Introduction

Overview of the Case

Diabetes is a disease in which the body does not produce or
properly use insulin. Insulin
is a hormone that is needed to convert sugar, starches and other food
into energy needed for daily
life. The cause of diabetes continues to be a mystery, although both
genetics and environmental
factors such as obesity and lack of exercise appear to play roles.

There are 18.2 million people in the United States, or 6.3% of the
population, who have
diabetes. While an estimated 13 million have been diagnosed with
diabetes, unfortunately, 5.2
million people (or nearly one-third) are unaware that they have the
disease.
The primary goals of treatment for patients with diabetes include
controlling blood
glucose levels and preventing acute and long-term complications.
Thus, the nurse who cares for
diabetic patients must assist them to develop self-care management
skills.
I chose the case for my case study. I have taken care of him for 2
consecutive days.
Let’s find out more about Diabetes Mellitus! My patient specifically has
Type 2 (Non-
Insulin Dependent Diabetes Mellitus) I hope you will learn many things
through my case study.

Objective of the Study

1
 This study is directed towards understanding the condition of the
chosen client as a part of the students’ learning about the
abnormalities related to the resistant to the effects of insulin and glucose.
Moreover, this study will also enhance students’ knowledge on
this particular case and perform nursing interventions efficiently
according to identified priority problems that we’ve observed during
my two – days exposure in caring the client.
Lastly, this case study will supplement the students’ learning to
value what was really the essence of performing a holistic care
towards the client from the time she was admitted, up to the time that
she will be discharged from the hospital.

Scope and Limitation of the Study

The extent of study includes only to the information being
gathered from the patient and the patient’s personal chart. It also
deals with the several factors observed during our assessment with the
client.
The information gathered was based on the manifestations and
complaints of the patient observed and the exact answers of the
patient’s significant others. Interventions were rendered gradually
depending on the objective assessment we’ve had gathered during our
two days (16 hours) of clinical duty.
The limitation of the study includes the place of interaction itself
which was in Sabal General Hospital Incorporation, General Ward. The
study was completed altogether by both research and actual hands-on
exposure and interaction with the client during the two days (16 hours)
of clinical duty, last April 24 to 25, 2010.

2
Health History
Profile of Patient
Name : Mrs. X
Age : 41 years old
Address : Corrales Ext., Brgy. 21 Cagayan de Oro City
Civil Status : Married
Birth date : July 2, 1948
Occupation : managing a small business “sari-sari
store”
Birthplace : Cagayan de Oro City
Sex : Female
Religion : Roman Catholic
Nationality : Filipino
Allergies : No known food and drug allergies
Date Admitted : April 23, 2010
Time Admitted : 9:18 am
Baseline Vital Signs upon Admission
Temperature : 37.9oC
Heart Rate : 80 bpm
Respiratory Rate : 20cpm
Blood Pressure : 180/100 mmHg
Weight : 61 kg
Height : 158 cm
Chief Complaint : Weak of upper and lower
extremities
Diagnosis : Diabetes Mellitus type 2
Physician : Dr. Daitia

3
Family and Personal health history
Patient Mrs. X was the third child of Mr. & Mrs .B . She was being
delivered through normal spontaneous vaginal delivery (NSVD) on a
health center and a fully immunized individual. She had no known food
and drug allergies. During the process of interaction the patient
opened up that this kind of disease run in the family, in both in the
maternal and paternal side.

History of Present Illness

Before the patient was admitted at Sabal hospital, patient Mr. X
was admitted at Northern Mindanao Medical Center due to
lightheadedness and body weakness. She was advised by the
physician to take rest at their home. She was diagnosed to have a
Diabetes Millitus and advised to have good diet. A few days prior
to admission, patient Mrs. X suffered lightheadedness, headache and
body weakness and took her maintenance medicines, Metformen and
Captopril but no relief. A day prior to admission she had experienced
weakness of upper and lower extremities and prompted admission at
Sabal Hospital Incorporation.

Chief Complaint
Patient Mrs. X 41 years old Filipino patient and a Roman
Catholic, who was currently residing at Corrales Ext., Brgy. 21 Cagayan
de Oro City, Misamis Oriental was brought to Sabal Hospital at station
2, last April 23 2010 at 9:18 o’clock in the morning due to weakness of
upper and lower extremities.

