Diabetes Mellitus
I
INTRODUCTION
Diabetes Mellitus, common disorder of metabolism in which the amount of glucose, or sugar, in the
blood is too high, a condition known as hyperglycaemia.
II
CAUSES
Diabetes develops either because the body’s pancreas is not producing enough of the hormone insulin
to metabolize glucose, or because the insulin fails to act on receptor cells in the blood. When blood
glucose rises above a certain level, it spills over into the urine. The condition, which may be
hereditary, affects roughly 3 per cent of men and 2 per cent of women; up to half of the affected
population may not have been diagnosed.
Though there is no cure for diabetes mellitus, proper insulin and other therapy together with a correct
diet enable most patients to live virtually normal lives with minimal side effects, though their mortality
rate is higher.
III
EFFECTS
Moderately raised blood glucose levels can eventually cause kidney failure; damage to vision from
ruptured blood vessels in the eyes; and restricted blood flow to the limbs, which may lead to gangrene
and subsequent amputation. Diabetes mellitus is also associated with a risk of coronary heart disease
that is two to three times higher in men, and four to five times higher in women before the
menopause. The risk of a stroke is increased two to three times.
Untreated, the disease can lead to coma and death, which was the usual outcome before the discovery
of insulin in 1921. Fifty years ago, about 30 per cent of pregnancies among women with diabetes
mellitus ended in stillbirth or death of the child within weeks of birth, as well as a high percentage of
abnormalities. Today, the stillbirths figure is far lower and the perinatal mortality rate (total of
stillbirths plus deaths in the first four weeks of life) 5.6 per cent, compared with l.4 per cent in the
general population. Babies of mothers with diabetes tend to be larger and have an increased risk of
complications, such as breathing problems and hypoglycaemia (low blood sugar) at birth.
IV
SYMPTOMS
A common symptom of diabetes mellitus is weight reduction caused by the loss of fluids and fat; this
is because of the inability of the body to break down carbohydrates. Other symptoms are passing
copious amounts of urine; increased thirst; disturbances of vision; limb numbness; genital itching;
cessation of menstruation in women; and a tendency to boils and skin infections. About half of people
affected are undiagnosed for some years until high glucose levels are detected in samples of blood or
urine during medical tests.
V
TREATMENT AND MANAGEMENT
The aim of treatment in all types of diabetes is to keep the blood glucose level as normal as possible
by administering insulin, or by providing glucose reduction therapy. Diet involves ensuring that meals
and snacks are so timed that the body’s insulin levels do not become overwhelmed.
Hypoglycaemia results from excessive amounts of insulin or sulphonylureas; lack of food; or excessive
exercise. It may occur in non-diabetics; in diabetics it occurs as a result of insulin overdose and lack of
carbohydrates. Hypoglycaemia produces a low blood glucose level, leading to eventual collapse and
possibly coma. It is vital for such patients to swallow some form of sugar quickly following symptoms
of sweating, confusion, faintness, or palpitations. The opposite condition, hyperglycaemia, occurs
when there is an excess of glucose in the blood because of lack of insulin treatment. Unless quickly
treated in hospital, hyperglycaemia may lead to coma and death.
Generally, insulin is self-administered by patients by injection, or with automatic drug injectors
attached to the body. Small pen-sized injectors containing a cartridge of insulin can be carried in the
pocket for ease and speed of treatment. Diabetes mellitus occurs in two major forms, the symptoms
and treatment of which are described below.
VI
NON-INSULIN DEPENDENT DIABETES MELLITUS
Also known as Type 2, this is the commonest form of the condition. Formerly known as adult-onset
diabetes, it usually affects people aged over 40 and progresses gradually. In this type the pancreas
has not ceased to produce insulin, but the quantity is insufficient, or the hormone is not stimulating
the glucose uptake in muscles and tissues required for energy. The result is a build-up of glucose in
blood and urine.
Although the cause of this malfunctioning is unclear, non-insulin dependent diabetes mellitus tends to
run in families. Other risk factors, such as increasing age, obesity, and a sedentary lifestyle, probably
contribute to its increased incidence in developed countries.
