nursing care in patient with diabetes mellitus

NURSING CARE IN Mrs. “S” WITH DIABETES MELLITUS

AT DR. SOETOMO GENERAL HOSPITAL

ON 11TH – 13TH NOVEMBER 2009

BY:

GROUP I

MIRA UTAMI NINGSIH (139015216)

NINIK ENDANG S (139015146)

AGUS (139015151)

DIONISIA R.W. DJAWA (139015164)

IRNA SUSIATI (139015219)

KASHMIR (139015226)

WIWIN NURMALANTIKA (139015234)

HUSNUL MUBAROK (139015235)

FACULTY OF NURSING

AIRLANGGA UNIVERSITY

SURABAYA

2009

PREFACE

We really grateful to the Most Glorious and the Most Merciful Allah SWT,

we can finished this case report about “Nursing care in Mrs. ‘S’ with chronic diabetes

mellitus at RS. DR. Soetomo on 11th – 13th November 2009” ontime. This paper is

written as a part of process in studying English in nursing science and technology.

Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer who has

generously provided us with constructive criticism and suggestions to completed this

paper. Special thanks to all of our colleagues in class B 12 who have participated in

our seminar discussion about the case in this paper. We aware that still there are

many lack in this paper so we could use some direction and we always open to your

suggestion to make it better. At last, we hope this paper may brings much

advantages to all of us.

Surabaya, 21st November 2009

Author

1

CONTENTS

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

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

Contents.................................................................................................................. iii

Nursing Care in Mrs. “S” with Diabetes Mellitus at DR. Soetomo General

Hospital, On 11th – 13th November 2009

A. Assesment.....................................................................................................1

B. Data Analysis and Nursing Diagnosis...........................................................6

C. Planning........................................................................................................9

D. Implementation............................................................................................13

E. Evaluation / Discharge Planning.................................................................18

2

NURSING CARE IN Mrs.“S” WITH DIABETES MELLITUS

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

A. ASSESMENT

NURSING HISTORY

Admission Date : 11th Nov 2009 Time : 08.56 a.m

No. Reg : 10177388 Medical Dx : Diabetes mellitus + diabetic

foot

Date of Assesment : 11th Nov 2009

I. Patient identity

1. Name : Mrs. “S”

2. Age : 60

3. Sex : female

4. Race : Java, Indonesia

5. Religion : Islam

6. Education : -

7. Occupation : Housewife

8. Address : Lamongan, Karang Anyar

II. History of present illness

1. Chief complain : shortness of breath

2. Present illness history : patient has a sudden shortness of breath since

an hour before hospitalized but it’s getting better. She had cough, nausea

and vomiting a day ago. She has pain, swollen and redness at right pedis

since three days ago. Feverish a day before hospitalized. She feel faint

and weakness. Patient has diabetic mellitus type II since twelve years ago.

III. Past nursing history

1. History of contagious disease : None

2. Hereditary disease : None

3. Allergic history : None

3

+

+

IV. Family health history :

Patient said that her family has no contagious disease one of her family

member, her aunt also has diabetes mellitus

Genogram

+

Explanation:

: male

: female

: client

: stay together with client

+ : pass away

V. Observation and physical examination

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

1. B1: Breathing

Complain : Cough (-), SOB (-), pain (-)

RR pattern : Frequency 20 x/mnt, Rhythm : Regular

Breathing : wheezing (-), ronchi (-), secret (-)

O2 adm : (-)

Problem : None

2. B2: Blood

Complain : chest pain (-), P = 72 times/minute

Heart sound : Normal

Rhythm : regular

CRT : 2 second

JVP : Normal

Edema : (-)

Problem : None

4

3. B3: Brain

Orientation : Person, Time and Place normal

Awareness : Composmentis

GCS : E4 V5 M 6

Eye : Pupil Isochors, Light reflex (+), eye lens: snoring (+/+).