4
Developmental data
The middle years from 40 to 65, have been called the years of
stability and consolidation. For most people, it is a time when children
have grown and moved away or are moving away from home. Thus
partners generally have more time for and with each other and time to
pursue interests that they may have deferred for years.
A number of changes take place during the middle years. At 40,
most adults can function as effectively as they did in their 20s.
However during ages 40 to 65 many physical changes take place.
SIGMUND FREUD’S FIVE STAGES OF PSYCHOSEXUAL
DEVELOPMENT
Genital Stage (12 years and above)
Based on the age bracket presented by Sigmund Freud on his
psychosexual theory, my patient belongs on this stage wherein we had
observed that energy is directed already toward full sexual maturity
and function and development of skills needed to cope with the
environment. This implies the encouragement of separation already
from the parents, achievement of independence, and decision making
by her self. We were able to observe these implications to our patient
making us to decide also that patient Mrs.X really belongs to the
genital stage of psychosexual development.

5
 ERIK ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT
Adulthood (25 – 65 years of age - Generativity versus Stagnation
My patient belongs to an adulthood level since her age fits within
the age bracket set by Erik Erikson on his psychosocial theory. On this
stage the indicators of positive resolution are creativity, productivity,
and concern for others; wherein I am able to observe this in my client.
The negative resolutions are characterized as self-indulgence, self-
concern, and lack of interests and commitments.
Erik Erikson views the developmental choice of the middle – aged
adult as generativity versus stagnation. Generativity is defined as the
concern for establishing and guiding the next generation. In other
words, the concern about providing for the welfare of humankind is
equal to the concern of providing for self. People in their 20’s and 30’s
tend to be self and family- centered. In middle age, the self seems
more altruistic, and concepts of service to others and love and
compassion gain prominence. These concepts motivate charitable and
altruistic actions, such as church work, social work and political work,
community fund-raising drives, and cultural endeavors. Marriage
partners have more time for companionship and recreation, thus
marriage can be more satisfying in the middle years of life. Partners
have time to work together in volunteer activities, and time for one
partner to go out for lunch and for the other to go camping or fishing.
Generative middle-aged persons are able to feel a sense of comfort in
their lifestyle and receive gratification from charitable endeavors.

JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT

Formal Operational Thought Stage (12 years old and above)
Patient Mrs. X was on the stage of Formal Operational Thought
stage due to the fact that she was already 61 years old, and above 12

6
years old is being considered to have already a formal operational
thought, according to Piaget.
On this stage, the middle-aged adult’s cognitive and intellectual
abilities change very little. Cognitive processes include reaction time,
memory, perception, learning, problem solving and creativity. Reaction
time during the middle years stays much the same or diminishes
during the later part of the middle years. Memory and problem solving
are maintained through middle adulthood. Learning continues and can
be enhanced by increased motivation at this time in life.
Middle-aged adults are able to carry out all the strategies
described in Piaget’s phase of formal operations. Some may use post
formal operations strategies to assist them in understanding the
contraindications that exist in both personal and physical aspects of
reality. The experiences of the professional, social, and personal life of
middle-aged persons will be reflected in their cognitive performance.
Thus approaches to problems solving and task completion will vary
considerably in a middle – aged group. The middle – aged adult can
“reflect on the past and current experience and can imagine,
anticipate, plan and hope.”

LAWRENCE KOHLBERG’S STAGES OF MORAL DEVELOPMENT

Middle Age (40 to 65 years old)
Post conventional Level (Level 5: Social Contract Legalistic Orientation)
Patient Mrs. X belongs to Post Conventional Level on Moral
development since her age is within the age bracket. On this stage the
person lives autonomously and defines moral values and principles
that are distinct from personal identification with group values. She
lives according to principles that are universally agreed on and that the
person considers appropriate for life. On this stage also the social rules
are not the sole basis for decisions and behavior because the person

7
believes a higher moral principle applies such as equality, justice or
due process.
According to Kohlberg, the adult can move beyond the
conventional level to the post conventional level. Kohlberg believes
that extensive experience or personal moral choice and responsibility
is required before people can reach the post conventional level.
Kohlberg found out that few of his subjects achieved the highest level
of moral reasoning. To move from stage 4, a law and order orientation,
to stage 5, a social contract orientation, requires that the individual
move to a stage in which rights of others takes precedence. People in
stage 5 take steps to support another’s rights.

