I.

DEMOGRAPHIC DATA

NAME: L.F.L

AGE: 45

ADDRESS: 031 Payatas B, Quezon City

GENDER: Female

DATE OF BIRTH: Nov. 27,1964

PLACE OF BIRTH: Butuan City

CIVIL STATUS: Married

OCCUPATION: Housewife

RELIGION: Roman Catholic

EDUCATIONAL ATTAINMENT: High School Graduate

II. NURSING HISTORY

PAST HEALTH HISTORY

The client verbalized that she has a complete vaccine, “Sabi kasi ng mga
magulang ko kumpleto ako ng vaccine”. She doesn’t have any diseases
when she was a child. Fever,cough and colds are the illnesses that she
encountered. And to threat this illnesses she always taking self prescribed
medicines like solmux, neozep and biogesic. She doesn’t have any allergies,
accidents and injuries. She also told us that it is her first time to be
hospitalized.

FAMILY HISTORY OF ILLNESS

She verbalized that her father was died because of “kulam”. “yun kasi yung
sabi nila kung bakit namatay, dahil daw sa kulam. Three years old ako nung
namatay sya kaya wala ako masyadong alam sa kanya”’ she added. Her
mother was died because of myoma at the age of 39. Her grandmother and
her grandmother (mother side) was died because of hypertension. “Yung lolo
at lola ko sa father side namatay sa katandaan”, she added. She also said
that they doesn’t have a history of diabetes.
 III.PATTERNS OF FUNCTIONING

HEALTH PERCEPTION AND HEALTH MANAGEMENT

For the client, being health means that you are taking good care of
yourself by means of taking a bath per day and by brushing her teeth 2x a
day, one in the morning and one in the evening. But she is not trimming her
nails since she was confined to the hospital. She rated her health as 9, 1 as
the lowest and 10 as the highest because she said that “inaalagaan ko ang
sarili ko, umiiwas ako sa bisyo, malinis ako sa katawan at lagi ako
nagpapachek-up lalo na kung kinakailngan”. She visits her physician
whenever she feels strange on her body especially when she was sick and
has fever.

She also stated that her husband is a chain smoker. “Naninigarilyo yung
asawa ko pero sa labas ng bahay kasi meron akong maliliit na mga apo”, she
added. She verbalized that there is a junk shop near their house. “Minsan
mabaho sa amin kasi nagsusunog sila ng copper tska alambre”, she stated.
She added that their ventilation is ok, “Ok naman kasi medyo maluwang
naman yung bahay tska may mga puno naman sa harap bakuran”. She
added “May mga alaga din akong baboy. 10 years na akong nagaalaga, yung
kulungan nasa likod naman ng bahay. Hindi naman nangangamoy.”

She takes metoprolol once a day for her health maintenance in

hypertension. The client usually cooks for herself before, but now that she
was hospitalized, she cannot prepare his own food because of her condition.
She said that it is alright because she knows that it is for the good of her
condition.

NUTRITIONAL AND METABOLIC PATTERN

Our client stated that proper nutrition is eating nutritious food. “Sa palagay
ko naman ay kumakain ako ng masustansyang pagkain kasi ospital ang
nagbibigay ng pagkain”, she also stated. She also told us that she hates
eating spicy foods, “Mas gusto kong kumain ng mga gulay katulad ng pechay
basta mg adahon dahon wag lang maanghang”. She usually eats at their
house together with his family. She also stated that she have sudden weigth
loss. “Hindi naman ako ganito kapayat dati, pero gawa ng akoy maospital eh
medyo pumayat ako”. She sometimes experiencing eating difficulty of eating
foods because of her illness.,”Minsan nawawalan akong ganang kumain,
marami kasing bawal”

3 DAY DIET RECALL

TUESDAY (AUGUST
10, 2010)

BREAKFAST LUNCH MERIENDA DINNER

1 medium bowl of 1 serving of adobo 2 pcs. Of tasty 1 medium bowl of

lugaw (1 pc. Chicken) bread lugaw

½ slice of orange 1 medium bowl of 1 glass of 1 serving of paksiw

lugaw pineapple juice nab angus(1/4 na
I pc. Of banana bangus)
(240 ml)
(lakatan) ½ serving of pansit

