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A Case Study

Diabetes Mellitus Type II

“The Weakest Link”

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I. Health history

A. Demographic profile

 Name: R.G
 Gender: Male
 Age: 41 years old
 Birth date: September 23, 1967
 Birth place: Pasig , Metro Manila
 Marital status: Married
 Nationality: Filipino
 Religion: Born Again- Christian
 Address: Brgy. Pantihan 3, Maragondon, Cavite
 Educational background: High school graduate
 Occupation: Factory worker in Monterey
 Usual source of medical care: Doctor/Healthcare Professional

B. Source and reliability of information

 The patient R.G is the primary source of information. He is conscious and


coherent, able to speak Tagalog fluently. His wife is also considered as source of
information regarding patient status and condition.

C. Reasons for seeking care or chief complaint (Top 3)

 1st – Loss of his weight


 2nd – Insufficient sleep at night
 3rd – Scaly of skin

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D. History of present illness

Patient R.G was handled during our duty at Brgy. Pantihan 3,


Maragondon,,Cavite with the chief complaint of insufficient sleep at night, loss of his
weight and scaly of skin. The laboratory test and special treatment for the patient are
not applicable because this case is base on community setting.

E. PAST MEDICAL HISTORY OR PAST HEALTH

• Pediatric/childhood

-Incomplete immunization- (-) serious illness on this stage

• Injuries or accidents

-1992, right leg accident due to mishandling of machine

• Serious or chronic illness

-December 2003, Diabetes Mellitus diagnosed clinically

-2x FBS result 300mg/dl

-2006 Pulmonary Tuberculosis, diagnosed clinically

-Chest X-ray and sputum AFB examination

-2007 Urinary Tract Infections

-Urinalysis (pyuria)

• Hospitalization

-1992, Water Rose General Hospital

Admitting diagnosis: Right leg machine accident

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-December 2003, Rizal Medical Center, Pasig City, Metro Manila

Admitting diagnosis: Diabetes Mellitus Type 2

• Operation

-not applicable

• Obstetric History

-not applicable

• Immunizations

-incomplete immunization (unrecalled)

• Allergies

-No known allergies to food and medication

• Medication

-Metformin 500mg/tab

1 tab TID p.c.

-Gliclezide 80mg/tab

1 tab OD a.c.

-Vitamin B Complex tablet

1 tab OD

-Alaxan 500mg/tab (Paracetamol + Ibuprofen)

1 tab PRN for fever and pain

• Last Examination Date

-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila

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F. FAMILY HISTORY

(+)
DM

55 y/o 83 y/o
(+) (+)
HPN CVA

39 38
y/o y/o 37
y/o

41
y/o LEGEND:
37y/o
(+) DM

Female

Male

Patient

1
1 Deceased
16 15 1 9 y/o 2
3
y/o y/o y/ y/
y/
o o
o
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G. SOCIO-ECONOMIC STATUS

Mr. R.G. lives in their own house at Pantihan 3, Maragondon, Cavite. His wife is
selling and making barbeque sticks as the source of their income while his 16 years old
son works as a vendor in a wet market at Dasmarinas, Cavite as additional source of
income. They also received financial support from their relatives in Pasig. They can be
measured up as to poor class family. The patient is occasionally drinker of alcohol and
cigarette smoking.

H. DEVELOPMENTAL HISTORY
Generativity vs Stagnation
Maturity (35-45 yrs old)

A person may experience midlife crisis between the ages of 35-45 years old, the
“deadline decade”. This occurs when the individual recognizes that he has reached the
halfway mark of life and according to Erik Erikson, the developmental task of the
middle-aged adult is Generativity vs. Stagnation.
As to our patient, who belongs to a middle age group and is suffering from a life-
threatening condition, he had experienced this developmental crisis, which led him to be
non-productive.
Being non-productive led him to be stagnant after the occurrence and diagnosis of
his disease which made him to be dependent with his family, he can’t attend, function
and be able to accomplish his responsibilities as a father, a husband and as part of the
community.