ROBERT HAVIGHURST’S DEVELOPMENTAL TASKS THEORY

Middle Age (25 to 65 years old)
Patient Mrs. X belongs to this level of task development based on
the theory anchored by Robert Havighurst. Each developmental task
provides a framework that the nurse can use to evaluate a person’s
general accomplishments.
A developmental task is a task which arises at or about a certain
period in the life of an individual, successful achievement of which
leads to happiness and to success with later tasks, while failure leads
to unhappiness in the individual, disapproval by society, and difficulty
with later tasks.
Middle – aged individual, just like patient Mrs. X, will possess the
following developmental task:
a. achieving adult civic and social responsibility
b. establishing and maintaining an economic standard of living
c. Assisting teenage children to become responsible and happy
adults
d. Developing adult leisure time – activities
e. Relating oneself to one’s spouse as a person

8
 f. Accepting and adjusting to the physiologic changes of middle
age
g. Adjusting to aging parents
Medical Management
Medical Orders and Rationale
DATE DOCTOR’S ORDER
April 23, 2010 - Pls. admit under the •
service of Dr. Daitia
- Secure consent
- Vital signs every 4 hours
- Start IVF with PNSS 1
liter at 20 gtts/min
- Laboratory:
a. CBC
b. Blood Chemistry
c. Xray
- Medications:
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RATIONALE
To closely monitor
the patient
• For legal purposes
• To monitor patient
status
• It is an efficient and
effective method of
supplying fluids into
the intravascular
fluid compartment
and also replacing
the electrolyte
losses. It also
provides a path for
the medications to
be given directly for
the fast effect into
the system.
• For diagnostic
purposes: To check
for occurrence of
infection in the
a. Captopril body, and provides
valuable
information
regarding the
health condition of
the client.

• Blocks ACE from

converting
angiotensin I to
angiotensin II, a
powerful
vasoconstrictor,
leading to
b. Citicoline decreased blood
pressure, decreased
aldosterone
secretion, a small
increase in serum
potassium levels,
and sodium and
fluid loss; increased
prostaglandin
synthesis also may
be involved in the
antihypertensive
action.kidney.
c. Clopidogril • Citicoline activates
the biosynthesis of
structural
phospholipids in the

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 neuronal
membrane,
increases cerebral
metabolism and
increases the level
of various
neurotransmitters,
including
acetylcholine and
dopamine.
April 24, 2010 - Monitor intake and Citicoline has shown
output every shift neuroprotective
- Monitor V/S every 4 effects in situations
hours of hypoxia and
ischemia.
• Reduce
atherosclerotic
events in patients
- Please inform the with atherosclerosis
attending physician documented by
April 25, 2010 recent stroke, MI, or
- Refer accordingly peripheral arterial
disease. Reduce
atherosclerotic
events in patients
with acute coronary
syndrome, including
- IVF to follow PNSS 1 liter those managed
at 20gtts/min medically and those
who are to be
vention or coronary

11
 artery bypass graft.
• To monitor patient
status

• To properly inform
the physician for
further
management and
evaluation of the
disease condition
• For further care to
the patient

• For Treatment of
complicated
Diabetes Mellitus.
For further
evaluation and co-
management of the
client’s condition .
• It is an efficient and
effective method of
supplying fluids into
the intravascular
fluid compartment
and also replacing
the electrolyte
losses. It also
provides a path for
the medications to

12
 be given directly for
the fast effect into
the system.

Laboratory Results
April 24, 2010
Complete Blood Count

13
 RESULTS NORMAL INTERPRETATIO
VALUES N
White blood 7.52 3.8 – 10.8 X Within normal
cell 103/ml3 limit
Red blood cell 4.63 X 3.69 – 5.13 X Within normal
106/ml3 106/ml3 limit
Platelet 236 X 103/ml3 150 – 400 X Within normal
103/ml3 limit
MCV 81 fL 80 - 100 fL Within normal
limit
MCH 30 pg 27 – 33 pg Within normal
limit
Differential
Count
Neutro 0.78% 0.45 – 0.73 % Bacterial
phils infection,
inflammation,
stress, drug
reaction
Monocyt 0.07% 0.00 – 0.10 % Within normal
es limit
Eosinoph 0.01% 0.00 – 0.05% Within normal
ils limit
Basophil 0.0 0.00 – 0.20% Within normal
limit

January 3, 2010
Blood Chemistry
RESULT NORMAL INTERPRETATION
VALUES
Potassium 3.82 mmol/L 3.5 – 5.5 mEq/ L Within normal limit