1 pc of banana

(1L/day of water)

WEDNESDAY
(AUGUST 11, 2010)

BREAKFAST LUNCH MERIENDA DINNER

2 pcs. Medium 1 medium bowl of skipped 1 serving of

sized of pandesal lugaw chopsuey
w/ meat loaf
1 serving of 1 medium bowl of
½ glass of sinabawang baka lugaw
powdered milk
1 serving of
adobong manok
 (1L/day of water)

THURSDAY
(AUGUST 12, 2010)

BREAKFAST MERIENDA DINNER

2 pcs. Medium 1 medium slice of skipped 1 medium bowl of

sized of pandesal papaya lugaw
w/ sausage
1 serving of 1 plate of pansit
½ glass of sinabawang baka
powdered milk 1 serving of
1 medium bowl of adobong baboy
lugaw
(1 matchbox sized)

(1L/day of water)

SLEEP AND REST PATTERN

The client usually sleeps 5-6 hours at night and she feels unrefreshed
every time she wakes up. “Putol-putol tulog ko kasi ihi ako ng ihi. Tapos para
akong pagod pagkagising ko”, she verbalized. She usually sleeps at 11pm
and wakes up at 5am. Watching TV and drinking milk helps her to easily fall
asleep. She is not engaged in self relation and any other activities. The client
sleeps in a room that have proper ventilation. She usually takes nap during
siesta on about 1-2 hours a day. She verbalized, “Natutulog na lang ako sa
hapon para makabawi ng tulog”.she is not using any drugs to fall her sleep.
She wants to sleep in lights off.

ELIMINATION PATTERN

The client usually defecates at least 1-2 times a day. She verbalized,
“dumudumi ako tuwing umaga pagkagising ko”. She usually goes to comfort
room when ahe feel the urge to defecate. She describes their comfort room
clean and have adequate space. She desribe her stool smooth, brown in
color and have foul odor. She was not experiencing any problems regarding
her bowel movement.

With regards in her urination, she said, “ihi ako ng ihi kaya pati pagtulog ko
naiistorbo”. The client describe her urine having yellowish color. She also
said that she has not experiencing any pain when she urinates. Pakiramdam ko
tuloy lagi akong nanghihina saka nauuhaw” she also added.

Self-Perception Pattern

The client perceived herself before hospitalization as a healthy and

happy person because “Inaalagaan ko naman ng mabuti yung sarili ko” as
verbalized by the client. She also added that she usually interacts with other
people to make herself happy. She verbalized “maayos naman akong tao,
para sakin malusog ako, kundi lang talaga ako nahospital”. She thinks of
herself as a healthy wife who takes good care of his husband and family. She
also verbalized “sana nga hindi na lang ako nagkasakit, hindi ko tuloy
masubaybayan yung pamilya ko ng mabuti”. She verbalized “para mas
maging maayos ako, inaalagaan ko naman ng mabuti sarili ko kahit may
sakit pa ako, minsan, irritable lang kasi medyo mainit tapos madami pa
nagtatanung na estudyante”

ROLE RELATIONSHIP PATTERN

The client said that she is currently living with her family. The client
stated that “ hindi naman mawawala ang problema sa isang pamilya, pero
syempre inaayos naming ito kaagad” .She said that voicing out her opinions
relieved her. According to her she is satisfied with her role in the family,
being the mother, and the wife. Right now the client is not going through big
changes in her life.

COGNITIVE PATTERN
 The client is not having difficulty in hearing, understanding following
instructions, except for she is having some difficulty in reading, the client
stated “ Malabo na mata ko, may salamin ako sa bahay,” the client uses
reading glasses with the grade of 100 both eyes.

VALUES AND BELIEF PATTERN

With regards to the Values and Belief of the client she stated that
“para maging healthy kaylangan mong magtrabaho sa bahay para di ma
stroke”. For her health is important she said that it is 100% important. She
has no religious practices relevance to her health. And she stated that
religion is very important for her because it helps a lot when she is dealing
with her problems in life.

SEXUALITY PATTERN

With regards to the sexuality of the client she said that she has no
difficulty with her opposite sex. She express herself by dressing and
grooming herself. until now she is engage in sex. But not often as before.
And her menstrual cycle is regular. And the client said that she is satisfied
with her sexuality. And she doesn’t have any diseases regarding her
reproductive system.

