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DEVELOPMENTAL TASK
It is important to obtain the knowledge of growth and development since the idea
can be utilize in patient care. By way of assessing and formulating an effective nursing
care plan which may lead to acquiring the ultimate goal of health promotion, restoration
and maintenance, and illness prevention.
Implication:
Implication:
My client’s developmental task as a middle age is to extend his concern not just
from himself, but also to his family, community and the world. He is now confident of
his status in life and is able to juggle various role as a father, a grandfather, and as a
citizen of this country.
Implication:
HEALTH HISTORY
HEMATOLOGY (05/06/07)
Conventional Unit Result
Hematocrit 35.0 – 50.0 % 19.1 - Anemia
Hemoglobin 11.0 – 16.5 7.0 - Anemia: Fluid Retention
WBC Count 5.0 – 10.0 1/mm 5.0
Platelet Count 140,000 – 440,000 164,000
Differential Count
Conventional Unit SI unit Result
Segmenters 55 – 65 % .55 - .65 59
Lymphocytes 25 – 35 % .25 - .35 41 - Chronic/Viral Infection
BLOOD TYPE: B RH TYPE: POSITIVE
HBSAG (06/07/07)
Result: HBSAG – Non reactive (–) Hepatitis
Hematology
06/07/07 10:35 am
Result Unit Reference
White Blood Cell count 4.8 1013/VL 5.0 – 10.5 - Hepatic Dysfunction
Red Blood Cells 3.49 1016/VL 3.80 – 5:80 - Anemia: Fluid overload
Hematocrit 10.6 g/dL 35.0 – 50.0 - Anemia
MCV 91.1 Fl 82.0 – 92.0
MCH 30.4 pg 26.5 – 33.5
Platelet count 120 1013/VL 140 – 440
Differential Count
Segmenters 77.0 % 55 – 65
Lymphocytes 22.0 % 25 – 35 - Chronic/ Viral Infection
(May 7, 2007)
Sodium LO 133 mmol/L 137 – 145 - Acute Renal Failure
Potassium 3.7 mmol/L 3.5 – 5.1
Albumin LO 2.0 g/dL 3.5 – 5.0 - Hypertension and
Hepatic Dysfunction
MEDICAL ORDERS
Date: 05/06/07
Day 1
DOCTOR’S ORDER RATIONALE
1. Start Venoclysis of PNSS 1 L 15 1. To maintain electrolyte balance.
qtts/min 2. To monitor v/s of pt. and determine
2. Monitor vital signs every 2 hrs. and condition and progress every 2 hours.
record on the patient’s chart. 3. To provide O2 supply and prevent
3. O2 inhalation 1L.min via nasal cannula hypoxia.
4. To determine the presence of occult
4. Note the stool characteristic blood and microorganisms (bacteria,
viruses)
5. To obtain accurate result in blood
5. NPO temporarily chemistry (BUN, Lipid profile)
6. To obtain accurate intake and output
6. Strict I and O of the patient.
7. To obtain the correct blood
7. Secure pt. blood type and inform component once needed for blood
undersign once available transfusion.
8.
8. Therapeutics: a. To suppress gastric acid secretion
a. Pantoprazol 40mg IVTT q12 b. To promote blood coagulation
b. Hemostan 1 ampule IVTT q8 c. To promote hepatic formation of
c. Vit. K 1 amp IV OD active coagulation.
d. Increase insulin; insulin supplement
d. Mixtard 25 “u” SQ before breakfast
and 15 “u” SQ before dinner 9. To determine the cause of illness, and
9. DIAGNOSTICS: formulate and verify diagnosis.
Routine CBC, HGT, Ultrasound the
upper abdomen, HBSAG, and Blood
Chemistry
Date: 05/07/07
Day 2
DOCTOR’S ORDER RATIONALE
PATIENT PROFILE
Name: Mr. A
Age: 64
Religion: Islam
Nationality: Filipino
Informant: Daughter
Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Effects/ Nursing
Name of Name Ordered Frequency/ of Action Indication indication Toxic Precaution.