Sodium 143.1 135-148 mEq/ L Within normal limit

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 Calcium --------- 8.8- 10.2 mEq/ L

Drug Study
Name of Drug clopidogril
Date Ordered April 23, 2010
Classification Antiplatelet
Dose/Frequency 75 mg P.O. O D
Route
Mechanism of Inhibits binding of ADP to its platelet receptor,
Action which inhibits ADP-mediated activation and
subsequent platelet aggregation. Because drugs
acts by irreversibly modifying the platelet ADP
receptor, platelet exposed to drug are affected for
their lifetime.
Specific Reduce atherosclerotic events in patients with
Indication atherosclerosis documented by recent stroke, MI,
or peripheral arterial disease.
Reduce atherosclerotic events in patients with
acute coronary syndrome, including those
managed medically and those who are to be
vention or coronary artery bypass graft.
Contraindicatio • Contraindicated in patients hypersensitive to
n drug or any of its components,
• and in those with pathologic bleeding, such as
peptic ulcer or intracranial hemorrhage.
Side Effects depression, fatigue, headache, pain, chest pain,
edema, hypertension, epistaxis, rhinitis, pain,
constipation, diarrhea,dyspepsia, gastritis,
Hemorrhage, ulcers, UTI, purpura, arthralgia, back
pain. bronchitis, cough, dyspnea. Upper respirator
tract infection, rash, pruritus

15
Nursing Use cautiously in patients with hepatic impairment
Precautions and in those at risk from increased bleeding from
trauma, surgery or other conditions.

Name of Drug Captopril

Date Ordered April 23, 2010
Classification ACE inhibitor, Antihypertensive
Dose/Frequency 25 mg PO bid
Route
Mechanism of Blocks ACE from converting angiotensin I to
Action angiotensin II, a powerful vasoconstrictor, leading
to decreased BP, decreased aldosterone secretion,
a small increase in serum potassium levels, and
sodium and fluid loss; increased prostaglandin
synthesis also may be involved in the
antihypertensive action.
Specific Treatment of hypertension
Indication Treatment of diabetic nephropathy
Treatment of left ventricular dysfunction after MI
Unlabeled uses: Management of hypertensive
crises; treatment of rheumatoid arthritis; diagnosis
of anatomic renal artery stenosis, hypertension
related to scleroderma renal crisis; diagnosis of
primary aldosteronism, idiopathic edema; Bartter's
syndrome; Raynaud's syndrome
Contraindicatio Contraindicated with allergy to captopril, history of
n angiodema, second or third trimester of
pregnancy.
Use cautiously with impaired renal function; CHF;
salt or volume depletion, lactation.
Side Effects Tachycardia,angina pectoris, MI,CHF, hypotension
in salt- or volume-depleted patientsRash,

16
 pruritus,alopecia,Gastric irritation, ulcers, peptic
ulcers, dysgeusia, anorexia, constipation
Proteinuria,
renal insufficiency, renal failure, polyuria, oliguria,
anemia,
Other: Cough,malaise, dry mouth
Nursing Be careful of drop in blood pressure (occurs most
Precautions often with diarrhea, sweating, vomiting,
dehydration); if light-headedness or dizziness
occurs, consult your health care provider.

Name of Drug citicoline

Date Ordered April 23, 2010
Classification
Dose/Frequency 50 mg every 8 hours IVTT
Route
Mechanism of Competitively inhibits the action of histamine at
Action the Histamine 2 receptors of the parietal cells of
the stomach, inhibiting basal gastric acid secretion
and gastric acid secretion that is stimulated by
food, insulin, histamine, cholinergic agonists,
gastrin and pentagastrin
Specific Treatment of heartburn, acid indigestion, sour
Indication stomach
Contraindicatio Contraindicated with hepatic / renal impairment
n and gastric malignancy.
Side Effects Constipation, dizziness, tiredness, diarrhea
Nursing a. Advise patient to avoid grapefruit juice and
Precautions grapefruit products while using this drug
b. Provide safety measures if dizziness and
lightheadedness occur