COPING STRESS TOLERANCE PATTERN

With regards to the coping stress tolerance of the client she stated that
“ pag nagkakasakit ako ganun ang nakaka stress sakin dahil di ako makapag
trabaho sa aming bahay at para mawala ito umiinom ako ng gamot at ako
ay nagdadasal. Nakakatulong naman ang mga paraan kong ito para ang
aking stress. The client has no big changes in her life in the past two years.
And whenever she is encountering problems in her life she prays a lot. And
by that she will feel relieved.

IV. ACTIVITIES OF DAILY LIVING

 PATTERN BEFORE AFTER INTERPRETATION
HOSPITALIZATION HOSPITALIZATION and ANALYSIS
Nutrition The client eats The client still Decreased
three times a day eats three times metabolic activity
the client prefer a day but she and decrease
foods with soup only consumed 1 physical activity
such as sinigang cup of rice during mean a decrease
and can her stay in the in caloric need.
consumed 1 ½ hospital and (Kozier 8th
cup of rice, the drinks 1 litter of edition,
client has no water a day Fundamentals of
allergies to any Nursing page
kind of food and 1243)
drinks 2 liters of
water a day.
Elimination According to the During her stay in Although peoples
client she the hospital the pattern of
urinates six times client doesn’t elimination ate
a day and know how many highly individual
defecate twice times she most people void
during the urinates because about 5 to 6
morning and she has a times a day.
afternoon, she catheter and she (Kozier 8th
described that only defecate edition,
her feces is once a day. Fundamentals of
brown, Nursing page
1290)
Activity and The client states The client always Exercise and
Exercise that when she is stays at bed, sit Activity are
at home she and walk in the essential
always clean the hallway. components for
house and wash maintaining and
their clothes and regaining health
this is her and wellness.
exercise (Kozier 8th
according to her. edition,
Fundamentals of
Nursing page
 1160)
HYGEINE The client told Since Personal hygiene
that she takes a hospitalization, is the self-care by
bath once she cannot take a which people
everyday, bath everyday attend to such
brushes her teeth because of her functions as
everyday twice, sickness. Her bathing, toileting,
one in the sister wipes her general body
morning and one body for her hygiene, and
in the evening. using a wet grooming.
She said that towel. In terms of Hygiene is a
over all, she brushing her highly personal
observes proper teeth, she still matter
hygiene. brushes her teeth determined by
twice a day. individual values
and practices. It
involves care of
the skin, hair,
nails, teeth, oral
and nasal
cavities, eyes,
ears, and
perineal-genital
areas. (Kozier 8th
edition,
Fundamentals of
Nursing page
742)
SUBSTANCE The client does The client does Lifestyle refers to
ABUSE not smoke or not smoke, drink, a person’s
drink alcoholic nor uses illicit general way of
beverages. The drugs. living, including
client does not living conditions
use any illicit and individual
drugs. “Ayoko patterns of
uminom o behaviour that
manigarilyo, are influenced by
masama yan” sociocultural
factors and
personal
 characteristics.
(Kozier 8th
edition,
Fundamentals of
Nursing page
301)
SLEEP AND REST According to the There are days of Most healthy
client, she usually difficulty of adults need 7 to
sleeps 10 in the sleeping. She 9 hours of sleep a
evening and sleeps night, (National
wakes 7 in the intermittently Sleep Foundation,
morning. The because of the n.d.b.). However
client does not temperature. She there is individual
have any verbalize that it is variation as some
problem when hot and probably adults may be
sleeping. Before because of her able to function
she sleeps, she sickness well (e.g., without
washes her face sleepiness or
as her ritual. drowsiness) with
6 hours of sleep
and others may
need 10 hours to
function
optimally. (Kozier
8th edition,
Fundamentals of
Nursing page
1168)
SEXUAL ACTIVITY The client The client During middle
verbalized “Oo, verbalized that adulthood both
nag gaganun pa “syempre hindi men and women
kami ni mister na” experience
bago ako decreased
nahospital, active hormone
pa”. The client production,
also verbalized causing the
that comparing climacteric,
before, they are usually called
not that active. menopause in
women. (Kozier
 8th edition,
Fundamentals of
Nursing page
1021)

