case press1

8/8/2019 Case Press1

1/35

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 doesnt have any diseaseswhen 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 doesnt 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 nungnamatay 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 doesnt have a history of diabetes.


2/35

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


3/35

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

lugaw

slice of orange

I pc. Of banana

(lakatan)

1 serving of adobo

(1 pc. Chicken)

1 medium bowl of

lugaw

2 pcs. Of tasty

bread

1 glass of

pineapple juice

(240 ml)

1 medium bowl of

lugaw

1 serving of paksiw

nab angus(1/4 na

bangus)

serving of pansit

1 pc of banana

(1L/day of water)

WEDNESDAY

(AUGUST 11, 2010)

BREAKFAST LUNCH MERIENDA DINNER

2 pcs. Medium

sized of pandesal

w/ meat loaf

glass of

powdered milk

1 medium bowl of

lugaw

1 serving ofsinabawang baka

skipped 1 serving of

chopsuey

1 medium bowl oflugaw

1 serving of

adobong manok


4/35

(1L/day of water)

THURSDAY

(AUGUST 12, 2010)

BREAKFAST MERIENDA DINNER

2 pcs. Medium

sized of pandesal

w/ sausage

glass of

powdered milk

1 medium slice of

papaya

1 serving of

sinabawang baka

1 medium bowl of

lugaw

skipped 1 medium bowl of

lugaw

1 plate of pansit

1 serving of

adobong baboy

(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


5/35

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 alsosaid 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


6/35

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 doesnt 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


7/35

PATTERN BEFORE

HOSPITALIZATION

AFTER

HOSPITALIZATION

INTERPRETATION

and ANALYSISNutrition The client eats

three times a daythe client prefer

foods with soup

such as sinigang

and can

consumed 1

cup of rice, the

client has no

allergies to any

kind of food and

drinks 2 liters of

water a day.

The client still

eats three timesa day but she

only consumed 1

cup of rice during

her stay in the

hospital and

drinks 1 litter of

water a day

Decreased

metabolic activityand decrease

physical activity

mean a decrease

in caloric need.

(Kozier 8th

edition,

Fundamentals of

Nursing page

1243)

Elimination According to the

client she

urinates six times

a day and

defecate twice

during the

morning and

afternoon, shedescribed that

her feces is

brown,

During her stay in

the hospital the

client doesnt

know how many

times she

urinates because

she has a

catheter and sheonly defecate

once a day.

Although peoples

pattern of

elimination ate

highly individual

most people void

about 5 to 6

times a day.

(Kozier 8th

edition,

Fundamentals of

Nursing page

1290)Activity and

Exercise

The client states

that when she is

at home she

always clean the

house and wash

their clothes and

this is her

exercise

according to her.

The client always

stays at bed, sit

and walk in the

hallway.

Exercise and

Activity are

essential

components for

maintaining and

regaining health

and wellness.

(Kozier 8th

edition,

Fundamentals of

Nursing page


8/35

1160)HYGEINE The client told

that she takes a

bath once

everyday,

brushes her teeth

everyday twice,

one in the

morning and one

in the evening.

She said that

over all, she

observes proper

hygiene.

Since

hospitalization,

she cannot take a

bath everyday

because of her

sickness. Her

sister wipes her

body for her

using a wet

towel. In terms of

brushing her

teeth, she still

brushes her teeth

twice a day.

Personal hygiene

is the self-care by

which people

attend to such

functions as

bathing, toileting,

general body

hygiene, and

grooming.

Hygiene is a

highly personal

matter

determined by

individual valuesand 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

ABUSE

The client does

not smoke or

drink alcoholic

beverages. The

client does not

use any illicitdrugs. Ayoko

uminom o

manigarilyo,

masama yan

The client does

not smoke, drink,

nor uses illicit

drugs.

Lifestyle refers to

a persons

general way of

living, including

living conditions

and individualpatterns of

behaviour that

are influenced by

sociocultural

factors and

personal


9/35

characteristics.