Ordered Route Effects
Drug
Phoenix Pantoprazole 05-06-07 Antiulcer 40 mg IVTT Suppress Elosive Contraindi- Headache, Step IV
sodium Drugs q12 gastric acid esphagitis cated to pt. insomnia, treatment
secretion caused by hyper- diarrhea, when P.O
diabetes sensitive to dizziness, form is war-
mellitus drugs. chestpain, ranted. Can
nausea & be given
vomiting without
regard to
meals
Mephyton Vit. K 05-06-07 Vitamins and 1 amp. IVTT Promotes Hypothrombo- Contraindi- Dizziness, Monitor PT
analogue minerals OD active nemia caused cated to py. hypotension, or INR to
phytond- coagulation by Vit. K mal- Hyper- weak pulse determine
dione absorption & sensitive to dosage effec-
drug theraphy drug. tiveness. S.C.
route is pre-
ferred to
avoid
hematoma.
DRUG STUDY
Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Effects/ Nursing
Name of Name Ordered Frequency/ of Action Indication indication Toxic Precaution.
Ordered Route Effects
Drug
Human Humulin 05-06-07 Insulins 12 “u” SQ Helps Moderate to Contraindi- Hypogly- Used in pt.
Insulin 70/30 before decrease severe cated to pt. cemia, with
breakfast glucose hyperglycemia hypersensi- hypokalemia. circulatory
level. tive to drugs Pruritus. collapsed,
& episodes diabetic
of hypogly- ketoacidosis
cemia or hyperka-
lemia
30% soluble Mixtard 30 05-06-07 Insulins 25 “u” SQ Increase Insulin Hypogly- Allergy & Watch for
human HM before insulin for requiring cemia & lipoatrophy any signs of
mono- breakfast, 15 insulin diabetes insulinomia allergy and
component “u” SQ supplement mellitus hyper-
insulin & before dinner glycemia.
70% OD.
isophane
human
mono-
component
DRUG STUDY
Generic Brand Date Classification Dose/ Mechanism of Specific Contra- Side Effects/ Nursing
Name of Name Ordered Frequency/ Action Indication indication Toxic Effects Precaution.
Ordered Route
Drug
Pregabalin Lyrica 05-06-07 Anticonvulsant 75mg P.O Prevents Neuropathic Contraindi-cated Dizziness, Instruct pt.
BID neuropathic pain pain, and in pt. that is euphoric that drug may
and partial epilepsy. hyper-sensitive to mood, affect this
seizures drugs. confusion ability to
decrease in drive and
libido operate
machinery.
Tranexamic Hemostan 05-07-07 Haemostatics 1 amp. Antihemorrhagic Traumatic Contraindicated in Nausea, Not advisable
acid IVTT 98 & antufibrolytic injuries; pt. that is vomiting, to use in
for effective hemorrhage hypersensitive to anorexia, prolonged
hemostasis drug hypotension period in pt.
predispose to
thrombosis.
Slictazide Diambron 05-08-07 Oral Antidia- 1 tab P.O Stimulate insulin Type II Contraindicated Nausea, Adjustment
betic agents RID before secretion from diabetes when use dose in headache, of dosage
breakfast & pancreatic B Type I diabetes rashes, GI may required
dinner (2 cells. with trauma or disturbance in cases of
wks) infection trauma and
shock
ANATOMY AND PHYSIOLOGY
Glucose is the leading source of energy for the human body. Glucose is stored in the
body for rapid release in times of stress and so that the serum concentration of glucose can be
maintained at a level that provides a constant supply of glucose to the neurons. The minute-to-
minute control of glucose level is the function of endocrine pancreas gland. The endocrine part
of the pancreas produces hormones in collection of tissue caked the islets of Largerhans. These
islets contain endocrine cells that produce specific hormones. The alpha cells release glucagons
in response to low glucose levels. The beta cells release insulin in response to high glucose level.