V. Physical Assessment

Physical Assessment
Area of Evaluation
Normal findings Actual findings
Assessment

Proportionate, endomorph Normal

Body build,
varies with
height, weight Wt: not taken
lifestyle

Relaxed, erect normal

Posture and
posture;
gait, standing Relaxed
coordinated
sitting walking
movement

Overall hygiene normal

Clean, neat Clean, neat
and grooming

No body odor or normal

minor body odor Has no notable
Body and
relative to work or body odor and
breath odor
exercise; no breath odor
breath odor

Signs of No distress noted There is distress Deviated

distress in noted from
posture and Normal
facial
expression

Obvious signs The client has Deviated

Healthy
of health and slightly weak looking from
appearance
illness appearance Normal

Cooperative, able Normal

Cooperative, able to
Attitude to follow
follow instructions
instructions

Appropriate to Appropriate to Normal

Affect/mood
situation situation

Understandable, Deviated
moderate pace; from
Quantity and
clear tone and Speech not clear, Normal
quality of
inflection; exhibits soft spoken
speech
thought
association

Relevance and Logical sequence; Logical sequence; Normal

organization of makes sense, has makes sense, has
thoughts sense of reality sense of reality

HEAD  Rounded  Rounded

(normocepha (normocephali
Normal
lic and c)
Skull symmetric
with frontal,
occipital and
parietal
prominence)
; smooth
skull  n/a
contour;
 Absence of
nodules and
 masses
 Lighter than
facial skin,
Normal
moist, no
 Lighter than
scar;
Scalp facial skin, no
 No lesions
scar
and
 n/a
tenderness
upon
palpation
 Evenly Normal
distributed;
Normal
 thick; silky  Evenly

Hair and distributed

resilient;  thick
 no infection  n/a
or
infestation
 Symmetric Normal
facial
 Symmetric
Face features
facial features
 Symmetric
 n/a
facial
movements
 No lesions Normal
 No lesions
EYES and
and
inflammatio
inflammations
ns
Eyebrows  Hair evenly  Hair evenly
distributed; distributed
Normal
skin intact  Symmetrically
 Symmetricall aligned; Normal
y aligned;  n/a
 equal
 movement
 Equally Normal
distributed;  Equally
Eyelashes distributed
 Curled
slightly  n/a
outward
 Skin intact;
no
Normal
discharge,
no
discoloration
 Lids close
symmetricall  no discharge, Normal
y no
 Approx. 15 – discoloration
20 Normal
involuntary
 Lids close
blinks per
Eyelids symmetrically
minute;
bilateral
blinking;  bilateral
 When lids blinking;
are open, no
visible sclera
above  n/a

corneas, and
upper and
lower border
of cornea
are slightly
covered
Conjuctiva:  Transparent;  n/a
capillaries
Bulbar
sometimes
Conjuctiva
 evident
 Shiny,
Palpebral  n/a
smooth, and
Conjuctiva
pink or red
 sclera Normal
Sclera  sclera
appears
appears white
white
 Transparent, Normal
shiny and
 Transparent,
smooth
Cornea shiny and
 Client blinks
smooth
when the
 n/a
cornea is
touched
 Proportional Normal
to the size of
 Proportional
Iris the eye, with
to the size of
transparent
the eye
anterior
chamber
 Black; equal
in size;
Normal
normally 3-7
inches in

Pupils diameter;  Black; equal

round, in size; round
smooth
border, iris
flat and
round
Visual acuity  Able to read  100/100
newsprint 14
Deviation
inches away
from
 20/20 vision
normal
on Snellen-
 type chart
 Pupils Normal
constrict  Pupils
when constrict
looking at when looking
near object; at near
Normal
pupils dilate object; pupils

Pupils reaction when dilate when

and looking at looking at far

Accommodation far objects; objects;