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I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

Subjective Objective

General

“Ito nangangayat na dahil sa Weight: 35 kg. (July 10, 2009)


sakit ko” as verbalized by the 87 kg. (December 2003)
patient.
(+) wt. loss 48kg.
(+) numbness at times(lower
extremities)
(+)excessive sweats, axilla
(+)weakness
(-)malaise
(-)chills
(-)fever
BP- 130/80 Temp. – 36.5 °C

Integument

Skin:
“Hindi makati sa binti, pero ang (+)itchiness (upper extremities)
braso, nangangati” as verbalized (+)scaly skin
by the patient. (-)history of skin disease

Hair:
“Dati malago ang buhok ko” as Thinning of hair, evenly distributed
verbalized by the patient. (+)itchy scalp (scratching)
(+)Oily hair

Nails:

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“Ito matigas na ang kuko ko (+)clubbing of nails (long nails)
kumpara dati” as verbalized by (+)Yellowish nail beds
the patient.

Amount of sun exposure: Exposure to sunlight every morning


Head:
“Sumasakit ang ulo ko na parang (+)frequent headache
tinutusok” as verbalized by the (+)dizziness
patient. (-) lumps

Eyes:
“Malabo na ang paningin ko” as (+)blurry vision
verbalized by the patient. (+)PERRLA
(+)Anicteric sclera
(+)Pale conjunctiva
(+)itchiness
(-)discharge

Ears:
“Malinaw pa naman ang Both ears hears well when the examiner
pandinig ko, pero may sumasakit is 3 feet away
minsan” as verbalized by the (-)cerumen
patient. (-)discharge

Mouth and Throat:

“Medyo hirap akong lumunok” (+)difficulty in swallowing


as verbalized by the patient. (+)lesions on tongue
(+)dental carries
(+)hoarseness of voice
Pink tonsils

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(-)bleeding gums
(+) gag reflex

Neck:
“Wala naming problema sa leeg (-)stiffness
ko” as verbalized by the patient. (-)pain
(+)palpable bilateral lymphs

Breasts and Axillae:

“Pawisin ang kilikili ko” as (+)excessive sweating, axilla


verbalized by the patient. (-)lump
(-)pain
(-)rash
(-)nipple discharge

Respiratory:
“Medyo nahihirapan akong RR – 28 bpm
huminga” as verbalized by the (+)difficulty of breathing
patient. (+)barrel chest
Productive cough
History of lung disease: pneumonia,
PTB, 2006
Last chest x-ray: 2007

Cardiovascular
Central:

“Paminsan- minsan sumasakit (+)chest pain

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ang dibdib ko” as verbalized by (+)dyspnea on exertion (bed to chair)
the patient. (+)nocturia

Peripheral:

(+)coldness(general)
(+)pallor in hands
(+)clubbing of nails
(+)tingling (sole of feet)
(-)numbness
(-)varicose veins
(-)ulcers
0-1 second, capillary refill

Gastrointestinal:

“Eto madalas magan ako (+)good appetite


kumain” as verbalized by the Food intake tolerated
patient. (+)minimal dysphagia
(-)hematemesis
Frequency of BM: 3x a week
Characteristic of stool: yellowish-
brown in color, formed in consistency
(+)constipation (arch and formed stool)
(-)hemorrhoids

Urinary:

“Ihi ako ng ihi” as verbalized by (+)polyuria


the patient. (+)dysuria

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(+)nocturia
Dark Yellow in color
History of urinary disease: UTI(2006)

Genitalia:
Refused
Musculoskeletal:

“Kumikirot ang kasukasuan at (+)minimal pain, knee area and ankle


buto-buto ko” as verbalized by (+)pain, calf area
the patient. (+)lower back pain, radiating
(+)weakness, leg muscles

Neurologic:

“Alam ko pa naman ang mga (-)history of seizure, stroke, fainting


sinasabi ko ngayon” as Mental:
verbalized by the patient. (-)nervousness
(+)depression
Self-pity and crying
Motor function:
(-)tremors
(-)paralysis
Sensory function:
Oriented to time, person and place

Hematologic:

“Pagkakaalam ko,wala naman (-)bruises


akong sakit sa dugo” as (+)palpable lymph nodes
verbalized by the patient. (+)bleeding tendency of skin (scaly

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skin)
(-)history of Blood Transfusion

Endocrine:

“Sa pamilya naming may (+)DM, type II


Diabetes, kaya ako merong (+)polydypsia
Diabetes” as verbalized by the (+)polyuria
patient. (+)polyphagia
(+)weight loss
(+)change in skin texture, scaly skin
(+)excessive sweating, axilla
(-)nervousness
(-)tremors

Cranial Nerves Assessment

I. Olfactory Nerve - Normal


II. Optic Nerve - Blurry vision
III. Oculomotor - Normal
IV. Trochlear - Normal
V. Abducens - Normal
VI. Trigeminal - Normal
VII. Facial - Normal
VIII. Acoustic - Normal
IX. Glossopharyngeal - Normal
X. Vagus - Normal
XI. Spinal Accessory - Normal
XII. Hypoglossal - Normal

J. FUNCTIONAL ASSESSMENT

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I. Health Perception/Health Management Pattern

Mr. R.G. is a 41 yrs old, male and seriously ill person. Once he felt something wrong
about his condition, he seeks for medical advice. Occasionally, he also had colds in the past. Last
December 2003, after a consultation from a physician and with accompanying lab result of blood
sugar level (2x done, result is increased 300mg/dl) he was diagnosed of DM type 2. The client
believes that he acquired his illness from his grandfather who also had Diabetes Mellitus.
According to Mr. R.G., eating nutritious food, exercise and religiously taking of prescribed
medication or what nurse’s and Doctor’s advise/suggest will keep him healthy. Due to financial
incapacity, this regimen was not taken into consideration.

II. Self Esteem, Self Concept/Self Perception Pattern

Before he was diagnosed with DM type 2, Mr. R.G. is a responsible husband and father
to his wife and kids. He was able to provide the needs of his family. The client possessed a jolly
and fun loving type of personality.
Since his illness started, most of the time, he felt self-pity and worthless. He is always
irritable and angry when he thinks that he was ignored. Because of his condition he became more
depress and the only thing that gave him hope and strength is through prayer.

III. Activity-Exercise Pattern


Perceived ability for: (Refer to Functional Level Code)

Feeding Level II Grooming Level II


Bathing Level II General Mobility Level II
Toileting Level II Cooking Level IV
Bed Mobility Level II House Maintenance Level IV
Dressing Level II Shopping Level IV

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Functional Level Code

Level 0 Full Self Care


Level I Requires Use of Equipment or Device
Level II Requires Assistance or Supervision from Another Person
Level III Requires Assistance or Supervision from Another Person and
device
Level IV Is Dependent and Does Not Participate

IV. Sleep/Rest Pattern

The patient had altered sleep pattern. Each day he only had a maximum of 2 hours of
sleep and despite of that he still fells god upon waking up. He said sometimes the pain he felt put
him into sleep.

V. Nutritional/ Elimination

The patient usually takes a glass of milk in his breakfast and he takes heavy meals more
frequently but after eating he usually felt stomach ache. He has supplements of vitamin B-
complex. He typically drinks more than an 8 glasses of water per day. Patient stated that prior to
his illness he weighted 87kgs but at present he weighs 39kgs.
We noticed that the patient skin is scaly all over his body. He also have lesion in his
tongue and positive dental carries.
The patient usually had 3x bowel movement per week with a dark yellowish brown color
stool, with hard formed in consistency. On the other hand he noted that he frequently void with
dark yellow in color urine and felt some discomfort when urinating.
During the day patient is experiencing excessive sweating in his armpit.

VI. Sexually- Reproductive Pattern

The patient is inactive in sexual intercourse due to present condition

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VII. Interpersonal Relationship / Resources

Patient can speak and understand English and Tagalog. He can clearly express himself.
He has 6 children and they were close to each other.
Before patient is very active and usually socializes with his neighbors.
Patient R.G’s family was very supportive and understanding, now that he is battling with
his disease.
The patient is dependent due to his illness.

VIII. Coping and Stress Tolerance

Before when patient R.G is anxious he wants to be alone, when he is stressed, he prefers
to drink liquor and involved himself in gambling.
When he was diagnosed of DM Type 2 there have been many changes occurred that
made difficult for him to adjust. He cannot perform the usual activities that he had before. When
patient R.G is stressed, he prefers to cry until he falls asleep. When it comes to problem, he tried
to calm himself through prayers.