Non-insulin dependent diabetes mellitus can often be controlled initially by diet alone, or in
combination with tablets that reduce the amount of blood glucose. There are two main types of blood
glucose-reducing drugs: sulphonylureas work mainly by stimulating the pancreas’s islet cells (known
as the islets of Langerhans) to produce more insulin, and biguanides increase the effectiveness of
insulin on cells. Eventually, however, patients may need insulin injections.
The aim is to maintain blood glucose at levels that are as normal as possible and to prevent obesity,
thus lowering the attendant risk of cardiovascular disease. Acarbose, the first of a new group of drugs
called alpha-glucosidase inhibitors, was introduced for treating non-insulin dependent diabetes
mellitus in 1993. By restricting the action of alpha-glucosidase, which helps digest sugars and starch
in the intestine, acarbose can limit an increase in blood glucose levels after eating.
VII
INSULIN-DEPENDENT DIABETES MELLITUS
Sometimes called Type 1 or juvenile-onset diabetes, this type of diabetes mellitus commonly occurs in
children and young adults and progresses rapidly. It is caused by failure of the pancreas to produce
insulin. The autoimmune defence system (the reaction of the body’s immune system to normal cells as
though they were of foreign origin) against disease is believed to incorrectly identify the islet cells as
foreign and destroy them. Insulin-dependent diabetes mellitus may also be triggered by viruses and
certain environmental chemicals in the presence of an inherited predisposition to the disease.
This form of diabetes requires immediate treatment by both diet and injections since it can quickly
prove fatal. If the body cannot absorb glucose from food, it starts to break down body fat as an
alternative source of energy; this leads to a build-up of toxic compounds called ketones, which results
in coma. There are each year an estimated l4.2 new cases of this type of diabetes per 100,000
children aged under 15.
PATHOPYSIOLOGY
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I.
Assessment
a.) Demographic data
Client’s name: JJO
Age: 80 yrs old
Sex: male
Marital status: married
Religion: Roman Catholic
Address: 16 Dunendin st BF homes paranaque city
Birthdate: February 15, 1927
Race/Nationality: Filipino
Usual source of medical care: At the hospital
Source and reliability of information: To know her health status.
b.) History of Present Illness
Patient was diagnosed case of DM 2 s/p CVD and was maintaining with
Solosa 3mg/tab ½ tab OD. 3Days PTA, patients caregiver noted that the patient
was always sleeping and show signs of body weakness despite of good appetite.
There are no associated signs and symptoms present like fever, cough, difficulty
of breathing, loss of appetite, vomiting, LBM. Morning PTA persistence of above
signs and symptoms patient unable to do his regular activity. Patient was
prompted to our institution and was subsequently admitted.
c.) Past Medical History
(+) DM
(-) Asthma
(-) HPN
(-) Allergies
(+) s/p CVD
d.) Family medical history
(-)HPN
(-)DM
(-)Asthma
e.) Personal/ Social History
Patient has no history of smoking and alcoholic beverage drinking
II.
Functional Assessment
1. health perception / health management pattern.
 She always follows what her parents told her. Her mother guides
her to drink her milk and to eat nutritious foods.
2. self esteem, self concept, self perception pattern
 her mother told us that she has a strong image. Sometimes she
quarrels with her classmates just to get her things back and she also
told that she participates in class without hesitation.
3. activity exercise pattern
 she regularly walks to school. She always run outside whenever
she is playing with her friends. But when she has cold and cough
she got easily tired and she catches her breath whenever she is
running.
4. nutritional-metabolic pattern
 her mother told us that her daughter sometimes is very choosy
regarding with her food so she eats very little when she doesn’t
like the food that is served but she eats vegetables. She drinks
water but not that often at least 4-5 glasses of water a day.
5. Elimination pattern
 She defecates at least once a day and she voids 3-4 times a day.
6. sleep pattern
 she sleeps at least 8-9 hours a day
7. cognitive perceptual pattern.
 she has no impairment with regards with her senses.
8. role relationship pattern
 her mother told us that as early as now her daughter knows her
responsibilities as a child and as a student.
9. sexuality- reproductive pattern
 her mother told us that her daughter seems to be satisfied with her
gender because she can see that her daughter plays her doll and
other girlie stuffs.
10. coping stress tolerance
 her mother told us that whenever she is angry she shouts and cry
very loud and then she sleeps and when she wakes up she is back
in good mood
11. value belief pattern
 her mother told us that she can never make her own decision
regarding some other matter but her mother make sure that she will
have an opportunity to make decision on her self like she let her
pick what flavor of the ice cream she likes. And her mother told us
that every night she pray for Gods guidance for their family and all
of her relatives.