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Name of Drug Metformin
Date Ordered April 23, 2010
Classification Antidiabetic
Dose/Frequency 500 mg 2 tablet, BID
Route
Mechanism of Decreases hepatic glucose production, decreases
Action intestinal absorption of glucose, and increases
peripheral uptake and utilization of glucose
Specific Improve glycemic control in clients with type 2
Indication diabetes
Extended-Release form used to treat type 2
diabetes as initial therapy
Contraindicatio Acute or chronic metabolic acidosis
n Abnormal hepatic function• Dehydration and
lactation
Side Effects - Hypoglycemia, diarrhea, N&V, asthenia,
flatulence, headache, abdominal pain/discomfort
Nursing > Metformin should be promptly withheld in the
Precautions presence of any condition associated with
hypoexmia, dehydration, or sepsis.
>hepatic disease
>Lactic acidosis

Pathophysiology with Anatomy and Physiology

Definition:
Results from insulin resistance, a condition in which cells fail to use insulin properly,
sometimes combined with an absolute insulin deficiency.
Precipitating factors: Predisposing factors:

1. frequent or chronic infections Family History

2. eating too much sweets Obesity
3. development of glucose intolerance during drug therapy Age above 40
4. delivery of over 9 lbs infants

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5. diet
6. sedentary lifestyle

Insulin resistance
Exhaustion of beta cells
insulin production/ decrease secretion of insulin
Absorption of glucose by the cell
Cell starvation
Stimulation of hunger mechanism via hypothalamus
Hunger
POLYPHAGIA (FBS  140 mg/dL)
Nerve Demyelinization Diffuse glomerular sclerosis
Impaired pain sensation POLYURIA
NON-HEALING ULCERS

F & E imbalance

 Number of solute relative to water

Sodium ions lost

POLYDIPSIA

Insufficient production of insulin (either absolutely or relative to the body's needs), production of defective
insulin (which is uncommon), or the inability of cells to use insulin properly and efficiently leads to
hyperglycemia and diabetes. This latter condition affects mostly the cells of muscle and fat tissues, and
results in a condition known as "insulin resistance." This is the primary problem in type 2 diabetes. The
absolute lack of insulin, usually secondary to a destructive process affecting the insulin producing beta cells
in the pancreas, is the main disorder in type 1 diabetes. In type 2 diabetes, there also is a steady decline of
beta cells that adds to the process of elevated blood sugars. Essentially, if someone is resistant to insulin,
the body can, to some degree, increase production of insulin and overcome the level of resistance. After
time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops.

Glucose is a simple sugar found in food. Glucose is an essential nutrient that provides energy for the proper
functioning of the body cells. Carbohydrates are broken down in thesmall intestine and the glucose in
digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by the bloodstream
to all the cells in the body where it is utilized. However, glucose cannot enter the cells alone and needs
insulin to aid in its transport into the cells. Without insulin, the cells become starved of glucose energy
despite the presence of abundant glucose in the bloodstream. In certain types of diabetes, the cells' inability

19
 to utilize glucose gives rise to the ironic situation of "starvation in the midst of plenty". The abundant,
unutilized glucose is wastefully excreted in the urine.

Insulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. (The pancreas is a
deep-seated organ in the abdomen located behind the stomach.) In addition to helping glucose enter the
cells, insulin is also important in tightly regulating the level of glucose in the blood. After a meal, the blood
glucose level rises. In response to the increased glucose level, the pancreas normally releases more insulin
into the bloodstream to help glucose enter the cells and lower blood glucose levels after a meal. When the
blood glucose levels are lowered, the insulin release from the pancreas is turned down. It is important to
note that even in the fasting state there is a low steady release of insulin than fluctuates a bit and helps to
maintain a steady blood sugar level during fasting. In normal individuals, such a regulatory system helps to
keep blood glucose levels in a tightly controlled range. As outlined above, in patients with diabetes, the
insulin is either absent, relatively insufficient for the body's needs, or not used properly by the body. All of
these factors cause elevated levels of blood glucose (hyperglycemia).

Nursing Assessment
(System Review and Nursing
Assessment II)
Name: Patient Aya
Date: December 29, 2009
Vital Signs: Pulse: 105 bpm RR: 24 cpm Temp:
37.5˚ C Height: 158 cm Weight: 64 kgs
EENT:
[ ] impaired vision [ ] blind