IX. Values-Belief Pattern

Patient R.G is a Born Again Christian, before according to the client he always hears
mass every Sunday with his family.
Due to his illness he wasn’t able to go to mass. According to the patient there are many
practices affects his illness.
He wasn’t able to follow therapeutic regimen due to financial problem and a strong faith
to God helps him to get through all the suffering he has.
After what happened, patient R.G is still not seeking for medical assistance due to
financial problem. Religious effort is still a part of patient R.G.’s life.

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X. Personal Habits

Before, patient R.G. used to maintain a good personal hygiene and had a diet without
restriction. He used to work as a factory worker 6 days per week and was able to help in doing
household chores when he got home. He had a good sleep pattern of almost 8 hours at night.
Every Sunday he goes to mass with his family and occasionally at his free time he drinks and
smoke with his friends.
At present, due to his illness, patient R.G wasn’t able to perform his usual routine. He had
to stopped from working in able to attend his health needs and become dependent to his family.

XI. Concept Map Demographic Profile:


Name: R.G
Gender: Male
Age: 41 years old
Marital status: Married
1. Imbalanced nutrition: less 3. Activity
Religion: Born Again-Christian
than body requirements intolerance related to
Occupation: Factory worker in
related to deficient insulin generalized weakness
Monterey
Educational Background: High

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2. Disturbed sleep pattern 4. Impaired skin integrity
related to prolonged discomfort related to impaired
secondary to disease process metabolic state
5. Risk for infection
related to
inadequate primary
defense

II. PROBLEM LIST

1. Imbalanced Nutrition Less than body requirements

2. Disturbed Sleep Pattern

3. Impaired Skin Integrity

4. Activity Intolerance

5. Risk for Infection

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III.

A.) ACTUAL OR ACTIVE PROBLEM

Problem No. Problem Date Identified Date Resolved Remarks


Imbalanced July 09, 2009 July 16, 2009 Client appetite was
1 Nutrition Less increase.
than body
requirements
2 Disturbed Sleep July 09, 2009 July 16, 2009 The client can sleep
Pattern now from 4-6 hours
unlike before.
Impaired Skin July 09, 2009 July 16, 2009 The wound is clean
3 Integrity and dry.
Activity July 09, 2009 July 16, 2009 The client able to
4 Intolerance perform some
minimal ADL

B.) High Risk or Potential

Problem No. Problem Date Identified

1 Risk for infection July 09, 2009

IV. NURSING CARE PLAN ( At The Last Page)


V. ANATOMY AND PHYSIOLOGY

ENDOCRINE SYSTEM
Homeostasis depends on the precise regulation of the organ and organ systems of the body. The
nervous and endocrine system are two major systems responsible for that regulation. Together
they regulate and coordinate the activity of nearly all other body structures. When these system

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fail to function properly, homeostasis is not maintained. Failure ofsome component of the
endocrine system to function can result in disease such as Diabetes Mellitus or Addison’s
disease.
The regulatory function of the nervous system and endocrine systems are similar in some
respects, but they differ in other important ways. The nervous system controls the activity of
tissues by sending action potentials along axons, which release chemical signals at their ends,
near the cell they control. The endocrine system releases chemical signals into the circulatory
sytem, whichh carries to all parts of the body. The cell that can detect those chemical signal
produce reponses.
The nervous system usually acts quickly and has short term effects, whereas the endocrine
system usually response more slowly and has longer-lasting effects. In general, each nervous
stimulus controls a specific tissue or organ, whereas each endocrine stimulus controls several
tissues or organ.

FUNCTIONS:
• It regulates water balance by controlling the solute concentratiuon of the blood.

• It regulates uterine contractions during delivery of the newborn and stimulates milk
release from the breast in lactating females.

• It regulates the growth of many tissues, such as bone and muslces, and the rate of the
metabolism of many tissues, which helps maintain a normal body temperature and
normal mental function. Maturation of tissues, which result in the development of adult
features and adult behavior, are also influence by the endocrine system.

• It regulaytes sodium, potassium and calcium concentrations in the blood.

• It regulates the heart rate and blood pressure and helps prepare the body for physical
activity.

• It regulates blood glucoce levels and other nutrient levels in the blood

• It helps control the production and function of immune cells.

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• It controls the development and the function of the reproductive systems in males and
females.

