I.

INTRODUCTION

Diabetes mellitus or simply Diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). There are three main types of diabetes mellitus (DM). Type 1 DM results from the body's failure to produce insulin, and presently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes". Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adultonset diabetes". The third main form, gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. It may precede development of type 2 DM. Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes. All forms of diabetes have been treatable since insulin became available in 1921, and type 2 Diabetes may be controlled with medications. Both types 1 and 2 are chronic conditions that cannot be cured. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, and diabetic retinopathy (retinal damage). Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body weight.

Types of Diabetes
Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to insulin deficiency. This type can be further classified as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated nature, in which beta cell loss is a T-cell-mediated autoimmune attack. There is no known preventive measure against type 1 diabetes, which causes approximately 10% of diabetes mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Type 1 diabetes can affect children or adults, but was traditionally termed "juvenile diabetes" because a majority of these diabetes cases were in children. "Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was traditionally used to describe to dramatic and recurrent swings in glucose levels, often occurring for no apparent reason in insulin-dependent diabetes. This term, however, has no biologic basis and should not be used. There are many reasons for type 1 diabetes to be accompanied by irregular and unpredictable hyperglycemias, frequently with ketosis, and sometimes serious hypoglycemias, including an impaired counterregulatory response to hypoglycemia, occult infection, gastroparesis (which leads to erratic absorption of dietary

carbohydrates), and endocrinopathies (e.g., Addison's disease). These phenomena are believed to occur no more frequently than in 1% to 2% of persons with type 1 Diabetes. Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most common type. The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise Individuals who are at high risk of developing Type II diabetes mellitus include people who:

are obese (more than 20% above their ideal body weight) have a relative with diabetes mellitus belong to a high-risk ethnic population (African-American, Native American, Hispanic, or Native Hawaiian) have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg) have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL have had impaired glucose tolerance or impaired fasting glucose on previous testing

In the early stage of type 2, the predominant abnormality is reduced insulin sensitivity. At this stage, hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver. Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2%5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable, but requires careful medical supervision throughout the pregnancy. About 20% 50% of affected women develop type 2 diabetes later in life. Though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin may inhibit fetal surfactant production and cause respiratory distress syndrome. Hyperbilirubinemia may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A Caesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia. Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 DM. Many people destined to develop type 2 DM spend many years in a state of prediabetes which has been termed "America's largest healthcare epidemic."

Diagnostic Tests:
1. Fasting Plasma Glucose Test- this test is to measure bloods plasma-glucose after fasting for at least 8 hours, thus the name fasting plasma glucose test. This test is useful to detect all types of diabetes. 2. Oral Glucose Tolerance Test- which measures blood glucose after 8 hours of fasting and 2 hours after the person drinks a glucose-containing beverage. This test is effective to diagnose all types of diabetes. 3. Random Plasma Glucose Test- also called a casual plasma glucose test, because there is no fasting required or worry about what we have eaten. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes. However, once random plasma glucose test confirms diabetes needs to be reconfirming by FPG or OGTT

Causes:
The cause of diabetes depends on the type: Type 1 diabetes is partly inherited, and then triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. A genetic element in individual susceptibility to some of these triggers has been traced to particular HLAgenotypes (i.e., the genetic "self" identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1 DM seems to require an environmental trigger. The onset of type 1 diabetes is unrelated to lifestyle. Type 2 diabetes is due primarily to lifestyle factors and genetics.

Signs and Symptoms:

Weight loss Polyuria ( frequent urination) Polydipsia (increased thirst) Polyphagia (increased Hunger) Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to changes in its shape, resulting in vision changes. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected. A number of skin rashes that can occur in diabetes are collectively known as diabetic dermadromes.

Complications of a Diabetic Patient

Diabetes complications begin because of blood vessel and nerve damages, causes due to highlevel of glucose in blood (uncontrolled diabetes), prolonged diabetes, high-cholesterol level, and high-pressure. Nerve damages of the respective organs are the root cause of diabetes complications. Uncontrolled diabetes can harm the nerves in your body causing diabetic neuropathy. Heart disease, stroke, heart attacks are all caused by blockage of blood vessels causing lack of oxygen in extreme case breakage of blood vessels may happen. Diabetic retinopathy caused due to blood vessel damage in retina causing lack of blood circulation thus lack of oxygen to nourish retina and in extreme cause leakage of blood in the retina. Diabetic Gastroparesis is a disorder of the stomach that takes too long to empty its contents, mostly due to vagus nerve damage. Diabetes kidney diseases are causes due to a small blood vessel of kidney is damage due to long run of high blood-glucose. Erectile dysfunction or impotence is due to over-all nerve damage, and may be nerves in penis.