 Pupils  Pupils
converge converge
when near when near
object is object is
moved moved
towards towards nose
nose
Lacrimal gland,
 No edema,
lacrimal sac
no
and
tenderness  n/a
nasolacrimal
or tearing
gland
noted
 Both eyes  Both eyes Normal
coordinated, coordinated,
Extraocular
move in move in
muscles
unison, with unison, with
parallel parallel
alignment alignment
Visual fields  When  n/a
looking
straight
ahead, the
client can
see objects
 in periphery
 Color same
as facial
Normal
skin;
symmetrical;
 Aligned with  Color same as
Normal
outer cantus facial skin;
of eye, symmetrical;
EARS about 10  Aligned with
degrees outer cantus
Auricles
from of eye, about
vertical; 10 degrees
 Mobile, firm from vertical;
and not  n/a
tender;
pinna recoils
after it is
folded
 Distal third
contains hair
follicles and
glands, dry
cerumen,
External Ear
grayish-tan
Canal  n/a
color, or
sticky, wet
cerumen on
various
shades of
brown
Hearing acuity  Normal voice  Normal voice
tones tones audible
Normal
audible;  n/a
 Able to hear
 ticking in
both ears
when
performing
the watch
thick test
 Sound is
heard in
both ears or
is localized
at the center  n/a
of the head
(Weber
Negative)
when
 n/a
performing
the tuning
fork test
 AC hearing
is greater
than BC
hearing
(positive
rinne)
NOSE  Symmetric  Symmetric
and straight; and straight;
External
No discharge No discharge
Internal or flaring; or flaring; Normal
Uniform Uniform color
Sinuses
color  no lesion
 Not tender;  n/a
no lesion  n/a
Normal
 Air moves  n/a
freely as the
 client
breathes
through the
snares
 Mucosa pink;
Clear watery
discharge;
no lesions;
nasal
septum is
intact and in
midline
 Maxillary
and frontal
sinuses are
not tender
 Outer lips:
Uniform pink  Outer lips:
Deviation
color; soft, Uniform dark
from
moist, pink color,
normal
smooth dry,
MOUTH texture; symmetry of Normal
symmetry of contour;
Lips
contour; ability to
ability to purse lips
purse lips  Inner lips:
 Inner lips: Uniform dark
Uniform pink pink color
color
Buccal mucosa  moist,  moist Normal
smooth,
soft,
glistening,
and elastic
 texture
 32 adult
teeth; Deviation
Teeth smooth,  Total of 4 from
white, shiny teeth normal
tooth
enamel
 pink gums; normal
moist and

gums firm texture  pink gums;

to gums; no moist
retraction of
gums
Tongue or floor  central  central
of the mouth position; position; pink
pink color; color; moist;
moist; slightly rough;
slightly thin whitish
Normal
rough; thin coating; no
whitish lesions;
coating;
smooth
lateral
margins; no  moves freely
lesions;  n/a
raised  n/a Normal
papillae
 moves
freely; no
tenderness
 smooth
tongue base
with
prominent
 veins
 smooth with
no palpable
nodules
 salivary duct
openings
have same
color of
buccal
mucosa and
floor of the
mouth
 light pink,
smooth soft
palate;
lighter pink
hard palate
Palates with
 n/a
irregular
Uvula  n/a
texture
 uvula is
positioned in
the midline
of soft
palate

Normal Actual
Body parts Interpretation
Findings Findings

Integumentar
y
 Skin

Skin color, Varies from

uniformity of light to deep
color brown; from
rudy pink to
light pink;
from yellow
overtones to Fair complexion.
olive Skin color is Normal
deep brown.

Generally
uniform
except on
areas exposed
to the sun.

Presence of No edema No Edema noted

Normal
edema in joints.

Presence of Freckles, some

lesions birthmarks,
Nevi and freckles
according to some flat and
noted on part of
location, raised nevi; no
the face. some Normal
distribution, abrasions or
skin areas are
size, shape, other lesions.
wrinkled.
type or
structure.

Skin moisture Moisture in

Deviation from
skin folds and Dry skin
Normal
the axillae

Skin Uniform;
Uniform
temperature within normal Normal
temperature
range

Skin turgor When pinched, Skin springs Normal

skin springs back to previous
back to state but not
previous state immediately
 because of
wrinkled skin.

Nails

Fingernail plate Convex

shape curvature;
Convex
angle of nail Normal
curvature
plate about
160º

Fingernail and Smooth

Smooth texture Normal
toenail texture texture

Fingernail and Highly

toenail bed vascular and
color pink in light-
skinned
clients; dark- Nail beds are
Deviation from
skinned clients brown client has
Normal
may have long dirty nails
brown or black
pigmentation
in longitudinal
streaks

Tissues Intact Tissues

surrounding epidermis surrounding the
Deviation from
nails nails are not that
Normal
intact and
sloughing off.

