252mg/dl *Increased Leukocyte: 12.5 x10/L Nursing Diagnosis Risk for infection related to presence of surgical incision secondary to uncontrolle d DM type 2 Scientific Explanation Risk for infection is defined as at a state of increased risk for being invaded by pathogenic organisms. Diabetes mellitus impedes healing in many ways thus increasing the patients risk for infection. Planning After 2 days of nursing interventions , the client will remain free from infection as manifested by: *Temperatur e within 36.5C to 37.4C *Absence of exudates or purulent drainage on the surgical incision site *Active wound healing Selected Intervention Independent *Monitor vital signs *Note risk factors for occurrence of infection *Assess and document skin conditions around incision site, noting presence of blood, exudates, foul smelling secretions *Note signs and symptoms of sepsis; fever, chills, diaphoresis, altered LOC, positive blood cultures *Stress proper hand hygiene by all care givers between therapies/clients *Maintain sterile technique for all invasive procedures *Keep the dressing of the incision site clean, dry and intact *Educate patient and SO in determining cardinal signs of infection *Monitor vital signs *Assess report of pain Dependent: *Administer prophylactic antibiotic if prescribed. Implemented Intervention Independent: *Monitored vital signs *Noted risk factors for occurrence of infection *Assessed and document skin conditions around incision site, noting presence of blood, exudates, foul smelling secretions *Noted signs and symptoms of sepsis; fever, chills, diaphoresis, altered LOC, positive blood cultures *Stressed proper hand hygiene by all care givers between therapies/client *Maintained sterile technique for all invasive procedures *Kept the dressing of the incision site clean, dry and intact *Educate patient and SO in determining cardinal signs of infection *Monitored vital signs *Assessed report of pain Dependent: *Administered Cefotaxime 1gm/ IVP q 8 Rationale Temperature, pulse, and respiration increase in response to infection. *To assess causative or contributing factors *To identify infectious factors that may lead to skin infection *Early detection of infection facilitates early intervention *As first-line defense against health care associated infections (HAI) *Avoids introduction of infectious organisms. *To prevent development of local infection and minimize complications *Prompt identification of symptoms of infection can facilitate prompt intervention and thus prevent complications. *Temperature, pulse, and respiration increase in response to infection. *Pain may be due to wound hematoma, a possible locus of infection, which needs to be surgically evacuated *Antibiotics reduce the risk for infection. Evaluation Goal partially met. After 2 days of nursing intervention s, the client remain free from infections as evidenced by the ff: *Temperatu re of 36.5C *(-) exudates on surgical incision site

Potential Diagnoses
Cues S: Nahihirapan akong kumilos lalo na yung pagpunta sa CR;nagpupuna s lang ako ng katawan hindi ko pa kasi kayang tumayo para maligo as verbalized by the patient O: *Swelling of the Right foot post-op surgery wrapped with elastic bandage & elevated with 2 pillows *(+)Restlessne ss *(+)Limitation of movement (+)Facial grimace when attempting to move
Nursing Diagnosis Scientific Explanation

Planning After 8 hours of nursing interventi ons, the patient will be able to identify her areas of weakness and needs, be able to perform self-care activities within the level of her own ability and verbalized willingnes s to participat e with the treatment regimens.

Selected Intervention *Establish rapport with the patient *Review medication regime for possible effects on alrtness/mentation, energy level, balance & perception *Assess barriers that could hinder patients participation in self-care *Determine individual strengths & skills of the patient *Perform or assists with meeting the patients need when she is unable to meet her own needs *Encourage patient & S/O to verbalized concerns *Provide privacy & equipment within easy reach during personal care activities *Allow sufficient time for patient to accomplish tasks to the fullset extent of ability and try to make any interruptions *As much as possible, take the patient to the bathroom or toilet or place a commode or bedpan at specified time intervals, taking into considerations the patients needs Collaborative: *Collaborate with rehabilitation professionals like physical or occupational therapist, to obtain assistive devices & mobility aids *Assist with rehab program if indicate

Implemented Intervention *Established rapport with the patient *Reviewed medications and identified its possible effects to patients mentation *Assessed and identified barriers that hinders the patients participation in self-care *Determined the patients strengths & skills *Assisted the patients need such as helping with mobility *Used therapeutic communication to converse with the patient *Provided patients privacy & equipments within easy reach during personal care activity *Allowed sufficient time for the patient to finish tasks *Provided perineal care and changed patients pad

Rationale *To gain patients trust and cooperation *Some medications has some effects to the patients level of consciousness so it needs to be referred *To identify contributing factors and to come up with some alternatives *To identify the patients limitation with physical functioning & be able to plan activities that is suited to the patients capacity *To provide patients comfort *To know patients thoughts & to discover barriers to participation in regimens & to work on solving the problems *To make it easier for the patient to perform tasks & to avoid occurrence of possible injury/accidents *To avoid making the patient consume much of her energy & for the patient to concentrate well in performing the tasks *To provide patient comfort & promote bowel & bladder function *To facilitate further treatment

Evaluation Goal: Met After 8 hours of nursing intervention s, the patient was able to identify the areas of her weakness & strength, performed self-care activities based in her capacity & verbalized willingness to participate in the treatment regimen.

