NURSING CARE IN Mrs.

“S” WITH DIABETES MELLITUS

AT DR. SOETOMO GENERAL HOSPITAL

ON 11TH – 13TH NOVEMBER 2009

BY:
GROUP I

MIRA UTAMI NINGSIH (139015216)

NINIK ENDANG S (139015146)
AGUS (139015151)
DIONISIA R.W. DJAWA (139015164)
IRNA SUSIATI (139015219)
KASHMIR (139015226)
WIWIN NURMALANTIKA (139015234)
HUSNUL MUBAROK (139015235)

FACULTY OF NURSING
AIRLANGGA UNIVERSITY
SURABAYA
2009
PREFACE
 We really grateful to the Most Glorious and the Most Merciful Allah SWT,
we can finished this case report about “Nursing care in Mrs. ‘S’ with chronic diabetes
mellitus at RS. DR. Soetomo on 11th – 13th November 2009” ontime. This paper is
written as a part of process in studying English in nursing science and technology.

Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer who has
generously provided us with constructive criticism and suggestions to completed this
paper. Special thanks to all of our colleagues in class B 12 who have participated in
our seminar discussion about the case in this paper. We aware that still there are
many lack in this paper so we could use some direction and we always open to your
suggestion to make it better. At last, we hope this paper may brings much
advantages to all of us.

Surabaya, 21st November 2009

Author

2
 CONTENTS

Cover...........................................................................................................................i

Preface.......................................................................................................................ii

Contents....................................................................................................................iii
Nursing Care in Mrs. “S” with Diabetes Mellitus at DR. Soetomo General
Hospital, On 11th – 13th November 2009

A. Assesment......................................................................................................1
B. Data Analysis and Nursing Diagnosis............................................................6
C. Planning..........................................................................................................9
D. Implementation.............................................................................................13
E. Evaluation / Discharge Planning..................................................................18

3
 NURSING CARE IN Mrs.“S” WITH DIABETES MELLITUS

AT DR. SOETOMO HOSPITAL, ON 11th – 13th NOVEMBER 2009

A. ASSESMENT

NURSING HISTORY
Admission Date : 11th Nov 2009 Time : 08.56 a.m
No. Reg : 10177388 Medical Dx : Diabetes mellitus + diabetic
foot
Date of Assesment : 11th Nov 2009

I. Patient identity

1. Name : Mrs. “S”

2. Age : 60
3. Sex : female
4. Race : Java, Indonesia
5. Religion : Islam
6. Education :-
7. Occupation : Housewife
8. Address : Lamongan, Karang Anyar

I. History of present illness

1. Chief complain : shortness of breath

2. Present illness history : patient has a sudden shortness of breath since
an hour before hospitalized but it’s getting better. She had cough, nausea
and vomiting a day ago. She has pain, swollen and redness at right pedis
since three days ago. Feverish a day before hospitalized. She feel faint
and weakness. Patient has diabetic mellitus type II since twelve years ago.

I. Past nursing history

1. History of contagious disease : None

2. Hereditary disease : None
3. Allergic history : None

4
I. Family health history :

Patient said that her family has no contagious disease one of her family
member, her aunt also has diabetes mellitus
Genogram
+ +

Explanation:
: +male
: female
: client
: stay together with client
+ : pass away

II. Observation and physical examination

Vital Sign: T:37,50C P: 75x/mnt RR: 20x/mnt BP: 100/60 mmHg

1. B1: Breathing
Complain : Cough (-), SOB (-), pain (-)
RR pattern : Frequency 20 x/mnt, Rhythm : Regular
Breathing : wheezing (-), ronchi (-), secret (-)
O2 adm : (-)
Problem : None

2. B2: Blood
Complain : chest pain (-), P = 72 times/minute
Heart sound : Normal
Rhythm : regular
CRT : 2 second
JVP : Normal
Edema : (-)
Problem : None