Blanch test of Prompt return

capillary refill of pink or
usual color Return for 2 Deviation from
(generally less seconds. Normal
than 4
seconds)

Thorax

Posterior
Thorax
 Size, shape, Anteroposterio
symmetry, r to transverse
diameter of the diameter in
anteroposterior ratio of 1:2
Chest symmetric Normal
thorax and
transverse
diameter. Chest
symmetric

Spinal Spine Client is kyphotic

alignment vertically but vertically
aligned aligned

Temperature, uniform During

tenderness and temperature, symptoms, there
masses no tenderness, is tenderness Normal
no masses and difficulty of
breathing.

Auscultation of Vesicular and

Vesicular and
posterior bronchovesicul
bronchovesicular Normal
thorax ar breath
sounds noted.
sounds

Anterior
Thorax

Breathing Quiet,
patterns rhythmic,and Quiet, irregular
Normal
effortless breathing
respirations

Temperature, uniform Uniform

tenderness and temperature, temperature, no
Normal
masses no tenderness, tenderness and
no masses massess

Respiratory Full and

Partial,
excursion symmetric
symmetric lung Normal
chest
expansion
expansion

Vocal fremitus Same as Vocal fremitus Normal

 posterior vocal
fremitus;
fremitus is
decreased over
normally
heart and breast
decreased
over heart and
breast tissue

Percussion of Percussion
anterior thorax notes resonate
down to the Resonate at the
sixth rib at the level of
level of the diaphragm but
diaphragm but flat over
are flat over mascular areas
areas of heavy and bone, dull
Normal
muscle and sounds are
bone, dull on heard on areas
areas of the of heart and
heart and the liver, tympanic
liver, and sounds on
tympanic over stomach.
the underlying
stomach

Auscultation of Bronchial and Bronchial and

the trachea tubular breath tubular sounds Normal
sounds present

Auscultation of Bronchovesicu
Bronchovesicular
the anterior lar and
and vesicular
thorax vesicular
sounds
breath sounds

Cardiovascula
r

Aortic and No pulsations

No pulsations Normal
pulmonic areas

Tricuspid areas No pulsations, No pulsations,

Normal
lift or heave lift or heave
 Apical area Pulsations
visible in 50%
no lift or heave Normal
adults; no lift
or heave

Auscultation of S1: usually

the aortic, heard at all
pulmonic, times and
tricuspid and usually louder
apical valves at apical area

S2: usually
heard at all
sites and S1 and s2
usually louder sounds present
at the base of at the sites
Normal
the heart where they are
usually heard
louder
S3 in children
and young
adults

S4 in many
older adults

Carotid
arteries

Palpation of Symmetric Carotid arteries

carotid artery pulse volumes; palpable with
full pulsations, symmetric pulse Normal
thrusting volumes and
quality thrusing quality

Auscultation of No sound No sounds Normal

carotid artery heard on auscultated
 auscultation

Abdomen

Skin integrity Unblemished

Striation present,
skin; uniform Deviation from
wrinkled
color; silver Normal
abdomenal skin
white striae

Symmetry of Symmetric Symmetric

Normal
contour contour contour

Auscultation of Audible bowel

the abdomen sounds
for bowel
Absence of Audible bowel
sounds,
arterial bruits sounds, no bruits Normal
vascular
and friction rubs
sounds, and Absence of
peritoneal friction rub
friction rub

Percussion of Tympany over

the four the stomach
quadrants and gas filled
Tympany over
bowels;
the stomach,
dullness Normal
dullness on liver
especially over
and spleen
the liver and
spleen or a full
bladder

Palpation of the No
four quadrants tenderness; No tenderness
relaxed relaxed
abdomen with abdomen with Normal
smooth, consistent
consistent tension
tension

Musculoskele
tal system

Muscles
 Muscles’ size Equal size on Equal size on
both sides of both sides of the Normal
the body body

Inspection of No No contractures
the muscle and contractures
Normal
tendons for
contractures

Fasciculations No tremors Has tremors Deviation from

and tremors Normal

Muscle tonicity Normally firm Normally firm Normal

Bones

Inspection of No deformities Deformities

skeleton for noted on joints Deviation from
structure specifically on Normal
joints.