Delta cells produce somatostatin, which blocks the secretion of insulin and glucagons. These
hormones work together to maintain the serum glucose level within normal limits.
Insulin is the hormone produced by the beta cells of the islets of Langerhans. The
hormone is released into the circulation when levels of glucose around these cells rise. Insulin
circulates through the body and reacts with specific insulin receptor sites to stimulate transport of
glucose into the cells to be used for energy, a process called facilitated diffusion. Insulin also
stimulates the synthesis of glycogen, the conversion of lipids into stored far in the form of
adipose tissue, and the synthesis of needed protein from amino acids.
Helps the body take up glucose, insulin also helps convert glucose into
glycogen, which is stored in the liver and muscle until needed for fuel.
Food digested
Ketoacidosis/hyperglycemia
Coma/death
NURSING CARE PLAN
At the end of 3 days on taking care of my patient Mr. A was able to elaborate to him the
nature of his disease condition in as much as he wanted to know more about it. He was indeed
suffering for generalized muscle weakness and numbness of his lower extremities as he always
complain it to me and to his daughter. I always have my initial assessment every shift. Observing
him whether he is still experiencing dizziness accompanied by a mild high blood pressure of
13/80 mmHg or still unable to perform self-care. After the administration of medications, he had
maintained a varying blood pressure of 100/70 mmHg with a pulse rate of 66 bpm, respiratory
rate of 23 cpm and a body temperature of 36.6 that I monitored every 2 hours. I had performed
blood transfusion with him once and that was successfully infused. His vital signs was closely
monitored before and after the blood transfusion to determine signs of hyperglycemia or
hypoglycemia and conduct a nursing action against it. He was able to gain understanding
regarding his dietary nutritional needs, the importance of his medication, and exercise before he
was discharged at 4:10 pm against medical advice. He was approachable and cooperative person
I’ve met who is eager enough to be cured and I was able to establish a rapport to him without a
problem. Having him as my patient during clinical exposure means learning Diabetes Melletus
disease process. I am so thankful presenting this case because I have learned a lot starting from
laboratory results, the physiology and pathophysiology of disease, drug study and the nursing
management for this kind of case. To generalize the experience, my interventions, the standard
nursing care and the patient health teaching was effective as manifested by his satisfying
performance on leg rising, and modifying his diet and lifestyle aiming to prevent complications
of his disease.
IMPLICATION
The patient will be able to gain control to his condition by instructing him to take his
medication ordered by the physician regularly with food or after meals to avoid epigastric pain.
Exercise such as elevation of legs alternately, and breathing exercise must be properly
demonstrated so that he can utilize it in home setting. He should be aware about his chronic
illness and the prevention of the possible complications. Review the importance of proper diet
and note the schedules of insulin therapy, and glucose testing. Most of all, health modification
regarding patient’s unhealthy habit of smoking must be emphasized to prevent an outburst of
another illness that may threaten his life.
REFERRALS
Regular check-up is very important in patient with chronic illness. Safe environment and
good sanitation must also be provided to prevent infection which will lead to complication of the
infected site. Family support also play importance in enhancing patient’s motivation by all means
of giving him regular medications at the appropriate time, monitoring his diet 1400 kcal/day with
200g/day of CHO, 100g/day of CHON and 30g/day of fat. Encouraging low sodium diet and of
course, avoid sugar. If necessary, assist him in taking meals regularly, maintain adequate fluid
intake and again, avoid over-eating. Health care providers, must give emphasis on family
education regarding the nature of the disease and its prevention. Conveying to them that proper
diet and exercise will avoid or delay the onset of the disease. Before discharge from the hospital
institution, healthy teaching must be properly communicated, referring them to the nearest
hospital or health center that could assist them and note the date one week after discharge a
follow-up check-up with the patient and his regular glucose monitoring.