 Physical Assessment
SYSTEM
A. Vital Signs
WHAT TO ASSESS
•Temperature, pulse,
respiration, BP
ACTUAL FINDINGS
Body Temp: 37.2 C
P- 81 bpm
R- 16 cpm
BP16120/80
1.Skin
•Color, odor, temperature,
moisture, texture, thickness,
mobility, turgor, vascularity,
swelling, rashes
 color tan
 odorless
 (+) flaking skin on the
lower extremities
 Dry skin.
 Scarring vesicles on the right
forearm
 Large red patches on both
 Feet
 Dark gray rashes seen in
the inguinal area
 poor skin turgor
2. Hair
•Distribution, thickness,
texture, lubrication, scalp,
characteristics
 Grayish-white color hair
 Equal thickness of hair
 Scalp is dry
B. Integumentary
3. Nail
4. Eyes
 Nails
•Nail bed color, consistency,  Good capillary refill
thickness, shape, texture,
 Thick and long nails
angle between nail and
nailbed, capillary refill
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•Visual acuity, extra ocular cannot be tested due to condition
movement, visual fields,  whitish cataract seen on both
position and alignment
retina, ocular movement
•Eyebrows: symmetry,
symetrical thick grayish and equal
movement, extension,
distribution of eyelashes
quanity of hair
•Eyelashes: distribution
•Eyelids: position and movement, color
•Conjunctiva: color
3. Ears
•Auricle: position, size,
shape, texture
•External auditory canal;
discharge or cerumen’s
color consistency
•Symmetrical.
•With upper attachment at
level of lateral canthus.
• Oblong in shape, light brown
in color, firm and smooth to
touch
(-) lesions and pain
•There is presence of
cerumen
4. Nose
•External nose: shape,
symmetry, texture, skin
color
•Nares: shape, symmetry,
discharge
•Mucosa: color and discharge
•Located at the midline of
the face
(-)masses, lesions, bleeding
and swelling.
•Nares is medium in size,
symmetrical.
•Mucosa is pinkish no discharge is
noted.
.
5. Mouth
•Lips: color, texture, hydration, contour
•Gums: color, hydration
•Teeth: position, color,
hygiene
•Tongue: color, position,
texture, coating, mobility
•Lips are dry and chapped
(-) lesions and inflammation
•(+) dental caries.
•Tongue has no abnormalities
and moves freely
6. Neck
•Mobility
• Can move in
•Thyroid gland: movement,
full range of motion with
size
no difficulties.
•Lymph nodes: number, size, •Thyroid is normal in size.
location, consistency
•Muscles are symmetrical
with head in central position
•(+) swollen lymph nodes
D. Thorax and Lungs
•Shape, symmetry
E. Breast and Axillae
• Skin color, and shape.
•Moles and other markings
•Areola: shape, and color
•Nipples: size, color, and
discharge.
F. Abdomen
H. Musculoskeletal
J. Neurologic
• symmetrical
•Rises and falls in unison
•Chest excursion or movement with respiratory.
• RR is 20pm
•RR and rhythm
•No abnormal respiratory
sounds are noted.
•Breath sounds
•Normal breath sounds are
noted.
(-) masses in the chest
• flesh- colored
•(-) moles
•Areola is round in shape
and pinkish in color.
•Nipples are small, pinkish
(-) discharge
•Contour, symmetry
•Abdomen is symmetrical
•Bowel sounds
unblemished skin and uniform
•Percussion notes
in color
•Umbilicus: position, shape, abdomen is flat and rounded
color
•Umbilicus is located in the
•Normal respiratory
midline.
movement
•Symmetric movement cause
by respiration.
24 bowel sounds per minute
•Gait, stance, posture
• No deformities
•Muscle contractures and
• (-) contractures and equal
strength
strength on each body sides.
•Range of motion of joints
•There is normal motion
•Muscle coordination
of joints.
•Smooth coordinated
movements.
•Level of consciousness,
• Conscious but slow in
language, response to
response.
stimulation, intellectual
•Can perform simple task like
function, abstract thinking, able to walk on tiptoes
ability to perform simple
time and place oriented.
tasks.