5
3. B3: Brain
Orientation : Person, Time and Place normal
Awareness : Composmentis
GCS : E4 V5 M 6
Eye : Pupil Isochors, Light reflex (+), eye lens: snoring (+/+).
Conjunctiva : hiperemi (-/-), sub conjunctiva bleeding (-/-)
Sclera : anemis
Nerves disturbance: sensory perceptual; visual
Problem : Disturbed sensory perception; visual.
Risk for Injury
4. B4: Bladder
Complain : polyuri
Fluid intake : Oral + 2500cc/day, Parenteral : 1000 cc/day
Urine output : + 3000 cc/day color: light yellow smell: normal
Others : cateter adm (-)
Problem : Altered urinary elimination pattern
Risk for deficit fluid volume

5. B5: Bowel
Mouth : normal
Abdomen : normal
Diit : Diit B1 2100 kkal
Alvi elimination : frequency once a day, consistency: soft
Peristaltic : 15 x/mnt
Others : none
Problem : none

6. B6: Bone
Joint Activity : Free
Back Injury : None
Integuments : pale, acral warm
Turgor : good
Others : right pedis: wound, swollen, redness, pain. Post
amputated falanx digit 1 pedis, osteomilitis.
Problem : impaired skin integrity
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 7. Endocrine system
Complain : CBS: 288, polyuria, polydipsi
Prolem : hyperglycemia

I. Psychosocial assessment
1. Client perception about his disease : God-struggle
2. Client expression toward his/her disease : Quite
3. Year reaction: cooperative
4. Self concept disturbance : none

I. Diagnosis test and medical treatment

1. Laboratory:
Hematology 11th Nov 2009
Hb : 10,3 Ca: 9
Leukosit: 17.800 Cl: 101
Plt: 221.000 K: 4,5
BG: 288 Na: 140
BUN: 19,5 Globulin: 4,98
Creatinin: 1,5 Albumin: 2,8
SGOT/SGPT: 10/8 Bilirubin direct: 0,26
2. Radiology:
Thorax photo (PA): cardiomegali
Pedis photo: osteomilitis amputated phalanx digit 1 pedis dextra.
3. Therapy
IVFD Pz 14 drops/minute
Humolin R 3x4 IU SC
Humolin N 4 IU SC malam
Ceftazidine 3 x 1gr IV
Metronidazole 3 x 500 mg IV
Metformin 3 x 500 per oral
Wound care
4. Additional data:
Consult internist: unregulated DM and selulitis pedis (D), osteomilitis
Consult ophthalmologist: OD cataract mature, OS cataract immature

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WEB OF CAUTION DIABETES MELLITUS

Decrease of insulin Insulin resistance Imbalanced

production (auto by liver fat and nutrition; less
immune) muscle cell than body

Ineffective Metabolize
glucose fat &protein Lead to
movement to the to gain loss of
energy weight
Increase
blood Negative
Uses
glucose calorie effect
more
energy
Hyperglycem
ia

Resists the Body tries to get rid Glucose +

flourishing of of the extra sugar in amino
WBC blood protein

Low Risk Excreting Accumulation of

immune for sugar AGE (advance
system through urine glicosilasi end

Decrease of Prompt
capability for urinate Induce
attacking foreign unwanted
particles and blood biological
Excess
fluid
Poor
excretion
wounding
healing
Altered Risk for
urine deficit fluid Glucose
Impaired metabolize
eliminatio
skin
n pattern
integrity

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A. DATA ANALYSIS AND NURSING DIAGNOSIS

No Data Etiology Problem Fatig

ue

1 Decrease of insulin hyperglikemi

S: Activity
production (auto intoleranc
– Patient said that she immune)
has had Diabetes Or
mellitus since 12 Insulin resistance by
years ago. liver, fat and muscle
O: cell
– BG: 288 mg/dl
Ineffective glucose
movement to the cell

Causes
Increase blood Neuron, blood damage of
vessel, Kidney, blood vessel
glucose level eye lens within the

Hyperglycemia

2 S: Hyperglycemia Sorbitol +
Impaired skin Osmotic
fructose load
– patient said that her integrity
Riskfoot
for has swollen, resists the flourishing
Decrease
fosfoinosida Lead blood and fluid
redness and pain of white blood cells into the surrounding
metabolism and
signal tissue
since three days ago.
low immune system
O: Impaired
sensory Neuropathy, Affects the
– there is aperception;
wound at retinopathy ability of
decrease ofnephropathy,
capability lenses to
right pedis that
for attacking foreign
seems swollen,
particles
redness
(microorganism etc.)
– Leukocyte : 17.800
and blood vessel
– Photo pedis:
repair
osteomilitis and

