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A. Personal Data
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ï Paternal Side
- Grandfather (+) DM
- Youngest Uncle (+) DM
- Father (+) DM
ï Maternal Side
- Grandmother (+) DM
- Eldest sister of Mother (+) DM
- Mother (+) DM
    

ï uccasional coughs
ï Colds

ï Fever
    
ï Diagnosed when she was 35
years old
ï FBS: 240 mg/dl

ï Medications given:

Glucophage 500 mg/tab, 1 tab

TID
Diamicron 80 mg/tab, ½ tab BID
    
ï •une 2006 - blurring of vision uU
ï •uly 2006 ± client undergone Laser
Therapy
ï uctober 2006 ± blurring of vision uS
ï November 2006 ± (+) bleeding vessels
uU
- performed Laser Therapy
ï December 2006 ± diagnosed of Diabetic
Retinopathy
    
ï March 2007 - (+) hypertension
- blurring of vision uU
ï April 2007 ± client undergone

Vitrectomy
ï August 2007 ± blurring of vision

uD
ï September 2007 ± performed

Vitrectomy uD
    
ï February 20, 2008 ± client
complained of seeing black color in
the corner of her left eye. She was
diagnosed of Retinal Detachment.
ï February 22, 2008 ± scheduled for
Scleral buckling, (+) HPN & unstable
blood sugar levels
ï February 25, 2008 ± the client
undergone Scleral buckling
  

 
 
  
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ï VS: BP-
BP- 140/90, T-T- 37, PR
PR-- 86, RR
RR-- 20
ï Head : round shape, no tenderness,
swelling or lesions noted upon palpation,
no abnormal configuration noted
ï Hair & Scalp : hair is evenly distributed,
thick, black, dry and wavy up to the
shoulder, no lice or dandruff noted upon
inspection, no lesions or masses
ï Face & Skull : symmetrical facial
movement, smooth skull, no nodules or
depressions

ï Skin : brown complexion

skin warm to touch
skin brings back to previous stat
after pinching
no edema or lesions noted
no pigmentation
ï Eyes : eyebrows symmetrically aligned
with equal movements,
eyebrows & eyelashes
are evenly distributed
uD - clear cornea, pupil react to light
and accommodation, can read newspaper
print, bold and small font at a distance of
12´ from the tip of the nose
uS ± hazy cornea, pupil not reactive to
light and accommodation, cannot read
newspaper print
ï Ears : symmetrical in shape, not
tender, recoils after it is folded; no
lesions, symmetrical with the outer
cantus of the eyes
ï Nose : no discharge, lesions &
tenderness
air moves freely through the
nares
ï Lips : no blisters/ cracks noted, moist,
smooth and glistening
ï Teeth and Gums : pink, not swollen,
slightly yellowish teeth

ï Tongue : no lesions, can move freely and

smoothly

ï Neck : no unusual mass noted upon

palpation
no enlargement of the lymph nodes
no distention of the jugular veins
ï Thorax and Lungs : spine is vertically
aligned, no tenderness, pain or
lesions upon palpation; present tactile
fremitus, with clear breath sounds

ï Heart & Breast : heart has regular

rhythm
no tenderness, masses or lesions
noted on the breasts
ï Abdomen : uniform in color, no
swelling or lump noted, tympanic
sound heard upon auscultation

ï Extremities : no edema, deformities,

tenderness noted; has symmetrical
upper and lower extremities; clean
finger and toenails; Blanch test of <3
secs.
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ï Urinalysis (February 22, 2008)
color : yellow
transparency : slightly cloudy
pH : 8
specific gravity : 1.005
Albumin : (+)4
Sugar : positive
Pus Cells : 2-
2 -4
RBC : 3-3 -5
ï Complete Blood Count (CBC)
Hgb : 122 mg/dl
WBC : 6.4
Hct : 0.40
ï Serum Creatinine : 1.7 mg/dl
ï Serum Potassium : 5.2 mEq/L
ï Serum Sodium : 148 mEq/L
ï FBS : 325 mg/dl (Feb.22, 2008)
122 mg/dl (Feb. 24, 2008)

ï RBS: 229 mg/dl (Feb. 20, 2008)

190 mg/dl (6am of Feb. 21, 2008)
185 mg/dl (12 noon)
287 mg/dl (6 pm)
200 mg/dl (6am of Feb. 22, 2008)
298 mg/dl (12 noon)
170 mg/dl (6 pm)
ï RBS : 150mg/dl (12mn, Feb. 23, 2008)
98mg/dl (6am)
260mg/dl (12noon)
180mg/dl (6pm)
175mg/dl (12mn, Feb.24, 2008)
100mg/dl (6am)
365mg/dl (12noon)
115mg/dl (6pm)
125mg/dl (6am, Feb. 25, 2008)
88mg/dl (12noon)
ï Chest X- X-ray
- no active parenchymal
infiltrate. The heart is markedly
enlarged. Pulmonary vascularity
is within normal. No remarkable
findings.

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ï Insulin

ï Glucagon
]

 
 
ï Conjunctiva
ï Iris

ï Pupil

ï Lens

ï Aqueous Humor

ï Vitreous Humor

ï Retina
Pathophysiology (Client-centered)
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ï IVF : PNSS 1L x KVu
ï Drugs:
Cefuroxime 750 mg IV Q8 (- (-)
ANST
Metformin 500mg/tab, 1 tablet TID
Glipizide 5mg/tab, 1 tablet BID PC
Captopril 25mg/tab, 1 tablet BID
ï Clonidine 75mcg/tab, 1 tablet SL stat
ï Humulin R sliding scale
(Subcutaneous)
160 to 200 : 4 units
201 to 250 : 6 units
251 to 300 : 8 units
301 to 350 : 10 units
<80 & >351 : refer to AP
ï Diet : Soft, Diabetic diet
NPu

ï Activity: Complete bed rest

with
bathroom privileges
 
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ï Soapie : Risk for Injury
ï NCPs
Prob. 1 : Disturbed visual sensory
perception R/t decreased sensory
perception and changes in visual acuity

Prob. 2 : Impaired physical mobility R/T

sensory perceptual impairment
Prob. 3 : Risk for injury R/T changes in
visual acuity

Prob. 4 : Risk for infection R/t invasive

procedure

Prob. 5 : Risk for impaired home

management R/t visual limitations and
activity restrictions
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Thank you very much

for listening!!! J