BIBLIOGRAPHY:
Smeltzer, Suzzane C. and Bare, Brenda G. Textbook of Medical-Surgical Nursing. 9th ed.
Philadelphia: Lippincott Williams and Wilkins. 2000.
Doenges, M. E., Moorehouse, M. F. and Geissler, A. C. Nursing Care Plans: Guidelines for
Planning and Documenting Patient Care. 3rd ed. Philadelphia: F. A. Davis Co. 1993.
Kozier, B., Erb, G., et. al. Fundamentals of Nursing: Concepts, Process, and Practice. 7th ed. New
Jersey: Pearson Education Inc. 2004.
Udan, J. Q. Medical-Surgical Nursing: Concepts and Clinical Application. 1st ed. Philippines:
Educational Publishing House. 2002.
FishBack, F.T. Nurse’s Quick References to Common Laboratory and Diagnostic Tests. 2nd ed.
Philadelphia: J. B. Lippincott Co. 1998.
Cotran, R. S., Kumar, V. Robbins, St. Robins Pathologic Basis of Disease. 4th ed. Canada: W. B.
Saunders Company. 1989.
IDEAL NURSING MANAGEMENT
Independent
Obtain history from patient/SO related to Assists in estimation of total volume depletion.
duration/intensity of symptoms such as vomiting, Symptoms may have been present for varying amounts
excessive urination. time (hours to days). Presence of infectious process
results in fever and hypermetabolic state, increasing
Monitor vital signs: insensible fluid losses.
Assess peripheral pulses, capillary refill, skin turgor, and Indicators of level of hydration, adequacy of circulating
mucous membranes. volume.
Monitor I&O; note urine specific gravity. Provides ongoing estimate of volume replacement needs,
kidney function, and effectiveness of therapy.
Serum osmolality;
Elevated because of hyperglycemia and dehydration.
Sodium;
May be decreased, reflecting shift of fluids from the
intracellular compartment (osmotic diuresis). High
sodium values reflect severe fluid loss/dehydration or
sodium reabsorption in response to aldosterone secretion.
Potassium.
Initially, hyperkalemia occurs in response to metabolic
acidosis, but as this potassium is lost in the urine, the
absolute potassium level in the body is depleted. As
insulin is replaced and acidosis is corrected, serum
potassium deficit becomes apparent.
NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements related to insulin
deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased
protein/fat metabolism) as evidenced by recent weight loss; weakness, fatigue, poor muscle tone.
Independent
Assesses adequacy of nutritional intake (absorption and
Weigh daily or as indicated.
utilization).
If patient’s food preferences can be incorporated into the Once carbohydrate metabolism resumes (blood glucose
meal plan, cooperation with dietary requirements may be level reduced) and as insulin is being given,
facilitated after discharge. hypoglycemia can occur. If patient is comatose,
hypoglycemia may occur without notable change in level
of consciousness (LOC). This potentially life-threatening
emergency should be assessed and treated quickly per
protocol. Note: Type 1 diabetics of long standing may not
display usual signs of hypoglycemia because normal
response to low blood sugar may be diminished.
Dependent
Bedside analysis of serum glucose is more accurate
Perform fingerstick glucose testing. (displays current levels) than monitoring urine sugar,
which is not sensitive enough to detect fluctuations in
serum levels and can be affected by patient’s individual
renal threshold or the presence of urinary retention/renal
failure. Note: Some studies have found that a urine
glucose of 20% may be correlated to a blood glucose of
140–360 mg/dL.
Monitor laboratory studies, e.g., serum glucose, acetone, Blood glucose will decrease slowly with controlled fluid
pH, HCO3. replacement and insulin therapy. With the administration
of optimal insulin dosages, glucose can then enter the
cells and be used for energy. When this happens, acetone
levels decrease and acidosis is corrected.