9
 shows amputated poor wound healing
phalanx digit 1 pedis
dextra
– BG: 288 mg/dl

3 S: Hyperglycemia Risk for deficit fluid

– Patient complains volume
about urinate Body tries to get rid of
frequently the extra sugar in the
O: blood by excreting it
– Polyuria through urine
– BG : 288 mg/dl
– Urine output: + 3000 Prompt urinate
cc/day frequently

Excess fluid excretion

(carries a large
amount of water out of
the body along with it)

4 S: Hyperglikemia Disturbed sensory

– Patient said that she perception; visual
has blurry vision Causes damage of

O: blood vessel within

the eye
– Eye lens: snoring (+/
+) leak blood and fluid
– Ophthalmologist into the surrounding
examina-tion: OD tissues
cataract mature, and
OS cataract affects the ability of
immature lenses to focus

10
 causes vision
problems
(blurry vision)

5 S: Eye lens snoring Risk for Injury

– Patient said that she
has blurry vision Affect the ability of

O: lenses to focus

– Eye lens: snoring (+/ Causes vision

+) problem
– Ophthalmologist
examination: OD Risk for injury
cataract mature, and
OS cataract
immature

Nursing Diagnostic

1. Hyperglycemia due to decrease of insulin production (auto immune) or insulin

resistance, signed by BG: 288 mg/dl.
2. Impaired skin integrity due to poor wound healing secondary to hyperglycemia,
signed by patient said that her foot has swollen, redness and pain since three
days ago, there is a wound at right pedis that seems swollen, redness, photo
pedis shows osteomyelitis and amputated phalanx digit 1 pedis dextra.
3. Risk for deficit fluid volume due to excess fluid excretion secondary to
hyperglycemia, signed by patient complains about urinate frequently, polyuri,
BG: 288 mg/dl, urine output: + 3000 cc/day.
4. Disturbed sensory perception; visual due to the decline of lenses ability to focus,
signed by patient said that she has blurry vision, eye lens: snoring (+/+), OD
cataract mature, and OS cataract immature.

11
5. Risk for injury due to vision problem, signed by patient said that she has blurry
vision, eye lens: snoring (+/+), OD cataract mature, and OS cataract immature

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A. PLANNING

Nursing Diagnosis Goal and Objective Nursing Orders

Goal: 1. Administer insulin therapy

Hyperglycemia due
regularly as ordered
to the decrease of After 3 hours of nursing
2. Consult nutritionist to
insulin production interventions, blood
develop diet planning
(auto immune) or glucose level will be
3. Administer IVFD
insulin resistance decrease and controlled
4. Monitor laboratory results:
Outcome criteria: CBS, aseton, pH, HCO3
– BG within normal 5. Teach client about the
limit: 120 – 160 importance of keeping diet
mg/dl therapy as it programmed
– Patient follow the 6. Promote comfortable
diet therapy environment to minimize
stressor that can induce
increase blood glucose level

1. Assess wound site for signs

Impaired skin Goal:
of infection such as
integrity due to
after 3 days of nursing swelling, redness, pain.
poor wound
intervention, shows 2. Review laboratory results
healing secondary
improvement of skin (Hb/Hct, blood glucose
to hyperglycemia
integrity blood and /or wound
culture, albumin) to evaluate
Outcome criteria;
causative factors or ability
– Shows skin to heal
tissue 3. Cleanse or irrigate wounds
regeneration using physiological solution
– Wound healing (e.g. isotonic saline) with

13
 shows syringe or gauze square,
progression avoiding cotton balls or
– Blood glucose other product that shed
within normal fibers
limit 4. Use appropriate barrier
– Free of infection dressing or wound covering
sign to protect wound and
surrounding tissue from
excoriating secretion/
drainage and to promote
wound healing
5. Carefully dress wounds and
stimulate circulation to
surrounding areas to assist
body’s natural process of
repair.
6. Maintain a moist
environment for wound
7. Practice and instruct client
in scrupulous hand washing
clean or sterile technique to
reduce incidence of
contamination or infection
8. Provide optimum nutrition
appropriate to diet planning
(including adequate protein,
lipids, calories, trace
minerals and multivitamins
[e.g., A, C, D, E]) to
promote skin health/healing
and to maintain general
good health
9. Administer/monitor
medication regimen (e.g.,