20
[ ] pain [ ] reddened [ ] drainage
Dizziness
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose, throat
For abnormality [x] no problem
RESPIRATORY Hypertensive
[ ] asymmetric [ ] tachypnea BP = 180/100 mmHg
[ ] apnea [ ] rales [ ]cough[ ] barrel chest
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ]dyspnea
[ ] orthopenea [ ] labored [ ]wheezing
[ ] pain [ ] cyanotic
Assess resp.rate, rhythm, depth, pattern
Breath sounds, comfort [x] no problem
CARDIOVASCULAR
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate, rhythm, pulse,
circulation, fluid retention, comfort [x] no
GENITO – URINARY AND GYNE
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
GASTRO INTESTINAL TRACT
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing,
Bowel sound, comfort [x] no problem
NEURO
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech [x] no problem
MUSCULOSKELETAL and SKIN
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [x] poor turgor [ ] cool [ ] deformity
[] wound [ ] rash [ ] skin color [ ] flushed
[ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist
Assess mobility, motion, galt, alignment, joint function/
Skin color, texture, turgor, integrity [x] no problem
NURSING ASSESSMENT ll
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] hearing loss Comments: “ [ ] glasses [ ] language
wala may [ ] contact lens [ ] hearing aide
[ ] visual changes problema sakoa R L
mata,” Pupil size: 3 mm Speech Difficulties: None
[x] denied as verbalized Reaction: Pupils Equally Round Reactive to
by the pt Light and Accommodation(PERRLA)

21
OXYGENATION: Respiration: [x] regular []
[ ] dyspnea Comments: “wala irregular
man koy
[ ] smoking history ubo, di pud ko Describe: Client had regular breathing
gapanigarilyo pattern during admission.
None
[ ] cough as verbalized by R. Symmetrical to the left.
the patient. L Symmetrical to the right
[ ] sputum
[x] denied

CIRCULATION: Heart Rhythm [x] regular []

[x] chest pain Comments: irregular
“Magsakit Ankle edema : None
[ ] leg pain akong dughan Heart : regular
usahay pag Carotid Radial Dorsal Pedis
[ ] numbness of maghuna-huna ko Femoral
extremities nga taas ang R___+ 105 bpm+______
akong BP,” +__________+_____
[ ] denied as verbalized by L___ + 105 bpm+______
the +__________+_____
Patient. Comments: All pulse sites were palpable
during physical assessment.
NUTRITION
Diet: Soft Diet [ ] Dentures [x] None
[]N []V Comments: Wala man
ko’y
character problema sa Full Partial With
pagkaon. Patent
[ ] recent change di man ko
kasukaon pud,” Upper [] [] []
[ ] weight, appetite as verbalized by
the patient Lower [] [] []
[ ] swallowin g
difficulty
[ ] denied
( x) no problem
ELIMINATION: Comments: Bowel Bowel Sounds:
Usual bowel pattern [ ] urinary Normoactive
frequency sound was
once a day. 5 - 6X a normoactive
day (oliguria) Abdominal
[ ] constipation [ ] distention
urgency Present [ ]
remedies [ ] Yes [x] No
dysurria
None []
hematuria
Date of last BM [ ]
incontinence
December 30, 2009 [ ]
polyturia
[ ] diarrhea [ ] foly in
place
Character None [ ] denied

22
MGT. OF HEALTH & ILLNESS Briefly describe the patient’s ability to
[ ] alcohol [ ] denied follow treatments (diet, medication, etc.) for
(amount, frequency) “Dili man ko chronic health problems (if present)
gainom” Patient took all the prescribed medications
[x]SBE last pap smear: unrecalled as prescribed by the doctor.
LMP : Menopause (Unrecalled)
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY: [ ] dry [ ] cold [ ] pale
[ ] dry Comments: ‘’wala man koy [ ] flushed [ ] warm
katul-katol [ ] moist [ ] cyanotic
[ ] itching As *rashes, ulcers, decubitus (describe size,
verbalized by the pt. location, drainage)
[ ] others Patient skin was not pale and cold clammy
[ ] denied to touched.

ACTIVITY/SAFETY: LOC and Orientation: The patient was

[ ] convulsion Comments: conscious and aware of time, place people
[x] dizziness “gakalipong man and date.
ko,” [ ] Gait [ ] Walker [ ] Care []
[ ] limited motion as verbalized by the Other
patient [ ] Steady [ ] Unsteady
of joints Sensory and motor losses in face or
limitation of ability extremities
to : Sensory and motor sensitivity was still
[ ] ambulate observed
[ ] bathe self [ ] ROM limitations: no limited range of
[ ] other motion
[ ] Denied
COMFORT/SLEEP/AWAKE [ ] facial grimaces
[ ] pain Comments: “wala
[ ] guarding
man
[ ] other signs of pain: irritable
(location, frequency koy
[ ] side rail release from signed (60+years):
poblema sa
not applicable
remedies) akong
tulog as
[ ] nocturia
verbalized by
[ ] sleep difficulties the pt.
[x] denied
COPING: Observed non-verbal behavior: none
Occupation: business woman Person (Phone Number):Not given
Members of the household: 4
Most Supportive Person: Husband
(SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)