Provide diet of approximately 60% carbohydrates, 20% Complex carbohydrates (e.g., corn, peas, carrots,
proteins, 20% fats in designated number of meals/snacks. broccoli, dried beans, oats, apples) decrease glucose
levels/insulin needs, reduce serum cholesterol levels, and
promote satiation. Food intake is scheduled according to
specific insulin characteristics (e.g., peak effect) and
individual patient response. Note: A snack at bedtime (hs)
of complex carbohydrates is especially important (if
insulin is given in divided doses) to prevent
hypoglycemia during sleep and potential Somogyi
response.
Administer other medications as indicated, e.g., May be useful in treating symptoms related to autonomic
metoclopramide (Reglan); tetracycline. neuropathies affecting GI tract, thus enhancing oral intake
and absorption of nutrients.
NURSING DIAGNOSIS: Infection, risk for [sepsis] related to high glucose levels, decreased
leukocyte function, alterations in circulation preexisting respiratory infection, or UTI.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Observe for signs of infection and inflammation, e.g., Patient may be admitted with infection, which could have
fever, flushed appearance, wound drainage, purulent precipitated the ketoacidotic state, or may develop a
sputum, cloudy urine. nosocomial infection.
Maintain aseptic technique for IV insertion procedure, High glucose in the blood creates an excellent medium
administration of medications, and providing for bacterial growth.
maintenance/site care. Rotate IV sites as indicated.
Dependent
Identifies organism(s) so that most appropriate drug
Obtain specimens for culture and sensitivities as
therapy can be instituted.
indicated.
NURSING DIAGNOSIS: Risk for disturbed sensory perception related to endogenous chemical
alteration: glucose/insulin and/or electrolyte imbalance.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Monitor vital signs and mental status. Provides a baseline from which to compare abnormal
findings, e.g., fever may affect mentation.
Address patient by name; reorient as needed to place, Decreases confusion and helps maintain contact with
person, and time. Give short explanations, speaking reality.
slowly and enunciating clearly.
Promotes restful sleep, reduces fatigue, and may improve
Schedule nursing time to provide for uninterrupted rest cognition.
periods.
Protect patient from injury (avoid/limit use of restraints as
able) when level of consciousness is impaired. Place bed Disoriented patient is prone to injury, especially at night,
in low position. Pad bed rails and provide soft airway if and precautions need to be taken as indicated. Seizure
patient is prone to seizures. precautions need to be taken as appropriate to prevent
physical injury, aspiration.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Discuss with patient the need for activity. Plan schedule Education may provide motivation to increase activity
with patient and identify activities that lead to fatigue. level even though patient may feel too weak initially.
Monitor pulse, respiratory rate, and BP before/after Indicates physiological levels of tolerance.
activity.
Discuss ways of conserving energy while bathing, Patient will be able to accomplish more with a decreased
transferring, and so on. expenditure of energy.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Create an environment of trust by listening to concerns, Rapport and respect need to be established before patient
being available. will be willing to take part in the learning process.
Work with patient in setting mutual goals for learning. Participation in the planning promotes enthusiasm and
cooperation with the principles learned.
Select a variety of teaching strategies, e.g., demonstrate Use of different means of accessing information promotes
needed skills and have patient do return demonstration, learner retention.
incorporate new skills into the hospital routine.
Reasons for the ketoacidotic episode; Knowledge of the precipitating factors may help avoid
recurrences.
Acute and chronic complications of the disease, Awareness helps patient be more consistent with care and
including visual disturbances, neurosensory and may prevent/delay onset of complications.
cardiovascular changes, renal
impairment/hypertension.
Discuss dietary plan, limiting intake of sugar, fat, salt, Medical nutrition therapy for diabetes encourages patient
and alcohol; eating complex carbohydrates, especially to make meal choices based on individual unique needs
those high in fiber (fruits, vegetables, whole grains); and and preferences. Awareness of importance of dietary
ways to deal with meals outside the home.
control aids patient in planning meals/sticking to regimen.