(Kozier 8th

edition,

Fundamentals of

Nursing page

301)SLEEP AND REST According to the

client, she usually

sleeps 10 in the

evening and

wakes 7 in the

morning. The

client does not

have any

problem whensleeping. Before

she sleeps, she

washes her face

as her ritual.

There are days of

difficulty of

sleeping. She

sleeps

intermittently

because of the

temperature. She

verbalize that it is

hot and probablybecause of her

sickness

Most healthy

adults need 7 to

9 hours of sleep a

night, (National

Sleep Foundation,

n.d.b.). However

there is individual

variation as some

adults may beable to function

well (e.g., without

sleepiness or

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

verbalized Oo,

nag gaganun pa

kami ni mister

bago ako

nahospital, activepa. The client

also verbalized

that comparing

before, they are

not that active.

The client

verbalized that

syempre hindi

na

During middle

adulthood both

men and women

experience

decreased

hormoneproduction,

causing the

climacteric,

usually called

menopause in

women. (Kozier


10/35

8th edition,

Fundamentals of

Nursing page

1021)

V. Physical Assessment

Physical AssessmentArea of

AssessmentNormal findings Actual findings

Evaluation

Body build,

height, weight

Proportionate,

varies with

lifestyle

endomorph

Wt: not taken

Normal

Posture and

gait, standing

sitting walking

Relaxed, erect

posture;coordinated

movement

Relaxed

normal

Overall hygiene

and groomingClean, neat Clean, neat

normal

Body and

breath odor

No body odor or

minor body odor

relative to work or

exercise; no

breath odor

Has no notable

body odor and

breath odor

normal

Signs of

distress in

posture and

No distress noted There is distress

noted

Deviated

from

Normal


11/35

facial

expression

Obvious signs

of health and

illness

Healthy

appearance

The client has

slightly weak looking

appearance

Deviated

from

Normal

Attitude

Cooperative, able

to follow

instructions

Cooperative, able to

follow instructions

Normal

Affect/moodAppropriate to

situation

Appropriate to

situation

Normal

Quantity and

quality of

speech

Understandable,

moderate pace;

clear tone and

inflection; exhibits

thought

association

Speech not clear,

soft spoken

Deviated

from

Normal

Relevance and

organization of

thoughts

Logical sequence;

makes sense, has

sense of reality

Logical sequence;

makes sense, has

sense of reality

Normal

HEAD

Skull

Rounded

(normocepha

lic and

symmetric

with frontal,

occipital and

parietal

prominence)

; smooth

skull

contour;

Absence of

nodules and

Rounded

(normocephali

c)

n/a

Normal


12/35

masses

Scalp

Lighter than

facial skin,

moist, no

scar;

No lesions

and

tenderness

upon

palpation

Lighter than

facial skin, no

scar

n/a

Normal

Hair

Evenly

distributed;

thick; silkyand

resilient;

no infection

or

infestation

Evenlydistributed

thick

n/a

Normal

Normal

Face

Symmetric

facial

features

Symmetric

facial

movements

Symmetric

facial features

n/a

Normal

EYES

No lesions

and

inflammatio

ns

No lesions

and

inflammations

Normal

Eyebrows Hair evenly

distributed;

skin intact

Symmetricall

y aligned;

equal

Hair evenly

distributed

Symmetrically

aligned;

n/a

Normal

Normal


13/35

movement

Eyelashes

Equally

distributed;

Curled

slightly

outward

Equally

distributed

n/a

Normal

Eyelids

Skin intact;

no

discharge,

no

discoloration

Lids close

symmetrically

Approx. 15

20

involuntary

blinks per

minute;

bilateral

blinking;

When lids

are open, no

visible sclera

above

corneas, and

upper and

lower border

of cornea

are slightly

covered

no discharge,

no

discoloration

Lids close

symmetrically

bilateral

blinking;

n/a

Normal

Normal

Normal

Conjuctiva:

Bulbar

Conjuctiva

Transparent;

capillaries

sometimes

n/a


14/35

Palpebral

Conjuctiva

evident

Shiny,

smooth, and

pink or red

n/a

Sclera sclera

appears

white

sclera

appears white

Normal

Cornea

Transparent,

shiny and

smooth

Client blinks

when the

cornea istouched

Transparent,

shiny and

smooth

n/a

Normal

Iris

Proportional

to the size of

the eye, with

transparent

anterior

chamber

Proportional

to the size of

the eye

Normal

Pupils

Black; equal

in size;

normally 3-7

inches in

diameter;

round,

smooth

border, iris

flat and

round

Black; equal

in size; round

Normal

Visual acuity Able to read

newsprint 14

inches away

20/20 vision

on Snellen-

100/100

Deviation

from

normal


15/35

type chart

Pupils reaction

and

Accommodation

Pupils

constrict

when

looking atnear object;

pupils dilate

when

looking at

far objects;

Pupils

converge

when near

object is

moved

towards

nose

Pupils

constrict

when lookingat near

object; pupils

dilate when

looking at far

objects;

Pupils

converge

when near

object is

moved

towards nose

Normal

Normal

Lacrimal gland,

lacrimal sac

and

nasolacrimalgland

No edema,

no

tenderness

or tearing

noted

n/a

Extraocular

muscles

Both eyes

coordinated,

move in

unison, with

parallel

alignment

Both eyes

coordinated,

move in

unison, with

parallel

alignment

Normal

Visual fields Whenlooking

straight

ahead, the

client can

see objects

n/a


16/35

in periphery

EARS

Auricles

Color same

as facial

skin;

symmetrical;

Aligned with

outer cantus

of eye,

about 10

degrees

from

vertical;

Mobile, firm

and not

tender;

pinna recoils

after it is

folded

Color same as

facial skin;

symmetrical;

Aligned with

outer cantus

of eye, about

10 degrees

from vertical;

n/a

Normal

Normal

External Ear

Canal

Distal third

contains hair

follicles andglands, dry

cerumen,

grayish-tan

color, or

sticky, wet

cerumen on

various

shades ofbrown

n/a

Hearing acuity Normal voice

tones

audible;

Able to hear

Normal voice

tones audible

n/aNormal


17/35

ticking in

both ears

when

performing

the watch

thick test

Sound is

heard in

both ears or

is localized

at the center

of the head

(Weber

Negative)

when

performing

the tuning

fork test

AC hearing

is greater

than BC

hearing

(positive

rinne)

n/a

n/a

NOSE

External

Internal

Sinuses

Symmetric

and straight;

No discharge

or flaring;

Uniform

color

Not tender;

no lesion

Air moves

freely as the

Symmetric

and straight;

No discharge

or flaring;

Uniform color

no lesion

n/a

n/a

n/a

Normal

Normal


18/35

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

MOUTH

Lips

Outer lips:

Uniform pink

color; soft,

moist,

smooth

texture;

symmetry of

contour;

ability to

purse lips

Inner lips:

Uniform pink

color

Outer lips:

Uniform dark

pink color,

dry,

symmetry of

contour;

ability to

purse lips

Inner lips:

Uniform dark

pink color

Deviation

from

normal

Normal

Buccal mucosa moist,

smooth,

soft,

glistening,

and elastic

moist Normal


19/35

texture

Teeth

32 adult

teeth;

smooth,

white, shiny

tooth

enamel

Total of 4

teeth

Deviation

from

normal

gums

pink gums;

moist and

firm texture

to gums; no

retraction of

gums

pink gums;

moist

normal

Tongue or floor

of the mouth

central

position;

pink color;

moist;

slightly

rough; thin

whitish

coating;

smooth

lateral

margins; no

lesions;

raised

papillae

moves

freely; no

tenderness

smooth

tongue base

with

prominent

central

position; pink

color; moist;

slightly rough;

thin whitish

coating; no

lesions;

moves freely

n/a

n/a

Normal

Normal


20/35

veins

smooth with

no palpable

nodules

salivary duct

openings

have same

color of

buccal

mucosa and

floor of the

mouth

Palates

Uvula

light pink,

smooth soft

palate;

lighter pink

hard palate

with

irregular

texture

uvula is

positioned in

the midline

of soft

palate

n/a

n/a

Body partsNormal

Findings

Actual

FindingsInterpretation

Integumentar

y


21/35

Skin

Skin color,

uniformity of

color

Varies from

light to deep

brown; from

rudy pink tolight pink;

from yellow

overtones to

olive

Generally

uniform

except onareas exposed

to the sun.