 Urinary incontinence, over active bladder, bladder problems are all cause by nerve damage due to prolonged high blood-glucose. Urinary tract infection is also due to nerve damage, but it is not directly relating with a nerve cause. Due to Diabetic Gastroparesis, there is a delay in the food emptying, which in-turn starts bacterial growth, and causes urinary tract infection. Furthermore, due to long term of diabetes, immune system losses it capacity thereby it is not able to fight the infection.

Diabetes Management:
1. Food - What you eat directly influences your blood-glucose levels. Follow the food pyramid for effective diabetes control or management. Take food at the same time also the same volume and never skip your food or even snack. 2. Physically active try to make your busy in your daily life routine or spent some time for physical exercises such as walking, swimming, exercising and playing. It produces positive results in blood-glucose control as well as a drop in medicine (pills or insulin) requirements. 3. Lose weight if you are obese or overweight, try to reduce weight by following food pyramid and increasing physical activity or exercising. Losing weight has a direct positive impact in your blood-glucose control. 4. Monitor glucose level closely monitor your blood-glucose, check your blood-glucose using home glucose monitor, and make a record. If you maintain your blood-glucose near normal, then you can avoid many diabetic complications. 5. A1C test Have A1C test at least two times a year. If you are very much concerned about your health, it is better to have A1C test for every three months. If you are able to maintain your blood-glucose near normal most of the time, then your A1C level will be at the best range. 6. Medicine Have your medicine or insulin in the same time every day without skipping or delaying. Learn to adjust your medicines with respect to your daily activity change of any rare diet change. 7. Scheduled exams Go for regular yearly exam for eye, kidney, heart, nerves, and teeth. If you have, any symptoms of diabetes complication immediately consult your doctor. 8. Vaccination high blood-glucose can weaken your immune system, which makes routine vaccination is important for diabetics. Ask your doctor for details. 9. Foot care Give a special importance to your foot. Wash your foot in lukewarm water, dry it gently, and moisturize it. Regularly check foot for any blisters, cuts, sores, redness or swelling, if found any consult your doctor immediately for treatment. 10. Blood pressure, Cholesterol if you are hypertension and or cholesterol keep it in control with medication to avoid or postponed diabetes complications such as heart disease, stroke, and kidney disease. 11. Aspirin - Aspirin interferes with your blood's ability to clot. Taking a daily aspirin can reduce your risk of heart attack and stroke a major concern when you have diabetes. 12. Do not smoke if you are a smoker plan to quit. Smoking increases your risk of various diabetes complications, including heart attack, stroke, nerve-damage, and kidney disease. 13. Alcohol if you are a drinker, do so only in moderation and always with a meal. 14. Stress stress causes hormonal imbalance and prevents insulin to work normally, end up with a high blood-glucose control. So take the stress seriously and try to calm yourself or practice meditation.

Nursing Responsibilities:

Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance. Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin. Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach. Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen. Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia. Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia. Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes. Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow.

II. NURSING HISTORY

Patient Name: BKA Age: 50 Sex: Female Address: Tandul, Cabatuan, Isabela Civil Status: Married Occupation: Vendor Religion: Espiritista Date and Time of Admission: August 01,2012/ 10:20 am Admitting Diagnosis: Non Healing Wound PAST HISTORY: During her previous life, patient BKA reported of having cataract and undergone debridement procedures. She had cataract on her both eyes which alarmed her and her family to take actions of it. Patient BKA undergone cataract extraction, after the surgery she was very much thankful that he sees normally again. In the year 1992, patient BKA experienced body malaise and dizziness that causes her to collapsed and was rushed to the hospital only find out that she has diabetes. Patient BKA reported that she undergone debridement due to her diabetes to prevent possible complication of her condition such amputation. Aside from her diabetes, she was also diagnosed of myoma and was operated in the year 2009.

PRESENT HISTORY: Patient BKA never knew that her condition will lead her to amputation. She viewed diabetes as a simple disease that can be treated by simple medications. Because of her oblivious attitude regarding her condition, it complicates until she begun to have non-healing wounds which causes her to undergone debridement on her left foot then followed by her right. When her right foot doesnt heal on debridement, she undergone below the knee amputation. FAMILY HISTORY: According to patient BKA, her family has history of diabetes which caused her mothers death. She is aware that she inherits her condition from her mother which was inherited by her daughter to her.