Conjunctiva : hiperemi (-/-), sub conjunctiva bleeding (-/-)

Sclera : anemis

Nerves disturbance: sensory perceptual; visual

Problem : Disturbed sensory perception; visual.

Risk for Injury

4. B4: Bladder

Complain : polyuri

Fluid intake : Oral + 2500cc/day, Parenteral : 1000 cc/day

Urine output : + 3000 cc/day color: light yellow smell: normal

Others : cateter adm (-)

Problem : Altered urinary elimination pattern

Risk for deficit fluid volume

5. B5: Bowel

Mouth : normal

Abdomen : normal

Diit : Diit B1 2100 kkal

Alvi elimination : frequency once a day, consistency: soft

Peristaltic : 15 x/mnt

Others : none

Problem : none

6. B6: Bone

Joint Activity : Free

Back Injury : None

Integuments : pale, acral warm

Turgor : good

Others : right pedis: wound, swollen, redness, pain. Post

amputated falanx digit 1 pedis, osteomilitis.

Problem : impaired skin integrity

5

7. Endocrine system

Complain : CBS: 288, polyuria, polydipsi

Prolem : hyperglycemia

VI. Psychosocial assessment

1. Client perception about his disease : God-struggle

2. Client expression toward his/her disease : Quite

3. Year reaction: cooperative

4. Self concept disturbance : none

VII. Diagnosis test and medical treatment

1. Laboratory:

Hematology 11 th Nov 2009

Hb : 10,3 Ca: 9

Leukosit: 17.800 Cl: 101

Plt: 221.000 K: 4,5

BG: 288 Na: 140

BUN: 19,5 Globulin: 4,98

Creatinin: 1,5 Albumin: 2,8

SGOT/SGPT: 10/8 Bilirubin direct: 0,26

2. Radiology:

Thorax photo (PA): cardiomegali

Pedis photo: osteomilitis amputated phalanx digit 1 pedis dextra.

3. Therapy

IVFD Pz 14 drops/minute

Humolin R 3x4 IU SC

Humolin N 4 IU SC malam

Ceftazidine 3 x 1gr IV

Metronidazole 3 x 500 mg IV

Metformin 3 x 500 per oral

Wound care

4. Additional data:

Consult internist: unregulated DM and selulitis pedis (D), osteomilitis

Consult ophthalmologist: OD cataract mature, OS cataract immature

6

WEB OF CAUTION DIABETES MELLITUS

7

Decrease of insulin production (auto immune)

Insulin resistance by liver fat and muscle cell

Ineffective glucose movement to the cell

Hyperglycemia

Resists the flourishing of WBC

Low immune system

Body tries to get rid of the extra sugar in blood

Decrease of capability for attacking foreign particles

and blood vessel repair

Poor wounding healing

Impaired skin integrity

Excreting sugar through urine

Prompt urinate frequently

Excess fluid excretion

Risk for deficit fluid

Causes damage of blood vessel within the eye

Lead blood and fluid into the surrounding tissue

Affects the ability of lenses to focus

Risk for

Altered urine

elimination

Glucose + amino protein

Accumulation of AGE (advance glicosilasi

end product)

Induce unwanted biological activity

Neuron, blood vessel, Kidney, eye lens

Glucose metabolized

Sorbitol + fructose Osmotic load

Decrease fosfoinosida metabolism and

signal transduction

Neuropathy, retinopathy nephropathy, cataract

Impaired sensory perception;

tactile, auditory,

Increase blood glucose level

Risk for infectio

Metabolize fat &protein to gain energy

Imbalanced nutrition; less

than body

Uses more energy

Negative calorie effect

Activity intolerance

Lead to loss of weight

Fatigue

B. DATA ANALYSIS AND NURSING DIAGNOSIS

No Data Etiology Problem

1 S:

- Patient said that she has

had Diabetes mellitus

since 12 years ago.

O:

- BG: 288 mg/dl

Decrease of insulin

production (auto

immune)

Or

Insulin resistance by

liver, fat and muscle

cell

Ineffective glucose

movement to the cell

Increase blood

glucose level

Hyperglycemia

hyperglikemi

2 S:

- patient said that her foot

has swollen, redness and

pain since three days ago.