Medical Management:
DOCTOR’S ORDER
2/24/07
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Please admit to ROC under Dr.Ebun
Strict aspiration precaution pls
Insert NGT(Silicon)
Facilitate transout to room
OF 1,800 Kcal DM diet CHON 30 grams
Decrease O2 to 1-2
Continue nebultaion Q8
Decrease protein 30n grams
IVF #10 plain Nss 1L X 16hrs
DC Aquamephyton (VIT K)
2/25/07
(+) Ronchi Bilateral
(+) Suction (Oral)
Suction as frequent as possible
D/c Tazocin
Continue Plavix
Repeat serum ammonia
Stable Hemodynamics
Continue cardiac monitoring
IVF #11 PNSS 1L X 16
Apply Mupirocin ointment over right forearm wound TID
IVF #12 D5nm 1L X 16
Shift IV ranitidine to Zantac 150 mg BID
2/26/07
For repeat NA, K, Creatinine today
Start Gascon 1 tab TID
Stable pulmonary assessment
Continue with pulmonary care
May D/C O2 inhalation
If IVF will be out pls hold reinsertion temp
Pls try to feed patient per orem w/ soft diet
Aspiration precaution but maintain OF
Continue Cardio MGT
2/27/07
IVF #13 D5nm 1L X 16
Please refer back for pulmo problem
Continue feeding per orem with
Aspiration precaution
Continue meds
Stable Hemodynamics
Suggest PEG insertion
IVF #15 D5 NM 1L X 16
2/28/07
Continue cardiac mngmnt
Repeat Serum ammonia tomorrow
Repeat Na, K, CBC
Increase 3mg one tab OD
Complete 10 days metronidazole then DC
Consume Heraclene forte then DC
3/01/07
Hold IVF insertion
Please follow up Official result of electrolytes
And ammonia
Fleet enema a
3/02/07
Repeat serum ammonia level
Agree with fleet enema
D/C Solona
Start Rosiglitazone+Avandamet 4mg/500mg
1 tab OD breakfast
3/03/07
Request Na,K,…
Cont meds
Start NaCl tabs 1 tab TID
3/04/07
D/C Kalium
Stable Hemodynamics
Consume Gaseon then D/C
Repeat Serum NH3 levels
Will keep NGT in place even after DC
Better feed via NGT
Awake and coherent, swallowing
Reflec is intact
Risk for aspiration
Still elevated ammonia levels
3/05/07
Increase NaCl 2 tabs TID
3/06/07
Increase Rosiglitazone + Metformin 4mg/500mg
Tab TID breakfast and dinner
Continue dephalac at 30 ml QID
3/07/07
Kept NGT in place
Watch out for fever
Repeat Na K Serum ammonia
Metformin 500mg
Pls give paracetamol 500mg 1 tab Q4
For fever t > 37.8
TSB
Repeat CBC blood extraction tomorrow
For urinalysis
3/08/07
For straight cath now
Pls relay labs once available
Refer to Dr M Dalluay
Reinsert IVF PNSS 1L X 12
For urine C/S
Start Fortum 2g IV
Continue meds
For repeat CxRay portable
For ABG and creatinine
No progressive productive cough
Chest and lungs normal breath sounds
(-) rales and (-) wheeze
Relay result ABG
Pls give paracetamol 1 amp IV PRN
For fever T > 38.5
IVF to follow PNSS 1L X 12
Please do gastric lavage
Repeat CBC
NPO except meds
May insert foley Cath
Monitor urine output input record pls
Dra Ebuna updated
Increase IVF 8hrs
IVF PNSS 1L X 8
3/09/07
IVF PNSS 1L X 8
Nubulization with berodual
Resume OF
IVF PNSS 1L X 8
May give Tramadol HCl 1 tab now
Afebrile (-) productive cough
O2 sat 99% at 1-2 L/min Via NC
Pale nail beds
Repeat CBC today
IVF PNSS 1L X 10
3/10/07
Open NGT now temporarily
Hold CBC now instead do CBC protein TRAG, Na K
Ammonia BUN Creatinine
DC metformin
Multivitamins
IVF to follow PNSS 1L X 10
3/11/07
Resume OF
IVF PNSS 1L X 12
Afebrile
Turn pt side to side
Stable hemodynamics
IVF ff PNSS 1L X 12
3/12/07
(+) Wheezing breath sounds
Pls folllow up urine C/S
DC Awandaret NacL
Start Glargine (Lantus) 10 units SQ OD 9pm
Kalium 1 tab TID X 3 days
IVF PNSS 1L X 12