Risk for self-care deficit r/t pain secondary to post-op surgery

Impaired ability to perform or complete feeding, bathing hygiene,dre ssing & grooming or toileting activities for oneself

Discharge Planning
M-edication
>Keep a list of your medicines Keep a written list of the medicines you take, the amounts, and when and why you take them. Bring the list of your medicines or the pill bottles when you see your doctors. Do not take any medicines, overthe-counter drugs, vitamins, herbs, or food supplements without first talking to doctors. >Take your medicine as directed Always take your medicine as directed by doctors. Call your doctor if you think your medicines are not helping or if you feel you are having side effects. Do not quit taking your medicines until you discuss it with your doctor.

Discharge Planning
>Taking insulin You may need to take insulin if your diabetes cannot be controlled with diet, exercise, or diabetes medicine. You may need one or more doses of insulin every day to decrease the amount of sugar in your blood. Insulin is available in the form of a liquid that is injected (given as a shot). Your doctor will talk to you about the different types of insulin and the type that is right for you. You, a family member, or a friend will also be taught how to give the insulin doses. >Instruct to continue taking maintenance drugs and vitamin Supplements >Other medicine: metformin 500mg/tab bid pc. glimeperide 2mg/tab odb4 breakfast, atorvastatin 20mg/tab odhs, silymarin 1tab tid, temisartan(micardis)80mg/tab od in am, covertan 80mg/tab od in am, cefotaxime 1gm/ivp q8

Discharge Planning
E-xercise/ Environment
>Instruct patient to exercise at least 3 days a week and avoid strenuous activity. Regular exercise, even of moderate intensity (such as brisk walking and stretching), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes

>Encourage ROM (range of motion) exercises to maintain and increase the motion of joints and strength of muscles. ROM exercises such as flexion, extension, rotation, abduction and adduction.

Discharge Planning

>Yoga is the best suggested exercise which focuses on awareness and balancing, reduces stress and combats lifethreatening condition. >Advise patient to stay in a clean, safe and well ventilated environment free from noise to restore energy needed for daily activities. >Avoid places that are stress provoking to facilitate fast recovery of the patient.

Discharge Planning
T-reatment
>Instruct the client to take prescribed medications >Tell patient to continue submitting self to diagnostic examination to make sure that she is not having any complications. >Monitor blood glucose level

Discharge Planning
H-ealth teaching
>Instruct pt. to comply with the given diet. >Explain the importance of exercise in maintaining or losing weight. >Advise patient to check blood glucose level before doing any activities and to eat carbohydrate snack before exercising to avoid hypoglycemia. Blood glucose levels should be monitored before and after exercise to establish blood glucose response patterns to the exercise regimen. If blood glucose is >250 mg/dl, the patient should delay the exercise session.

Discharge Planning
>Advise patient to wear shoes to prevent injury. >Advise patient to stay in a cement place to avoid injury. >Instruct patient to ensure safety of the affected part. >Instruct patient to maintain the dryness of the bivalve cast application. >Instruct patient to exercise his distal part to facilitate flow of blood. >Encouraged client to increase fluid intake >Advise client to have at least 8 hours of sleep to promote energy and restful feeling >Encourage and explain to client the importance of maintaining proper hygiene. This is to prevent infections and further occurrence of disease because of his DM. >Advise patient to stop drinking alcohol and avoid exposure to cigarette

Discharge Planning
O-PD follow-up
>Arrange for the client to have follow-up check-up.

>Keep all appointments. Write down any questions you may have. This way you will remember to ask these questions during your next visit
>Encourage regular consultation to monitor health Condition >Instruct to go to physician immediately if there is unusual feeling

Discharge Planning
D-iet
>Diabetic Diet
Carbohydrates should provide 45 - 65% of total daily calories. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Fats should provide 25 - 35% of daily calories. Limit fatty foods consumption Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient individual health requirements

>Avoid eating too much sweet foods and salty foods.

>Eat foods rich in fiber such as banana.

>Encourage to increase fluid intake at least 8 glasses per day >Encourage to take vitamin supplements

Discharge Planning
S piritual Advise
>Advise patient to go to church every weekends to uplift of spiritual health. >Advise the patient to have firm faith with God. >Advise patient to always pray to our lord and never lose hope in any obstacle that we may encounter.

Thank You! God Bless!!

BSN 4F

Under
MRS. RUBY LACRO