O:

- there is a wound at right

pedis that seems swollen,

redness

- Leukocyte : 17.800

- Photo pedis: osteomilitis

and shows amputated

phalanx digit 1 pedis

dextra

Hyperglycemia

resists the flourishing

of white blood cells

low immune system

decrease of capability

for attacking foreign

particles

(microorganism etc.)

and blood vessel

repair

Impaired skin

integrity

8

- BG: 288 mg/dl poor wound healing

3 S:

- Patient complains about

urinate frequently

O:

- Polyuria

- BG : 288 mg/dl

- Urine output: + 3000

cc/day

Hyperglycemia

Body tries to get rid of

the extra sugar in the

blood by excreting it

through urine

Prompt urinate

frequently

Excess fluid excretion

(carries a large

amount of water out of

the body along with it)

Risk for deficit fluid

volume

4 S:- Patient said that she has

blurry vision

O:

- Eye lens: snoring (+/+)

- Ophthalmologist

examina-tion: OD

cataract mature, and OS

cataract immature

Hyperglikemia

Causes damage of

blood vessel within

the eye

leak blood and fluid

into the surrounding

tissues

affects the ability of

lenses to focus

causes vision

problems

(blurry vision)

Disturbed sensory

perception; visual

9

5 S:- Patient said that she has

blurry vision

O:

- Eye lens: snoring (+/+)

- Ophthalmologist

examination: OD cataract

mature, and OS cataract

immature

Eye lens snoring

Affect the ability of

lenses to focus

Causes vision

problem

Risk for injury

Risk for Injury

Nursing Diagnostic

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

resistance, signed by BG: 288 mg/dl.

2. Impaired skin integrity due to poor wound healing secondary to hyperglycemia,

signed by patient said that her foot has swollen, redness and pain since three

days ago, there is a wound at right pedis that seems swollen, redness, photo

pedis shows osteomyelitis and amputated phalanx digit 1 pedis dextra.

3. Risk for deficit fluid volume due to excess fluid excretion secondary to

hyperglycemia, signed by patient complains about urinate frequently, polyuri,

BG: 288 mg/dl, urine output: + 3000 cc/day.

4. Disturbed sensory perception; visual due to the decline of lenses ability to

focus, signed by patient said that she has blurry vision, eye lens: snoring (+/+),

OD cataract mature, and OS cataract immature.

5. Risk for injury due to vision problem, signed by patient said that she has blurry

vision, eye lens: snoring (+/+), OD cataract mature, and OS cataract immature

10

C. PLANNING

Nursing Diagnosis

Goal and Objective Nursing Orders

Hyperglycemia due

to the decrease of

insulin production

(auto immune) or

insulin resistance

Goal:

After 3 hours of nursing

interventions, blood

glucose level will be

decrease and controlled

Outcome criteria:

- BG within normal limit:

120 – 160 mg/dl

- Patient follow the diet

therapy

1. Administer insulin therapy

regularly as ordered

2. Consult nutritionist to develop

diet planning

3. Administer IVFD

4. Monitor laboratory results: CBS,

aseton, pH, HCO3

5. Teach client about the

importance of keeping diet

therapy as it programmed

6. Promote comfortable

environment to minimize stressor

that can induce increase blood

glucose level

Impaired skin

integrity due to

poor wound

healing secondary

to hyperglycemia

Goal:

after 3 days of nursing

intervention, shows

improvement of skin

integrity

Outcome criteria;

-Shows skin tissue

regeneration

-Wound healing shows

progression

-Blood glucose within

normal limit

-Free of infection sign

1. Assess wound site for signs of

infection such as swelling,

redness, pain.