Fair complexion.

Skin color is

deep brown.

Normal

Presence of

edema

No edema No Edema noted

in joints.Normal

Presence of

lesions

according to

location,

distribution,

size, shape,

type or

structure.

Freckles, some

birthmarks,

some flat and

raised nevi; no

abrasions or

other lesions.

Nevi and freckles

noted on part of

the face. someskin areas are

wrinkled.

Normal

Skin moisture Moisture in

skin folds and

the axillae

Dry skinDeviation from

Normal

Skin

temperature

Uniform;

within normalrange

Uniform

temperature Normal

Skin turgor When pinched,

skin springs

back to

previous state

Skin springs

back to previous

state but not

immediately

Normal


22/35

because of

wrinkled skin.

Nails

Fingernail plate

shape

Convex

curvature;

angle of nail

plate about

160

Convex

curvatureNormal

Fingernail and

toenail texture

Smooth

textureSmooth texture Normal

Fingernail and

toenail bed

color

Highly

vascular and

pink in light-skinned

clients; dark-

skinned clients

may have

brown or black

pigmentation

in longitudinal

streaks

Nail beds are

brown client has

long dirty nails

Deviation from

Normal

Tissuessurrounding

nails

Intactepidermis

Tissuessurrounding the

nails are not that

intact and

sloughing off.

Deviation from

Normal

Blanch test of

capillary refill

Prompt return

of pink or

usual color

(generally less

than 4seconds)

Return for 2

seconds.

Deviation from

Normal

Thorax

Posterior

Thorax


23/35

Size, shape,

symmetry,

diameter of the

anteroposterior

thorax and

transverse

diameter.

Anteroposterio

r to transverse

diameter in

ratio of 1:2

Chest

symmetric

Chest symmetric Normal

Spinal

alignment

Spine

vertically

aligned

Client is kyphotic

but vertically

aligned

Temperature,

tenderness and

masses

uniform

temperature,

no tenderness,

no masses

During

symptoms, there

is tenderness

and difficulty of

breathing.

Normal

Auscultation of

posterior

thorax

Vesicular and

bronchovesicul

ar breath

sounds

Vesicular and

bronchovesicular

sounds noted.

Normal

Anterior

Thorax

Breathing

patterns

Quiet,

rhythmic,and

effortless

respirations

Quiet, irregular

breathingNormal

Temperature,

tenderness and

masses

uniform

temperature,

no tenderness,

no masses

Uniform

temperature, no

tenderness and

massess

Normal

Respiratory

excursion

Full and

symmetric

chest

expansion

Partial,

symmetric lung

expansion

Normal

Vocal fremitus Same as Vocal fremitus Normal


24/35

posterior vocal

fremitus;

fremitus is

normally

decreased

over heart and

breast tissue

decreased over

heart and breast

Percussion of

anterior thorax

Percussion

notes resonate

down to the

sixth rib at the

level of the

diaphragm but

are flat over

areas of heavy

muscle and

bone, dull on

areas of the

heart and the

liver, and

tympanic over

the underlying

stomach

Resonate at the

level of

diaphragm but

flat over

mascular areas

and bone, dull

sounds are

heard on areas

of heart and

liver, tympanic

sounds on

stomach.