14
 antimicrobials, drip infusion
into osteomyelitis,
subeschar clysis, topical
antibiotics)

Risk for deficit fluid Goal: 1. Monitor input and output.

volume due to After 3 days nursing Note urine specific gravity
excess fluid intervention, risk for 2. Monitor orthostatic blood
excretion deficit fluid volume pressure changes
secondary to avoided and 3. Weigh daily
hyperglikemia demonstrate adequate 4. Maintain fluid intake at least
hydration 3000 ml / day within cardiac
Outcome criteria: tolerance with oral intake is
– Vital sign WNL resumed.
– CRT 2 second 5. Promote comfortable
– Balance intake environment. Cover patient
and output with light sheets to reduce/
– Electrolyte WNL replenish trans epidermal
water loss.

Collaborative:

6. Administer fluids as
indicated (e.g normal saline
with or without dekstrose)
7. Monitor electrolyte results

Disturbed sensory Goal 1. Note particular vision

perception; visual After 3 hours nursing problem (e.g., loss of visual
due to the decline intervention, patient can field, change in depth
of lenses ability to recognize/compensate perception, double vision,
focus for sensory impairments blindness) that affects
And Outcome criteria: client’s ability to perceive

15
Risk for injury due – Patient environment and
to vision problem demonstrate learn/relearn motor skills
using resources 2. Speak to visually impaired
effectively and client frequently, especially
appropriately when entering room/client’s
– Patient can presence to provide
Identify/ modify auditory stimulation and
external factors prevent startle reflex.
that contribute to 3. Position objects to take
alterations in advantage of intact visual
sensory/perceptu field, and use eye patch,
al abilities when needed, to decrease
– Be free of injury sensory confusion when
client has loss of vision or,
field of vision in one eye.
4. Supply adequate lighting for
reading and activities.
5. Place glasses/contacts
where they can be easily
found and encourage client
to wear corrective lenses
during waking hours.
6. Arrange bed, personal
articles, and food trays to
take advantage of functional
vision.
7. Maintain bed/chair in lowest
position with wheels locked
8. properly placing alarms/fire
extinguishers
9. Place assistive devices
(e.g., walker, cane, glasses,
hearing aid) within reach,
make sure call light is within

16
reach and client knows how
to operate it.

17
A. IMPLEMENTATION
Date Number
Implementation Evaluation
Time Dx

11-11-09 I – Maintain IVFD PZ 14 S: client said that they

drops/minute understand and will keep
– Monitoring her diet as it programmed
laboratory: blood O:
glucose, electrolyte, – Blood glucose: 264
Hb, Hct, Albumin, mg/dl Hb: 10,3 gr%
BUN, Creatinin albumin: 2,8
– Teaching client about – Client finish her meal
the importance of appropriate to her diet
keeping diet as it – Vital sign: T: 36,50C,
programmed RR: 20x/mnt, BP:
– Observing vital sign 110/70 mmHg, P:
– Injecting Humolin R 4 72x/mnt
IU per SC t.d.s (07-
A: Goal met partially
12-15)
– Helping and ensuring P: Continuing intervention
patient eat her meal
appropriate to her
II diet (B1 2100 kal)
– Injecting Humolin N 4
IU per SC od (0-0-1)
– Administering
antibiotic : ceftazidine
1gr t.d.s and
metronidazole 500 S:
mg IV t.d.s – Client complain about
– Cleansing and pain, redness and
irrigating wound swelling in his right
using normal saline, pedis