2. Review laboratory results

(Hb/Hct, blood glucose blood

and /or wound culture, albumin)

to evaluate causative factors or

ability to heal

3. Cleanse or irrigate wounds

using physiological solution (e.g.

isotonic saline) with syringe or

gauze square, avoiding cotton

balls or other product that shed

11

fibers

4. Use appropriate barrier dressing

or wound covering to protect

wound and surrounding tissue

from excoriating secretion/

drainage and to promote wound

healing

5. Carefully dress wounds and

stimulate circulation to

surrounding areas to assist

body’s natural process of repair.

6. Maintain a moist environment

for wound

7. Practice and instruct client in

scrupulous hand washing clean

or sterile technique to reduce

incidence of contamination or

infection

8. Provide optimum nutrition

appropriate to diet planning

(including adequate protein,

lipids, calories, trace minerals

and multivitamins [e.g., A, C, D,

E]) to promote skin

health/healing and to maintain

general good health

9. Administer/monitor medication

regimen (e.g., antimicrobials,

drip infusion into osteomyelitis,

subeschar clysis, topical

antibiotics)

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

12

volume due to

excess fluid

excretion

secondary to

hyperglikemia

After 3 days nursing

intervention, risk for

deficit fluid volume

avoided and

demonstrate adequate

hydration

Outcome criteria:

- Vital sign WNL

- CRT 2 second

- Balance intake and

output

- Electrolyte WNL

urine specific gravity

2. Monitor orthostatic blood

pressure changes

3. Weigh daily

4. Maintain fluid intake at least

3000 ml / day within cardiac

tolerance with oral intake is

resumed.

5. Promote comfortable

environment. Cover patient with

light sheets to reduce/ replenish

trans epidermal water loss.

Collaborative:

6. Administer fluids as indicated

(e.g normal saline with or

without dekstrose)

7. Monitor electrolyte results

Disturbed sensory

perception; visual

due to the decline

of lenses ability to

focus

And

Risk for injury due

to vision problem

Goal

After 3 hours nursing

intervention, patient can

recognize/compensate

for sensory impairments

Outcome criteria:

- Patient demonstrate

using resources

effectively and

appropriately

- Patient can Identify/

modify external

factors that contribute

to alterations in

sensory/perceptual

1. Note particular vision problem

(e.g., loss of visual field, change

in depth perception, double

vision, blindness) that affects

client’s ability to perceive

environment and learn/relearn

motor skills

2. Speak to visually impaired client

frequently, especially when

entering room/client’s presence

to provide auditory stimulation

and prevent startle reflex.

3. Position objects to take

advantage of intact visual field,

and use eye patch, when

13

abilities

- Be free of injury

needed, to decrease sensory

confusion when client has loss

of vision or, field of vision in one

eye.

4. Supply adequate lighting for

reading and activities.

5. Place glasses/contacts where

they can be easily found and

encourage client to wear

corrective lenses during waking

hours.

6. Arrange bed, personal articles,

and food trays to take

advantage of functional vision.

7. Maintain bed/chair in lowest

position with wheels locked

8. properly placing alarms/fire

extinguishers

9. Place assistive devices (e.g.,

walker, cane, glasses, hearing

aid) within reach, make sure call

light is within reach and client

knows how to operate it.

14

D. IMPLEMENTATION

DateTime

Number Dx

Implementation Evaluation

11-11-09 I

II

- Maintain IVFD PZ 14

drops/minute

- Monitoring laboratory:

blood glucose, electrolyte,

Hb, Hct, Albumin, BUN,

Creatinin

- Teaching client about the

importance of keeping diet

as it programmed

- Observing vital sign

- Injecting Humolin R 4 IU

per SC t.d.s (07-12-15)

- Helping and ensuring

patient eat her meal

appropriate to her diet (B1

2100 kal)

- Injecting Humolin N 4 IU

per SC od (0-0-1)

- Administering antibiotic :

ceftazidine 1gr t.d.s and

metronidazole 500 mg IV

t.d.s

- Cleansing and irrigating

wound using normal

saline, smearing

Garamicyn cream then

dressing it with gauze and

Bactigras. Keeping aseptic

and sterile technique

S: client said that they

understand and will keep

her diet as it programmed

O:

- Blood glucose: 264 mg/dl

Hb: 10,3 gr% albumin: 2,8

- Client finish her meal

appropriate to her diet

- Vital sign: T: 36,50C, RR:

20x/mnt, BP: 110/70 mmHg,

P: 72x/mnt

A: Goal met partially

P: Continuing intervention

S:

- Client complain about pain,

redness and swelling in his

right pedis

- Client said that they will

keep sterile technique

O:



P: 72x/mnt

- Leukocyte: 17.800

15

III

IV,V

- Teaching client about

scrupulous hand washing

clean or sterile technique

to reduce incidence of

contamination or infection


- Monitoring laboratory result

:leukocyte

- Monitoring intake and

output

- Suggesting clients to drink

at least 2500cc/ day

- Monitoring electrolyte,

BUN, creatinin, blood

glucose

- Placing alarm near patient

and teaching her how to

operate it

- Suggesting client to place

glasses or any assistive

device within reach where

she can easily found.

- Ensuring the light is

adequate for clients sight

- Maintaining client’s bed

- Wound clean and dressing

well, there is no skin

regeneration yet

A: goal not met yet

P: continuing intervention

S: client complain about

urinate frequently

O:

- Intake per oral: 2500 cc,

parenteral: 1000 cc

- Output urine: 3000 cc

- Vital sign WNL

- CRT 2 second


- BUN: 19,5, creatinin: 1,5

- Electrolyte WNL: Ca: 9

Cl: 101, K: 4.5, Na: 140



S: client said that they under-

stand how to compensate

the impaired of vision

O:

- Patient demonstrate using

resources effectively and

appropriately

- Patient free of injury

A: goal met

P: intervention stopped

16

and chair in lowest position

with wheels locked

11-12-09 I

II


per SC t.d.s (07-12-15)




Creatinin





2100 kal)


per SC od (0-0-1)




t.d.s


wound using normal

saline, smearing







S: -

O:






P: 76x/mnt


P: Continuing intervention

S:



right pedis



O:



P: 76x/mnt



regeneration yet


A: goal not met yet


17

III output



- Maintaining IVFD 14 drops

/minute

S: -

O:


parenteral: 1000 cc


- Vital sign WNL

- CRT 2 second




11-13-09 I

II


per SC t.d.s (07-12-17)




Creatinin





2100 kal)


per SC od (0-0-1)




t.d.s


wound using normal

saline, smearing




S: -

O:






P: 72x/mnt

A: Goal not met

P: modify intervention.

I: administer Humolin R 8 IU

per SC t.d.s (07-12-17)

S:



right pedis





P: 72x/mnt


18

III




output



- Maintaining IVFD 14 drops

/minute


regeneration yet

A: goal not met yet


S: client complain about

urinate frequently

O:


parenteral: 1000 cc


- T: 36,50C, RR: 20x/mnt, BP:

100/60 mmHg, P: 72x/mnt

- CRT 2 second




19

E. EVALUATION / DISCHARGE PLANNING

Item Messages

Control - Control to Policlinic Ophthalmology, cataract division

- Control to Policlinic DM and Rehabilitation

Medicine Insulin 4 IU t.d.s before meals

Metformin 500 mg t.d.s

Dressing Cleansing and irrigating wound using normal saline, smearing

Garamicyn cream then dressing it with gauze and Bactigras.

Keeping aseptic and sterile technique.

Done by nurse in homecare

Diet B1 2100 kal

Nutrition At 06.00 : 4 spoon rice + side dishes

At 10.00 : 1 boiled potatoes

At 12.00 : rice + fruit (apple, papaya)

At 17.00 : 4 spoon rice + fruit

At 20.00 : 2 slice of bread

Water at least 3000 cc/day

Others Wearing suitable pad

Exercise appropriate to client’s ablity

Keeping the diet therapy

20

nursing care in patient with diabetes mellitus

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