64 kilograms Weight Daily N/A PT/OT

180/100 mmHg BP q Shift N/A Irradiation
N/A Neuro vs (/) Urine Test
N/A CVP/SG. Reading N/A 24 Hour Urine Collection

23
 Date Diagnostic/ Date Date I.V. Date done
Ordered Lab exam done ordere fluids/blood
d
4-23-10 Blood 4-24-10 4-23- Pnss 1 liter at 4-23-10
Chemistry and 10 20 gtts/min
CBC
4-23-10 X-ray 4-24-10

Nursing Management
Ideal Nursing Management
Nursing Diagnosis: Activity Intolerance; Level I r/t difficulty
walking secondary to body weakness
Interventions Rationale
1. .establish rapport 1. To facilitate NPI.
2. place the client in a 2. To prevent backaches or
comfortable position muscle aches.
3. Determine patient's perception 3. These may be temporary or
of causes of fatigue or activity permanent, physical or
intolerance. psychological. Assessment
guides treatment.

4. Assess patient's level of

4. This aids in defining what
mobility.
patient is capable of, which is
necessary before setting
realistic goals.

5. Assess nutritional status. 5. Adequate energy reserves are

required for activity.
6. Teach energy conservation 6. These reduce oxygen

24
techniques consumption, allowing more
prolonged activity.

25
Nursing Diagnosis: Cardiac Output, risk for decreased Risk factors
may include
Reduced myocardial contractility.
Interventions Rationale
1. Auscultate heart sounds, 1. Specific dysrhythmias are
noting rate, rhythm, more clearly detected
presence of extra audibly than by palpation.
heartbeats, dropped beats. Hearing extra heartbeats or
dropped beats helps
identify dysrhythmias in the
unmonitored patient.
2. Palpate pulses (radial, 2. Differences in equality,
carotid, femoral, dorsalis rate, and regularity of
pedis), noting rate, pulses are indicative of the
regularity, amplitude effect of altered cardiac
(full/thready), and output on
symmetry. systemic/peripheral
3. Provide calm/quiet circulation.
environment. Review 3. Reduces stimulation and
reasons for limitation of release of stress-related
activities during acute catecholamines, which can
phase. cause/aggravate
dysrhythmias and
vasoconstriction, increasing
4. Demonstrate/encourage myocardial workload.
use of stress management 4. Promotes patient
behaviors, e.g., relaxation participation in exerting
techniques, guided some sense of control in a
imagery, slow/deep stressful situation.
breathing.
5. Drug Levels 5. Reveal therapeutic/toxic
level of prescription
medications or street drugs
that may affect/contribute
26
to presence of
dysrhythmias.
Nursing Diagnosis: Ineffective tissue perfusion related to
kidney obstruction / impairment of kidney functioning
Interventions Rationale
1. Observe for skin changes 1. May indicate presence of
dehydration. Continued losses
without adequate replacement
2. Monitor patient’s neurologic may lead to hypovolemia.
status for changes in level of 2. Decreased perfusion may result
consciousness in cerebral perfusion decreases
resulting to lethargy, weakness.
3. Monitor for complaints of 3. May indicate impairment of
numbness, muscle cramps. neuromuscular activity,
hypocalcemia, and potential to
4. Monitor intake and output of decreased cardiac perfusion and
patient function.
4. Decreased in urinary outputs
that do not respond to fluid
challenges cause renal
vasoconstriction and decreased
perfusion from renin secretions.