Palpation of No tenderness
bones to locate or swelling
No swelling or
any areas of Normal
tenderness
edema or
tenderness

Joints

Swelling No swelling No Swelling Deviation from

noted Normal

Tenderness, No
smoothness of tenderness,
movement, swelling,
swelling, crepitation, or no swelling joints Normal
crepitation, ad nodules
presence of
Joints move
nodule.
smoothly
 Range of Varies to some
motion degree in
accordance
with person’s
Limited range of
genetic Normal
motion
makeup and
degree of
physical
activity.

VI. LABORATORY AND DIADNOSTIC PROCEDURES

XI. ECOLOGIC MODEL

A. Hypothesis

Diabetes Mellitus is a condition in which the pancreas can no longer

produce enough insulin or cells stop responding to the insulin that is
produced, so that glucose in the blood cannot be absorbed in the cells of the
body.
In the case of our patient, the form of diabetes she has is Type 2; it is
sometimes called age-onset or adult- onset diabetes. She is aged 43 years
old and lives a sedentary lifestyle by being a vendor on their little store,
sitting the whole day. Our client was also diagnosed with Coronary Artery
Disease and some other complications.

B. Predisposing Factors

Host
-Female
-45 years old
-sedentary lifestyle
 -Coronary Artery Disease

Agent
-Chemical- glucose (and any type of sugar)

Environment
-living conditions (average)
-economic level (average)

C. Ecologic Model

HOST

ENVIRONMENT
AGENT

D. Analysis

The agent-host-environment model is primarily use in predicting illness

rather than promoting wellness, although identification of risk factors that
result from the interactions of agent, host, and environment are helpful in
promoting and maintaining health. Because each of the agent-host-
environment factors constantly interacts with others, health is an ever
changing state. Health is seen when all three elements are in balance while
illness is seen when one, two, or all three elements are not in balance.
(Fundamentals of Nursing by Kozier)

Type 2 Diabetes Mellitus, previously called NIDDM or adult-onset

Diabetes Mellitus, is a disorder involving both genetic and environmental
factors. Type 2 Diabetes Mellitus is the most common type of Diabetes
Mellitus, affecting 90% of all people who have the disease. In addition, the
prevalence of Coronary Artery Disease in people with DM is twice that in non-
diabetic population. (Medical-surgical nursing by Black)

E. Conclusion and Recommendations

We therefore conclude that our client is suffering from Type 2 Diabetes

Mellitus, probably due to her age, sedentary lifestyle, as well as her
predisposition to coronary artery disease. Other risk factors may also involve
such as age and the way of living. There are complications that preceded her
Diabetes mellitus such as chronic kidney disease, Type 2 Diabetes Mellitus,
hypertensive diabetes mellitus, and PTB4.

Recommendations would include health promotion in assisting the

client and family to understand DM and the necessary lifestyle changes such
as regular and well-balanced diet.

VIII. PROBLEM IDENTIFICATION

CUES NURSING DIAGNOSIS

Subjective data: Ineffective Management of Therapeutic

Regimen related to knowledge deficit
• The client always verbalized, “Ang related to Diabetes Mellitus
pait naman ng mga gamot na yan,
para san ba ang mga yan?”
• “Ano ba ang dapat kong gawin sa
sakit ko?

Objective:

• The client always asking about her

disease progression.
S-“ihi ako ng ihi sa gabi”…. Imbalanced Nutrition: less than body
requirements
M-glucose is 150mg/dL

O-the client is weak

“Pakiramdam ko Fluid volume deficient related to osmotic

lagi akong diuresis from hyperglycemia

nanghihina saka

nauuhaw”

IX. PROBLEM PRIOTERIZATION

Nursing diagnosis Rank Justification

Imbalanced nutrition High
less than body
requirements related to
deficiency of insulin.
Ineffective management Medium
of therapeutic regimen
This is because the need
for food requirement
specially glucose for
cells is depressed.
Therefore, it needs
prompt attention. This is
a life threatening
situation if not
immediately treated it
may risk the life of the
patient since the
physiologic needs is
involved. This can be
modified since there is
sufficient foods. This can
lead to malnutrition and
exaggeration of other
complications brought
about by DM., if not
treated. The client
wants all regimens to be
done for hr wellness.
This is health
threatening because if
not immediately
 resolved it may risk the
health of the client
specially in managing
her situation. If
management still
ineffective other
complications may
Fluid volume deficient Low arise. The clients want
related to osmotic to improve and have
diuresis from knowledge about
hyperglycemia managing her situation.