18
 smearing Garamicyn
cream then dressing
it with gauze and
Bactigras. Keeping
O:
aseptic and sterile
technique
– Teaching client about
scrupulous hand
III washing clean or
sterile technique to
reduce incidence of
contamination or
infection
– Observing vital sign
– Monitoring laboratory
A: goal not met yet
result :leukocyte
– Monitoring intake and P: continuing intervention
output
– Suggesting clients to
drink at least 2500cc/
day
– Monitoring electrolyte, S: client complain about
BUN, creatinin, blood
IV,V glucose O:
– Client said that they
will keep sterile
technique
– Vital sign: T: 36,50C,
RR: 20x/mnt, BP:
110/70 mmHg, P:
72x/mnt
– Leukocyte: 17.800
– Wound clean and
dressing well, there is
no skin regeneration
yet
urinate frequently
– Intake per oral: 2500
cc, parenteral: 1000 cc
– Output urine: 3000 cc
– Vital sign WNL
– CRT 2 second
– Blood glucose: 264
mg/dl
– BUN: 19,5, creatinin:
1,5
19
 – Electrolyte WNL: Ca: 9

Cl: 101, K: 4.5, Na: 140

– Placing alarm near A: Goal met partially

patient and teaching
P: continuing intervention
her how to operate it
– Suggesting client to
S: client said that they under-
place glasses or any
stand how to compensate
assistive device
the impaired of vision
within reach where
O:
she can easily found.
– Patient demonstrate
– Ensuring the light is
using resources
adequate for clients
effectively and
sight
appropriately
– Maintaining client’s
– Patient free of injury
bed and chair in
lowest position with A: goal met
wheels locked
P: intervention stopped

11-12-09 I – Injecting Humolin R 4 S: -

IU per SC t.d.s (07- O:
12-15) – Blood glucose: 252
– Monitoring mg/dl
laboratory: blood – Client finish her meal
glucose, electrolyte, appropriate to her diet
Hb, Hct, Albumin, – Vital sign: T: 36,50C,
BUN, Creatinin RR: 20x/mnt, BP:
– Observing vital sign 110/60 mmHg, P:
– Helping and ensuring 76x/mnt
patient eat her meal
A: Goal met partially
appropriate to her
diet (B1 2100 kal) P: Continuing intervention
II – Injecting Humolin N 4

20
 IU per SC od (0-0-1)
– Administering
antibiotic : ceftazidine
1gr t.d.s and
metronidazole 500
S:
mg IV t.d.s
– Client complain about
– Cleansing and
pain, redness and
irrigating wound
swelling in his right
using normal saline,
pedis
smearing Garamicyn
– Client said that they
cream then dressing
will keep sterile
it with gauze and
technique
Bactigras. Keeping
aseptic and sterile O:
technique
– Vital sign: T: 36,50C,
– Observing vital sign
RR: 20x/mnt, BP:
III
110/60 mmHg, P:
76x/mnt
– Wound clean and
dressing well, there is
no skin regeneration
yet
– Blood glucose: 252
mg/dl
– Monitoring intake and
output A: goal not met yet
– Suggesting clients to
P: continuing intervention
drink at least 2500cc/
day
– Maintaining IVFD 14
S: -
drops /minute
O:
– Intake per oral: 2500
cc, parenteral: 1000 cc

21
 – Output urine: 3000 cc
– Vital sign WNL
– CRT 2 second
– Blood glucose: 252
mg/dl

A: Goal met partially

P: continuing intervention

11-13-09 I – Injecting Humolin R 4 S: -

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

22
 it with gauze and technique
Bactigras. Keeping – Vital sign: T: 36,50C,
aseptic and sterile RR: 20x/mnt, BP:
III technique 100/60 mmHg, P:
– Observing vital sign 72x/mnt
– Wound clean and
dressing well, there is
no skin regeneration
– Monitoring intake and yet
output
A: goal not met yet
– Suggesting clients to
drink at least 2500cc/ P: continuing intervention
day
– Maintaining IVFD 14 S: client complain about
drops /minute urinate frequently
O:
– Intake per oral: 2500
cc, parenteral: 1000 cc
– Output urine: 3000 cc
– T: 36,50C, RR:
20x/mnt, BP: 100/60
mmHg, P: 72x/mnt
– CRT 2 second
– Blood glucose: 330
mg/dl

A: Goal met partially

P: continuing intervention

23
A. EVALUATION / DISCHARGE PLANNING

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

24