GORDONS 11 FUNTIONAL PATTERN

HEALTH PERCEPTION BEFORE: patient BKA considered diabetes as a simple disease only. She ignored the fact that it may result into many complications. She seldom goes to hospital for check-up until one day she collapsed following body malaise and dizziness that makes her family to rush her to the hospital only to find out that her diabetes was being triggered. When she was diagnosed with diabetes the doctor recommended her to take medications such as insulin and placil. She also told us that she started exercising and consulting the doctor. PRESENT: after the surgery, she still viewed herself as a healthy person thinking that she can still live and do the things she used to do without her right foot. She also added that she will still continue selling in the market even without her one foot. NUTRITIONAL- METABOLIC PATTERN BEFORE: during patient BKAs childhood, she loves to eat sweets such as tira-tira, pastillas, etc She is also fond of drinking softdrinks before she was diagnosed of diabetes. Though she eats three times a day, she used to consume foods rich in sugar. PRESENT: when she was diagnosed of diabetes, her doctor together with her family restricted her from consuming foods high in sugar including sodas. Looking at her physical condition, she had incomplete teeth; her skin is dry especially at her extremities. ELIMINATION PATTERN BEFORE: before she undergone surgery, patient BKA void twelve times a day and defecate once a day. She consumed 2 liters of water but her skin remains dry due to underlying condition. PRESENT: patient BKA was catheterized when she undergone surgery measuring 100ml all throughout the procedure. ACTIVITY AND EXERCISE PATTERN BEFORE: patient BKA is a vendor and considered a habit already. Before she starts working, she used to do simple exercise such as stretching. It has been her routine already selling in the market and she can do things she wanted to do. PRESENT: after she was amputated, she told us that she will still sell in the market even without her right foot. She concluded that having an amputated leg doesnt stop her from doing what she wants.

COGNITIVE AND PERCEPTUAL PATTERN BEFORE: patient BKA decides in her own as she told us and goes for check-up all by herself. She only consulted her family if it requires family decision. Patient BKA experienced blurring of vision only when looking from distant places. PRESENT: she has still sharp memory that she can still able to manage in decision making and remembered past events. Her vision remains the same, experiencing blurring of vision form a distant area. SLEEP-REST PATTERN BEFORE: patient BKA sleeps 5 hours per day starting 10pm-3am. She seldom had rest due to her occupation being a vendor working whole day in the market. She only rested when she sold all her manufactured goods already or if theres no customer. She is aware of her sleeping pattern and considered it normal rationalizing that its a part of aging and she need to do that for her work. PRESENT: when she was diagnosed of diabetes and had undergone debridement, she tried to cope up in her sleeping pattern. She told us that she sleep earlier compared before. Aside from that, she also tried to look for time to give herself a rest even when she is at work. ROLE RELATIONSHIP PATTERN BEFORE: patient BKAs husband is a farmer, though her husband earned enough money to support his family, patient BKA still decided to work to help her husband in working and to support his daughters study as well. She was very much satisfied to her relationship with her family. PRESENT: her relationship with her family was established properly; when we are having our interview we saw how they are intimate to one another, throwing jokes and can still manage to laugh despite of her condition. SEXUAL REPRODUCTIVE PATTERN BEFORE: patient BKA had 2 children both are girl. She delivered her second child in the hospital due to gestational diabetes but still managed to deliver it normally. PRESENT: she is already 50 years old and was menopause already. COPING STRESS BEFORE: patient BKA is a religious person, she believes that stress can be relieved through prayer and trusting to the almighty God. She also considered the presence of her family as a factor in relieving her stresses in life. PRESENT: she never fails to acknowledge the presence of GOD. When she knew she will undergo surgery, she prayed to GOD to lessen the stress she is experiencing. VALUES-BELIEF PATTERN BEFORE: patient BKA is an espiritista, she regularly attend church services every Saturday and Sunday. Her faith of God is very deep putting in mind that it is only God who can help her in every situation of her life. PRESENT: after what happened to her, she never did blame God of her condition because she believes that everything happens for a reason and it is her fault anyway.

DATE: 08-01-12; TIME: 2:45pm GENERAL APPEARANCE: the patient looks weak, feels dizzy, irritable with the IFC, and complains that she still doesnt feel her left leg, the patient still smiles while she talks to her relative but hardly to cooperate due to weakness and under the presence of anesthesia.