Pancreas
 an elongated gland extending from the duodenum to the spleen; consist of a head, body,
and the tail. There is an exocrine portion, which secretes digestive enzymes that are
carried by the pancreatic duct to the duodenum, and pancreatic islet, which secrete insulin
and glucagon.

 The endocrine part of the pancreas consists of pancreatic islets (small islands; islet of
Langerhans) dispersed among the exocrine portion of the pancreas. The islets secrete two
hormones –insulin and glucagon—which function to help regulate blood nutrient levels,
especially blood glucose.

 Alpha cells of the pancreatic islets secrete glucagon.

 Beta cells of the pancreatic islet secrete insulin.

 It is very important to maintain blood glucose levels within a normal range of values. A
decline in the blood glucose levels within a normal range causes the nervous system to
malfunction because glucose is the nervous system’s main source of energy. When blood
glucose decreases, other tissues to provide an alternative energy source break fats and
proteins rapidly. As fats are broken down, the liver to acidic ketones, which are release
into the circulatory system, converts some of the fatty acids. When blood glucose level
are very low, the break down of fats can cause the release of enough fatty acid and
ketones to cause the pH of the fluids to decrease below normal, a condition called
acidosis. The amino acids of proteins are broken down and used to synthesize glucose by
the liver.

 If blood glucose levels are too high, the kidneys produce large volumes of urine
containing substantial amounts of glucose because of the rapid loss of water in the form
of urine, dehydration result.

 Insulin is released from the beta cells primarily response to the elevated blood glucose
levels and increased parasympathetic stimulation that is associated with digestion of a

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meal. Increase blood levels of certain amino acids also stimulates insulin secretion.
Decreased result from decreasing blood glucose levels and from stimulation by the
sympathetic of the nervous system. Sympathetic stimulation of the pancreas occurs
during physical activity. Decreased insulin levels allow blood glucose to be conserved to
provide the brain with adequate glucose and to allow other tissues to metabolize fatty
acids and glycogen stored in the cell.

 The major target tissues for insulin are the liver, adipose tissue, muscles, and the area of
the hypothalamus that controls appetite, called satiety center (fulfillment of hunger).
Insulin binds to membrane-bound receptor and, either directly or indirectly, increases the
rate of glucose and amino acid uptake in these tissues. Glucose is converted to glycogen
or fat, and the amino acids used to synthesize protein.

 Glucagon is released from the alpha cell when blood glucose level is low. Glucagon
binds to membrane-bound receptors primarily in the liver and caused the conversion of
glycogen storage in the liver to glucose. The glucose is then released into the blood to
increase blood glucose level. After a meal, when blood glucose levels are elevated a
glucagon secretion is reduced.

 Insulin and glucagon function together to regulate blood glucose levels. When blood
glucose increase, insulin secretion increases, and glucagon secretion decreases. When
blood glucose levels decrease, the rate of insulin secretion declines and the rate of
glucagon secretion increase. Other hormones, such as epinephrine, cortisol, and growth
hormones, also function to maintain blood levels of nutrients. When blood glucose level
decrease, these hormones are secreted at a greater rate. Epinephrine and cortisol caused
the breakdown of protein and fat and the synthesis of glucose to help increase blood
levels of nutrients. Growth hormone slows protein breakdown and favors fat breakdown.

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VI. PATHOPHYSIOLOGY

Diabetes Mellitus Type 2 is referred to as non-insulin dependent diabetes mellitus


(NIDDM), or adult onset diabetes mellitus (AODM).In case our patient we classified the risk
factor into two categories the modifiable and non-modifiable. Under modifiable is the diet
because diet high in cholesterol increases number of adipose tissue and this tissue are resistant to
insulin therefore glucose uptake by cell is poor and the stress because stress stimulates secretion