Fiber can slow glucose absorption, decreasing
fluctuations in serum levels, but may cause GI
discomfort, increase flatus, and affect vitamin/mineral
absorption.
Review medication regimen, including onset, peak, and
duration of prescribed insulin, as applicable, with Understanding all aspects of drug usage promotes proper
patient/SO. use. Dose algorithms are created, taking into account drug
dosages established during inpatient evaluation, usual
amount and schedule of physical activity, and meal plan.
Including SO provides additional support/resource for
patient.
Review self-administration of insulin and care of
equipment. Have patient demonstrate procedure (e.g., Verifies understanding and correctness of procedure.
drawing up and injecting insulin, insulin pen technique, Identifies potential problems (e.g., vision, memory, and
or use of continuous pump). so on) so that alternative solutions can be found for
insulin administration. Note: If multiple daily injections
are required, combinations of regular, intermediate, and
long-acting insulin are used. If the pump method is used,
patient programs his or her own basal and bolus settings.
Only regular insulin is administered, with a basal dose
throughout the day and bolus doses before meals and as
needed. An insulin pump more closely mimics normal
pancreatic activity because the basal rate may be changed
relative to patient’s activity level, presence of
stressors/infection or menstrual cycle.
Discuss timing of insulin injection and mealtime. One of the many inconveniences people with diabetes
cope with is having to decide at least 30–60 min in
advance when they are going to have a meal for the
timely administration of regular Humulin injections. A
newer product, insulin lispro (Humalog), may be helpful
because it works best when taken within 15 min of eating.
With the onset twice as fast as regular human insulin and
a duration approximately half as long, Humalog closely
mimics pancreatic activity. However, hypoglycemia may
develop more rapidly and be more severe than with use of
regular insulin. A blood glucose level below 80 mg/dL
indicates that insulin should be injected after eating rather
than before the meal.
Review individual’s target blood glucose levels. Although this range varies per person, the ideal range for
the adult diabetic is considered to be 80–120 mg/dL.
Note: Patients with an insulin pump may maintain blood
glucose levels between 120 mg/dL and 200 mg/dL with
no urinary ketones.
Review effects of smoking on insulin use. Encourage Nicotine constricts the small blood vessels, and insulin
cessation of smoking. absorption is delayed for as long as these vessels remain
constricted. Note: Insulin absorption may be reduced by
as much as 30% below normal in the first 30 min after
smoking.
Establish regular exercise/activity schedule and identify
corresponding insulin concerns. Exercise times should not coincide with the peak action
of insulin. A snack should be ingested before or during
exercise as needed, and rotation of injection sites should
avoid the muscle group that will be used in the activity
(e.g., abdominal site is preferred over thigh/arm before
jogging or swimming) to prevent accelerated uptake of
insulin.
Recommend avoidance of over-the-counter (OTC) drugs These products may contain sugars/interact with
without prior approval of healthcare provider. prescribed medications.
Identify community resources, e.g., American Diabetic Continued support is usually necessary to sustain lifestyle
Association, Internet resources/online diabetes bulletin changes and promote well-being.
boards, visiting nurse, weight-loss/stop-smoking clinic,
contact person/diabetic instructor.
PATHOPHYSIOLOGY
Diabetes Mellitus - chronic disorder affecting carbohydrate, fat and protein metabolism.
Predisposing Factors: Age (64 yrs old), Diet, Lifestyle
Precipitating Factors: Family History, Stress, Obesity
Inadequate insulin
Increase
Gluconeogenesis Plasma Free acids
Hyperglycemia
S/Sx: Polyphagia,
Cell Dehydration Cell Starvation Muscle weakness
Muscle Wasting
Fatigue
Decrease Blood
Viscosity
Hypovolemia
Shock Muscle wasting
S/Sx: Polyuria,
Polydipsia
Draw out fluids from the
renal tubules
Thrombosis
Metabolic Acidosis
Shock
Decrease Cellular K
Cardiac Dysrhythmias