Normal

Auscultation of

the trachea

Bronchial and

tubular breath

sounds

Bronchial and

tubular sounds

present

Normal

Auscultation of

the anterior

thorax

Bronchovesicu

lar and

vesicular

breath sounds

Bronchovesicular

and vesicular

sounds

Cardiovascula

r

Aortic and

pulmonic areas

No pulsationsNo pulsations Normal

Tricuspid areas No pulsations,

lift or heave

No pulsations,

lift or heaveNormal


25/35

Apical area Pulsations

visible in 50%

adults; no lift

or heave

no lift or heave Normal

Auscultation ofthe aortic,

pulmonic,

tricuspid and

apical valves

S1: usuallyheard at all

times and

usually louder

at apical area

S2: usually

heard at all

sites andusually louder

at the base of

the heart

S3 in children

and young

adults

S4 in many

older adults

S1 and s2sounds present

at the sites

where they are

usually heard

louder

Normal

Carotid

arteries

Palpation of

carotid artery

Symmetric

pulse volumes;full pulsations,

thrusting

quality

Carotid arteries

palpable withsymmetric pulse

volumes and

thrusing quality

Normal

Auscultation of

carotid artery

No sound

heard on

No sounds

auscultated

Normal


26/35


27/35

Muscles size Equal size on

both sides of

the body

Equal size on

both sides of the

body

Normal

Inspection of

the muscle andtendons for

contractures

No

contractures

No contractures

Normal

Fasciculations

and tremors

No tremors Has tremors Deviation from

Normal

Muscle tonicity Normally firm Normally firm Normal

Bones

Inspection of

skeleton for

structure

No deformities Deformities

noted on joints

specifically on

joints.

Deviation from

Normal

Palpation of

bones to locate

any areas of

edema or

tenderness

No tenderness

or swellingNo swelling or

tendernessNormal

Joints

Swelling No swelling No Swelling

noted

Deviation from

Normal

Tenderness,

smoothness of

movement,

swelling,

crepitation, ad

presence ofnodule.

No

tenderness,

swelling,

crepitation, or

nodules

Joints move

smoothly

no swelling joints Normal


28/35

Range of

motion

Varies to some

degree in

accordance

with persons

genetic

makeup and

degree of

physical

activity.

Limited range of

motionNormal

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 isproduced, 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


29/35

-Coronary Artery Disease

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

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

C. Ecologic Model

HOST

ENVIRONMENTAGENT

D. Analysis

The agent-host-environment model is primarily use in predicting illnessrather than promoting wellness, although identification of risk factors that

result from the interactions of agent, host, and environment are helpful inpromoting 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


30/35

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

Recommendations would include health promotion in assisting theclient and family to understand DM and the necessary lifestyle changes suchas regular and well-balanced diet.

VIII. PROBLEM IDENTIFICATION

CUES NURSING DIAGNOSIS

Subjective data:

The client always verbalized, Ang

pait naman ng mga gamot na yan,para san ba ang mga yan?

Ano ba ang dapat kong gawin sasakit ko?

Objective:

The client always asking about herdisease progression.

Ineffective Management of Therapeutic

Regimen related to knowledge deficit

related to Diabetes Mellitus

S-ihi ako ng ihi sa gabi.

M-glucose is 150mg/dL

O-the client is weak

Imbalanced Nutrition: less than body

requirements

Pakiramdam ko

lagi akong

Fluid volume deficient related to osmotic

diuresis from hyperglycemia


31/35

nanghihina saka

nauuhaw

IX. PROBLEM PRIOTERIZATION

Nursing diagnosis Rank JustificationImbalanced nutrition

less than body

requirements related to

deficiency of insulin.

Ineffective management

of therapeutic regimen

High

Medium

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 bedone for hr wellness.

This is health

threatening because if

not immediately


32/35

Fluid volume deficient

related to osmotic

diuresis from

hyperglycemia

Low

resolved it may risk the

health of the client

specially in managing

her situation. If

management still

ineffective other

complications may

arise. The clients want

to improve and have

knowledge about

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.


33/35

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 asnormal 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


34/35

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 clients needs and to

assess glycemic control is necessary. Advise the client to have a follow-upcheck 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 glucoselevels, 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.


35/35

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. (equalto ~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.

case press1

Documents