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of epinephrine, norepinephrine and glucocorticoids and this neurotransmitters increases glucose
level. In the non-modifiable factor hereditary because it can be transfer from parents to offspring.
In the case of our his father has a diabetes also. And the age with strong heritability patterns
which present as type 2 diabetes early in life, usually before 30 years in the case of our patient he
was diagnosed at the age of 37 years old. In type 2 diabetes, can still produce insulin, but do so
relatively inadequately for their body's needs, beta cells are primary affected and there is a poor
production of insulin. Insulin is also the principal control signal for conversion of glucose to
glycogen for internal storage in liver and muscle cells. Lowered glucose levels result both in the
reduced release of insulin from the beta cells and in the reverse conversion of glycogen to
glucose when glucose levels fall. If the insulin is deficient the intracellur and the intravascular
space are affected. In the intracellular space there is a failure of glucose to enter in the
intracellular space because there is a lack of insulin and insulin acts as the key to be able the
glucose to enter in the cell. And when this happened the glucose supposed to be absorb by the
cells are staying in the blood and this term is hyperglycemia. If cell was not able to absorb the
sugar their will be intracellular and extracellular dehydration and body will compensate and the
person will have the urge to drink more water it is term polydipsia. Also if cell has no glucose
intake their will be cellular starvation and the person will have the urge to eat and eat and it is
termed polyphagia.

In the intravascular area if the insulin is insufficient and glucose are not absorb by the cell the
glucose is staying in the blood stream and the glucose level in the blood will increase as the
sugar in blood increase the blood circulation will become viscose. Prolonged high blood glucose
level leads to sluggish circulation and when the glucose concentration in the blood is raised
beyond its renal threshold, reabsorption of glucose in the proximal renal tubuli is incomplete, and
part of the glucose remains in the urine (glycosuria). This increases the osmotic pressure of the
urine and inhibits reabsorption of water by the kidney, resulting in increased urine production
(polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water
held in body cells and other body compartments, causing dehydration and increased thirst. In a
sluggish circulation due to high blood content in blood the oxygen supply in the peripheral site is
insufficient and when this happened there is a proliferation of microorganism in the case of our
patient his wound doesn’t easily heal due to poor oxygen delivery and microorganism take place
and multiply.

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Pathophysiology

Modifiable Non-modifiable
• Diet • Hereditary

• Stress • Age

Poor production of Beta 24


cells delivery Increase Osmotic
ECF/ICF
Intracellular: failure of glucose to Poor oxygen
Proliferation of Intravascular: increase glucose
Polyphagia pressure
Systemic in renal
blood
Polydipsia
dehydration Hypergylcemia Cell Starvation Insulin
enter in ICS tomicroorganism
peripheral area
Deficiency in bloodSluggish circulation
Polyuria
tubules
Viscosity
Poor
wound
VII. MEDICAL MANAGEMENT healing
A. Pharmacotherapeutics/Medicines
GN (BN) Indication Nursing Responsibilities
Classification stock (Client specific) And Implications
Dosage and Frequency (Pre,Intra,Post)
Generic Name: Metformin Indication: Pre:
Brand Name: Formet  Treatment for NIDDM  Check for allergies
Classification: Anti-diabetic (Type II) not  Ask for history of heart
agent responding to dietary disease (for dose

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modification adjustment)
Intra:
Dosage and Frequency:  Take with meal
 Tell patient not to
500mg/tab TID crush, chew or break
1 tab TID (may cause too much
of drug to be released
at one time)
Post:
 Test blood (to assure
that Metformin is
helping the patient’s
condition)
 Advice patient to avoid
drinking alcohol (may
decrease blood sugar
and increase risk of
lactic acidosis)

Generic Name: Gliclazide Indication: Pre:


Brand Name: Ritemed  Type 2 diabetes not  Check the patient for
Gliclazide controlled by diet allergies
Classification: antidiebetic alone Intra:
agent  Take with meal
Dosage and frequency:  Instruct the patient to
swallow the tablet
80 mg/tab whole, without
1 tab OD breaking, crushing or
chewing it, it may
cause too much of drug
to be released at one
time
Post:
 Advice the patient not
to drink alcohol
because it may cause
severe decrease of
blood sugar
Generic Name: Indication: Pre:
Vitamin B Complex  Dietary supplement for  Ask patient if he is
Classification: food certain patient who do taking any prescription
supplement not receive a proper or non prescription
amount of vitamin medicine, herbal
from the diet preparation or dietary
Dosage and frequency: supplement
1 tab OD