The problem is a health

deficit and requires less
immediate attention
because this is only
manifestation of
underlying disease. It is
modifiable since it
requires treating the
underlying disease. If
not prevented it will
result to dehydration
from polydipsia and
polyuria associated with
DM.
 XII. DISCHARGE PLAN

M – edications to take at home

Medications of the patient should include Cefixime, Indur, Amlodipine,

Spirinolactone, Aspirin, Enalapril, Digoxin, Furosemide. These drugs should
act not only for the DM of the patient but as well as the other complications
brought about her illness. Advise patient to have strict compliance on the
medication regimen given by her physician.

E – xercise

Client is advised to start any new activity at a well-tolerated intensity

level and duration(three to five times weekly or depending on the preference
of the client), with gradual (over a period of weeks or months) increases in
intensity and duration until preset exercise goals. Exercise should include
warm-up and cool-down periods before and after activity. It is best to
exercise once, at the same time of the day, if possible.

T – reatments

Tell patient that treatments or medical management for Diabetes

Mellitus includes restoring and maintaining blood glucose levels to as near as
normal as possible by balancing diet, exercise, and the use of oral
hypoglycemic agents. Educate client that multiple medications are often
needed to achieve optimal glycemic control.

After adhering to the treatment regimen, the client should learn how to
monitor her blood glucose. You should demonstrate the techniques of blood
glucose self-monitoring, discuss the normal blood glucose range, goals for
good control (individualized for each client), when to test, how to record test
results, and what to do when abnormal results are obtained.

H – ealth Teachings

Initial as well as ongoing client education is vital in helping the client

manage this chronic condition. As a nurse educator, you should explain to
the client and the family the basic pathophysiologic mechanism of Diabetes
mellitus and how the disorder is managed. Health promotion actions and
health maintenance activities for Type 2 diabetes mellitus are as follows:

• Follow eating habits based on the diet ordered by the dietician.

• Avoiding foods high in refined sugars and saturated fats.

• Maintaining ideal body weight

• Exercising regularly

• Using strategies shown to reduce complications of diabetes mellitus by

gradually removing coexisting factors such as smoking, hypertension,
and hyperlipidemia. (high-fat diet)

• Teach meal planning and physical activity

• Control of the complications by following the treatment regimen.

O – ut patient follow-up

Clients require consistent follow-up, updating, and reinforcement.

Performing periodic assessments to determine the client’s needs and to
assess glycemic control is necessary. Advise the client to have a follow-up
check up when they see emerging symptoms or complications of diabetes
mellitus. This, in turn, could prevent possible recurrence of the disease
and to reinforce learning needs as well. The out patient visit is advised by
the physician.

D – iet

Emphasize to the client and family members that they are not eating a
“diabetic diet” but, rather, are following a balanced meal plan. You should
also emphasize that nutritional changes can help to lower blood glucose
levels, decrease lipid levels, and lower blood pressure.

We should also consider the effect of alcohol and artificial sweeteners.

Clients may not need to give up alcohol beverages entirely; it should be in
moderation since the alcohol has calories which may, as well, affect the
glucose level of the patient. In regard with the artificial sweeteners, it
may help client achieve desired caloric restrictions.
Recommended nutritional guidelines for clients with DM:

Calorie – sufficient to achieve and maintain reasonable weight

Protein – adequate to ensure maintenance of body protein stores. In

general, 10%-20% of total daily calories should be from protein. (equal
to ~0.8 g/kg/day)

Fats – less than 30% of calories should be from fat, less than 10% of
that from saturated fat sources; cholesterol intake should be limited to
300 mg/day or less.

Carbohydrates – 50%-60% of total calories should be from

carbohydrates.

Fiber – consume 20-35 g of fiber per day.