PHYSICAL ASSESSMENT:
T: 36.9 o C PR: 96 bpm IFC: 100cc PARTS HAIR HEAD TECHNIQUE USE Inspection Inspection Palpation Inspection Palpation Inspection ABNORMAL FINDINGS White strands Dry Oily Round, symmetry; no mass or nodules Facial grimace, irritable Cold to touch Oily With eye bag Sclera: pale ANALYSIS Due to aging RR: 20 cpm BP: 110/80 mmhg

Normal Due to post-operative Due to Due to poor hygiene Due to inadequate sleep Due to decrease red blood cells secondary to surgery and anemia

FACE

EYES

EARS

Inspection

Palpation

NOSE

Inspection Palpation

LIPS MOUTH

Inspection Palpation Inspection

Bulbar and palpebral conjunctiva are pale Due to decrease red blood cells Pupils black in color; equal secondary to surgery in size and anemia Pupils constrict when Normal illuminated and looks at near object; dilates when Normal illuminated and looking at far Symmetrical, aligned with Normal outer canthus Dry cerumen Oily auricle Due to poor hygiene Auricle return to normal Normal after recoil Oily Due to poor hygiene No tenderness Normal No difficulty in inhaling or Normal exhaling Cracked lips Due to Dry lips Due to With bad breath Poor hygiene

TEETH VAGINA

Inspection Inspection

Incomplete Presence of polyps

Due to aging Due to complication of diabetes Due to poor hygiene Due to increase urination Due to poor blood circulation or anemia Due to anemia or poor blood circulation Due to poor hygiene Due to unhealing wound and impaired skin integrity Due to impaired skin integrity

UPPER EXTREMITIES NAILS Inspection SKIN Inspection Palpation

Dirty fingernails Dry skin Pale nail bed

PALM

Inspection

Pale

LOWER EXTREMITIES SKIN Inspection Inspection

Dry skin BKA right leg

Debridement left leg

III. ANATOMY AND PHYSIOLOGY

FUNCTIONS OF ENDOCRINE SYSTEM:
Water balance Uterine contractions & milk release Growth, metabolism, & tissue maturation Ion regulation Heart rate & blood pressure regulation Blood glucose control Immune system regulation Reproductive functions control

The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). The pancreas is made up of two types of glands: Exocrine- The exocrine gland secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas.

Endocrine- The endocrine gland, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the Pancreas:

The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine gland in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum. The hormones secreted by the endocrine gland in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones).

Pathophysiology:

Precipitating factor: Eating sweets and fatty foods

Diabetes mellitus Type II

Predisposing factor: Genetics Age45 years old Gender: female

Decrease insulin production of pancreas

Fat is broken down in adipose tissue Releases fatty acid in the blood stream.

Glucose is not metabolize by the body

Accumulation of glucose in the blood stream Too much glucose cannot hold the kidneys threshold

Increase glucose in the blood stream

Fatty acids convert into ketones by the liver.

Sluggish flow of blood Increase urine production (Polyuria)

Source of energy

Poor circulation of blood

Polydyspia Glycosuria

Occurrence of obstruction in the blood stream

Dry skin, dry lips

Decrease O2 supply in the body

Loss of Electrolyte and Balance

Gestational diabetes

osteomyelitis

Body malaise, nausea and vomiting, pale.

Peripheral neuropathy

Infectious vaginitis

Non healing wound

Deterioration of small blood vessels that nourish retina Opacity in the lens Blurred vision

Debridement on the left and right foot

Diabetic retinopathy

BKA on the right foot

IV. LABORATORY RESULTS

August 01 2012

Tests Hemoglobin Monocyte White cell

Normal Values F (12-18 g/dl) F (37-47%) blood 4.0-10.0

Results 10.2 30.0 18.4

Interpretation Due to anemia Due to bacteria Due to infection

Granulocyte Lymphocyte

44.2-80.2% 28.0-48.0%

76 24

Normal Due to the presence of wound

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VI. COURSE IN THE WARD

August 01,2012

POST-OP ORDERED
DATE 8/1/12 TIME 11:45am DOCTORS ORDER To ward/ status post BKA right under SAB Diabetic diet, if with full motor and sensory VS q 15mins. until stable For Hgb- now, then q 8 hours thereafter IVF:PNSS 1Lx8 hours x 3 cycles Meds: 1. Ketorolac 2. Tramadol 3. Metoclopromide Startdiabetic meds and antibiotic once on DAT Elevate with one pillow operative site Watch out for bleeding on operative site I & O q 1 hour and record Refer as needed RATIONALE For the patient recovery To prevent aspiration To monitor baseline V/S and any changes after operation To prevent blood loss NURSING RESPONSIBILITIES Endorse to ward. Check for the full motor and sensory Monitored V?S q15min Request for laboratory