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 Ask the patient if he
has allergies to
medicines, foods or
other substances (some
meds may interact with
vitamin B)
Intra:
 May be given with or
without food, if
stomach upset occurs,
take with food to
reduce stomach
irritation
 Advise the patient to
take it as soon as
possible if he missed a
dose
 Tell the patient to skip
missed dose if it is
almost time for the
next dose and go back
to the regular dosing
schedule
 Remind patient not to
take two doses at once
Generic Name: Indication: Pre:
Iboprofen+Paracetamol  Relief of mild to  Check the patient for
Brand Name: Alaxan moderately severe pain allergies
Classification: NSAID of musculoskeletal Intra:
origin  Take with food to
lessen stomach upset
Dosage and frequency: Post:
500mg/tab  Instruct patient not to
1 tab PRN continue taking drug
more than 10 days for
pain or 3 days for fever

VIII. DISCHARGE HEALTH TEACHING PLANS


Content Strategy
1.Compliance Medication Metformn(Formet) • Do not crush, chew or
500mg/tab, 1tab TID, take break. Avoid drinking
with meal. alcohol.

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Gliclazide • Take with meal swallow
80mg/tab, 1tab OD whole, without breaking,
chewing or crushing it (it
may cause too much of
drug to be released at one
time.
• Do not drink alcohol (it
may cause severe decrease
of blood sugar.

Vitamin B complex • If missed a dose, take


1tab OD, take with/ without as soon as possible skip-
food. missed dose if it is almost
time for the next dose and
go back to regular dosing
schedule.
Ibuprofen+paracetamol • Do not continue taking
500mg/tab, 1 tab PRN, take drug more than 10 days for
with food. pain or 3 days for fever.
2. Diet Low carbohydrate diet • Reduce intake of rice

High fiber diet • Eat fruits and


vegetables
• Teach patient to read
labels of "health" foods
because they contain sugar
product such as honey,
brown sugar and corn
syrup.
3.Exercise Light stretching • Flexing and extending

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very slowly of upper and
lower extremities.
Rotating of the extremities
at a very light and slow
motion.

Chin to chest • Touch chin to the chest


slowly

Head to shoulder • Flex the head to the


right and to the left
shoulder at a very slow
movement.
• Note: the exercise
should be done with
assistance of significant
others at a very slow
motion to avoid further
complication.
4. Activity/Lifestyle Positive reinforcement • Give positive
reinforcement for self-care
behaviors.
Changes instruct family to
assist in the situation of the
client.
• Have a regular interaction
with patient to avoid low
self-esteem.
Social support is very
important to the client.

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IX. SUMMARY OF CLIENT STATUS OR CONDITION AS OF LAST DAY OR
CONTACT

Date Problems encountered (actual and resolved)


Actual problems that are identified are and have been resolved last
July 9, 2009 July 16, 2009:

First is imbalanced nutrition: less than body requirements. As


evidence by verbalization of the client and based on the assessment
done that the client really loss weight. It should be the first priority, to
meet the metabolic needs of the body by intake of sufficient nutrients
and able to gain weight. Because of the necessary nursing interventions
that have been done the client’s appetite increased.

Second is disturbed sleep pattern. As evidence by verbalization of


the client “di ako masyado makatulog sa gabi, lagi akong pagising
gising”. And based on the assessment done that there are (+) sunken
eyeballs and weakness. It should be the second priority because the
client is experiencing a insufficient time or period of sleep. The
necessary nursing interventions should be done for the client to be able
to maintain a comfortable environment. After doing so, the client
verbalized improvement in sleep pattern and can sleep now from 4-8
hours.

Third is impaired skin integrity. As positively evidence by skin


disruption of skin surface and as verbalized by the client that “para na
nga akong isda na kinakaliskisan eh, naniniklap na yung balat ko”.
Necessary nursing interventions should be done; and after doing so the
client’s wound becomes dry and clean.

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And Forth is activity intolerance. It should be identify for the
client to have sufficient energy to endure or complete required or
desired daily activities. The problem was evidence by verbalization of
the client that “di na ko makalabas ng bahay at di na rin ako makatayo
ng matagal” and positive immobility, weakness and weight loss based
on the assessment done. Because of the necessary nursing interventions
that have been formulated the client was able to perform some minimal
ADL.

July 9, 2009 There is a potential problem that had been identified during our
contact with the client and this is risk for infection due to the disruption
of the skin which is the primary defense. Necessary nursing
interventions should be done to prevent infection and complications.

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