27
 Actual Nursing Management
S “galisod man ko ug ginhawa”, as verbalized by the patient.
O - Irritability as noted
A Ineffective breathing pattern related to hyperventilation
P At the end of 15 – 20 mins, the patient will be able to verbalize
good ventilation at a tolerable level
I Interventions Rationale
INDEPENDENT:
1. Elevate head of the bed 1. Promotes ease of maximal
and instruct to do deep inspiration, allowing
breathing exercises. optimal lung
expansion
2. Maintain calm attitude 2. This will limit client’s level
while dealing with client & of anxiety.
significant others.
3. Assess color of the skin and 3. To determine cyanosis
oral mucosa including the
tongue. 4. Relaxation minimizes
4. Encourage client to use oxygen demand
relaxation technique like 5. It helps client to be aware
diversional activities of the
5. Teach client and significant condition at it reduces the
others with risk for
the contributing factors of reoccurrence of ineffective
the condition. breathing
COLLABORATIVE: episodes.
Provide oxygen inhalation as To increase oxygenation,
ordered. improve ventilation, and

28
 reduce dyspnea.
E At the end of 15 – 30 mins, the patient had verbalized good
ventilation at a tolerable level.

S “Ing-ana man gyud na siya, masige na nuon na siya ug huna-

huna sa kataas sa iyang blood pressure. Mahadlok siya basin
unsa mahitabo sa iya kay taas iyang dugo,” as verbalized by
patient’s son.
O - T= 37.0C
- BP = 180/100
A Anxiety related to change in health status
P At the end of 30 mins., the patient will be able to demonstrate
anxiety to a manageable level.
I Interventions Rationale
1. Monitor physical responses 1. To determine the anxiety
such as pulse rate. level, either mild, moderate
and panic thus to provide the
2. Provided comfort measures proper interventions needed.
such as pursed lip breathing 2. To reduce anxiety or
and back rubbing. tension
3. Instructed significant others
not to tell the patient about 3. To prevent increase of
her blood pressure and other anxiety level
anxiety provoking situations.

29
 4. Encouraged client to
acknowledge and express
feelings such as fear.
5. Stayed with the client and
maintaining a calm and
confident manner.
7. Reduces level of anxiety or
the tension level of the
client
5. This could lessen the
anxiety level of the client.

E At the end of 30 mins, the patient had already demonstrated

anxiety to a manageable level.

Health Teachings
MEDICATI o The patient was advised to take all the medications as
ONS prescribed by the physician.
a. Clopidogril 75 mg P.O. O D
b. Captopril 25 mg PO bid
c. Citicoline 50 mg every 8 hours IVTT
d. Metformin 500 mg 2 tablet, BID
The patient must report to the physician if experiencing
any adverse effect of medication such as allergic
reactions or rashes. Patient is encouraged to keep a list of
the medication with him all times and should not use any
other over the counter medications without consulting or
prescription from the physician.
EXERCISE o For most pt. WALKING is the safe and beneficial for the
exercise.
TREATME o Diabetes must control the glucose level before

30
NT initiating any activities.
CHECK – o Advised patient to have follow-up check up to her
UP Diabetes.
DIET o Plan for the caloric intake distributed as follows CHO
50-60%; Fats 20-30%; Protein 10-20%.

Referrals and Follow – up

Although our patient having Diabetes Millitus and can be
prevented and treated, the patient was then instructed to religiously
follow medication regimen as prescribed by the physician such as
antiplatelet, antihypertensive, drugs to prevent complications and
further damage. The patient was advised to have an appointment with
a physician or a health care provider, 2 weeks after discharging or if
there is any abnormalities observe by the client to check for any
complications and to check the condition of the client. The significant
others also was being instructed to guide the patient in taking her
medications and to have regular check-up, especially in her blood
pressure, to any near health centers on their community and also to
visit her physician on the schedule given.

Recommendations
Prevention is always better than curing. As Ben
Franklin said, “An ounce of prevention is worth a pound of cure”.
Since the patient seek for medical attention, health care provider
was given her the right care that she needs.

31
 Liceo de Cagayan University
R.N. Pelaez Blvd. Carmen Cagayan de Oro City
College of Nursing

In Partial Fulfillment of the Course of the NCM501204

32
 Related Learning Experience

Submitted to:
Ms.Charito Gerong R.N MAN
Clinical Instructor

Submitted by:

Christina C. Flores

May 21, 2010

TABLE OF CONTENTS

Introduction
Overview of the Case
Objective of the Study
Scope and Limitation of the Study
Health History
Profile of Patient
Family and Personal health history
History of Present Illness
Chief Complaint
Developmental data
Medical Management

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 Medical Orders and Rationale
Laboratory Results
Drug Study
Pathophysiology with Anatomy and Physiology
Nursing Assessment (System Review and Nursing Assessment II)
Nursing Management
Ideal Nursing Management
Actual Nursing Management
Health Teachings
Referrals and Follow – up
Recommendations
Bibliography

34