To maintain fluid and electrolyte IV hooked and regulated and meds imbalances administered and recorded To alleviate sign and symptoms

To prevent the occurrence of infection and for maintenance To prevent for bleeding To check for infection For urine elimination monitoring To inform ROD

Give diabetic meds and antibiotic once on DAT Elevate with one pillow atoperative site Watch out for bleeding on operative site then report. I and O monitored q1hr Referred

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VIII. NURSING CARE PLAN

August 01, 2012 ASSESSMENT Subjective: hindi mabilis gumaling ang sugat ko. As verbalized by the patient. Objective: Altered sensation Delayed wound healing DIAGNOSIS Ineffective peripheral tissue perfusion related to decreased blood flow to the area of non healing wound due to obstruction of blood vessels PLANNING After 3o minutes of nursing interventions the patient will be able to verbalize understanding of condition, therapy regimen, side effects of medications and when to conduct health care provider. INTERVENTION Get vital signs and record. Establish rapport. Educate client in active range of motion exercise. Elevate head of bed at night. Discourage wearing constrictive clothing, crossing legs. Provide other post-op teaching appropriate for the situation. RATIONALE For base line data. EVALUATION

Goal met. After 3o minutes of nursing To gain the patient interventions the patient was trust. able to verbalize To promote circulation understanding of condition, of blood. therapy regimen, side effects of medications and when to conduct health care provider. To increase gravitational blood flow. To promote blood circulation.

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 Encourage early ambulation when possible.

To promote peripheral circulation and limit mplication associated with poor perfusion.

Discuss care of foot care as appropriate.

When circulation is impaired, changes in sensation place client at risk for development of lesions or ulcerations that are often slow to heal.

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August 01, 2012 ASSESSMENT Subjective: ang alam ko noon sa diabetes simpleng sakit lang, pero hindi pala as verbalized by the patient. DIAGNOSIS Deficient knowledge about the disease process, diet, care and treatment related to lack of information. PLANNING After 3 hours of nursing interventions the patient will be able to verbalized importance of having healthy lifestyle and correctly perform prescribed health behaviors. INTERVENTION Get vital signs and record. Establish rapport. Provide information to support selfefficacy, self regulation and self management by focusing on problem solving and decision making. Tailor the delivery of instructions to the clients cognitive level by accessible words. Provide health teaching related to disease condition. Evaluate learning outcomes using verbalizations. RATIONALE For base line data. To gain the patient trust. EVALUATION After 3 hours of nursing interventions the patient was able to verbalized importance of having healthy lifestyle and correctly performs prescribed health behaviors.

Evaluation serves as an assessment.

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August 01, 2012 ASSESSMENT DIAGNOSIS PLANNING After 8 hours of implementing the nursing intervention the patient will be able to manifest the decrease of infection. INTERVENTION Check vital signs q 15 Observe for localized signs of infection at insertion site of wound Stress proper hand hygiene by all caregivers between therapies and clients before cleaning the wound RATIONALE For baseline data EVALUATION After 8 hours of nursing intervention the patient was able to reduce/lessen the infection

OBJECTIVE: Risk for Infection Increase WBC related to post Presence of operative surgery wound due to operation

To prevent cross contamination of the infection

To reduce infection

Change surgical To reduce infection wound dressing, as And prevent indicated, using contamination proper technique for changing/ disposing of contaminated materials.

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 Encourage the client to increase protein intake Administer ceftriaxone prescribe

To promote wound healing

as

To reduce infection

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VIII. DRUGS STUDY

DRUG NAME KETORALAC

INDICATION

ACTION

CONTRAINDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES 1. Assess for rhinitis increased risk for developing hypersensitivity reactions. 2. Assess pain (note type, location and intensity) prior to 1-2 hours following administration.

Short term Inhibits prostaglandin Hypersensitivity; cross CNS: drowsiness, dizziness, management of synthesis, producing sensitivity with other headache Classification: pain. peripherally mediated NSAIDs may exist. Nonsteroidal antianalgesia. Also have Respiratory: dyspnea inflammatory and antipyretic and antinon opioid inflammatory CV: edema, pallor, analgesic properties. vasodilation Therapeutic effects: decrease pain. GI: oliguria

Route: IV every 6 hours Dosage: 30 mg- 4 doses

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DRUG NAME TRAMADOL Classification: Analgesic Route: slow IV push Dosage: 50 mg- 4 doses

INDICATION Moderate severe pain

ACTION

CONTRAINDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES 1. Assess type, pain location, intensity of pain and 2-3 (peak) after administration. 2. Assess BP and respiratory rate before and periodically during administration. 3. Prolonged use may lead to, physical and psychological dependence and tolerance. If tolerance develops, changing to an opiod may be required to relieve pain.

to Binds to mu-opioid Hypersensitivity; cross CNS: dizziness, headache receptors. Inhibits sensitivity with opioids reuptake of may exist. serotonin and GI: constipation, nausea norepinephrine in the CNS. Therapeutic effects: decrease pain

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DRUG NAME METOCLOPROMI DE Classification: antiemetics Route: IV Dosage: 10 mg PRN

INDICATION

ACTION

CONTRAINDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES 1. Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administration. 2. Assess for extrapyramidal reactions. 3. Monitor for tardive dyskinesia. 4. Assess patient for signs of depression periodically throughout therapy.

-Treatment pi post Block dopaminre Hypersensitivity; possible CNS: drowsiness, surgical and diabetic receptors in G.I. obstruction/ extrapyramidal gastric stasis. chemoreceptor trigger hemorrhage. reactions, zone of the CNS. restlessness. -Treatment and Motilates motility of the prevention post ipper G.I. tract and GI: constipation, operative nausea and accelerates gastric nausea vomiting. emptying. Therapeutic effects: decrease nausea and vomiting and decrease symptoms of gastric stasis.

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DRUGS Drug name: Metformin Classification: Anti diabetic ROUTE: P.O DOSAGE: 500mg x a day with meal l

INDICATION Management of type 2 diabetes mellitus; may be used with diet,insulin, or sulfonylurea oral hypoglycemic.

ACTION
Decrease hepatic glucose production

CONTRAINDICATION Hypersensitivity; metabolic acidosis; dehydration,sepses, hypoxemia, hepatic impairment.

SIDE EFFECT
1. Nausea and vomiting, hypoglycemia 2. Decrease vitamin B12

NURSING RESPONSIBILITIES 1. Obtain baseline and periodic

kidney and liver function tests; drug contraindicated in the presence of renal or hepatic insufficiency. Monitor blood glucose and HbA1C, and lipid profile periodically. 2. Assess renal function before initiating. 3. monitor serum folic acid and vitamin B12. 4. Encourage patient to follow prescribed diet, medication, and exercise regimen to prevent hyperglycemic or hypoglycemic.

THERAPEUTIC
EFFECTS: Maintenance of blood glucose

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DRUGS Drug name: INSULIN Classification: Anti diabetics Route: sub cut Dosage: 0.5 to 1 unit/ kg per day

INDICATION Control of hyperglyce mia in patients with type 1 or type 2 diabetes mellitus

ACTION

CONTRAINDICATION

SIDE EFFECT

NURSING RESPONSIBILITIES 1. Monitor body weight periodically. Changes in weight may necessities changes in insulin dose. 2. Monitor blood glucose every 6 hours during therapy, more frequently in times of stress. 3. Notify physician promptly for presence of acetone with sugar in the urine; may indicate onset of ketoacidosis. Acetone without sugar in the urine usually signifies insufficient carbohydrate intake. 4. Monitor for hypoglycemia (see Appendix F) at time of peak action of insulin. Onset of hypoglycemia (blood sugar: 5040 mg/dL) may be rapid and sudden. 5. Check BP, I&O ratio, and blood glucose and ketones every hour during treatment for ketoacidosis with IV insulin. 6. .Emphasize the importance of compliance with nutritional

lower blood hyperglycemia, allergy or erythema, lipodystrophy, glucose uptake in hypersensitivity to a prurutis, swelling skeletal muscle particular type of insulin. and fat, inhibiting hepatic glucose production.

THERAPEUTIC EFFECTS: Control of hyperglycemia in diabetic effects.

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guidelines and regular exercise as directed by health care professional.

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