3/13/07
Heroclene forte 1 cap
For repeat CxR portalble
Cont meds
Stable hemodynamics
Anti embolic stockings for 12 hrs
Nurses notes
2/24/07
6am-2pm
>received pt with GCS 13with incompetent words at times
>O2 @ 2-3
>Hooked to cardiac monitor with O2 sensor
>IVF of PNSS (380cc) @ 16 regulated
with SD of aminoleban 500ml/ 12 hour regulation via infusion pump
>need attended
on condom catheter
>CBG taken
>noted to be drowsy
>Strict aspiration precaution
>NGT inserted
>OF requested
>endorsed
2/25/07
6am-6pm
>received pt on bed
> not in respiratory distress
>due meds given
>nebulization done
>seen patient by Dr Daluay
>needs attended
>endorsed
6pm-6am
>Received patient on bed on a moderate high fowler position
with ngt silicon
>afebrile
>V/s checked and recorded
>due meds are given as ordered
>OF 1800kcal
>with CBG monitoring
2/26/07
6am-2pm
S> “ganyan talga siya, ayaw magpakuwa ng BP, nanuntok pa yan”
As verbalized by the guardian
O>Received patient on bed wi th D5Nm 1L X 16 hrs infusing well
At the level of 970cc
>with NGT O2 AT 1-2L/m
A>Non compliance r/t altered thought process
P> at the end of the shift patient will participate in the development of
The treatment plan
I>Monitored V/S and recorded
>Morning care done
>Provided assistance
>OF given
>CBG taking done
>Needs attended
>Due meds given
>I&O monitored and recorded
E>Goal met, the client was able to participate in the development of his
Treatment
2pm-10pm
S>”masakit yung tiyan niya dahil sa kabag” as verbalized by the PN
O>Received pt awake on bed
>With IVF d5nm 1L X 16hrs
>with NGT
>Wound on right forearm
>(+) guarding behavior
A>Alteration in comfort r/t gas pain as manifested by guarding behavior
P>At the end of the shift the PT will be relieved from pain
I>V/S taken and recorded
>IVF monitored and regulated
>Encouraged Fiber rich food
>Kept comfortable
>OF given
E>Goanl not met, the patient still feels the pain in his stomach
2/27/07
10pm-6am
O> Disruption of skin surface
>Body weakness noted
>PT is immobile
A> Impaired skin integrity r/t physical immobility
P> After the nursing intervention client will participate in
Precautions and treatment program
I>Repositioned client
>Kept area clean and dry
>Use appropriate padding devices
E>Goal was partially met, the client was able to display
Timely healing of pressure sore w/o complication
6am-6pm
>received pt in bed with ivf d5nm x 1L
>afebrile
>V/S checked and recorded
>with anti embolism stockings
>due meds given as ordered
>kept patient comfy
>CBG monitored
>needs attended
6pm-6am
>received on bed awake in respiratory distress
>with ivf d5nm x 1L at 100cc level
>with NGT, OF given
>CBG done and recorded
>VS taken and recorded
>afebrile
>on moderate high fowler posn
>with embolic stockings
>Dr Yap informed og CBG result
2/28/07
6am-2pm
>received pt asleep on bed
>with IVF d5nm x 1L @ 600cc level
>with NGT
>on OF via NGT 300cc Q4
>kept on MHBR posn
>in berodual neb
>in CBG monitoring
>TSB done
>Rounds by Dr Aquino
>Doctor Aquino suggested PEG insertion
2pm-10pm
>received pt on mhbr on bed
>afebrile
>on OF 1800kcal
>Due meds given
>V/S checked recorded
>kept patient comfy
>endorsed
10pm-6am
>received on bed awake, in respiratory distress
>with d5nm 1l x 16 at 350cc level
>with NGT intact
>V/S taken and recorded
>CBG taken and recorded
>With embolic stockings
>For Serum ammonia, Na, K, CBC
>neb with berodual done
>kept dry and comfy
>endorsed
3/1/07
6am-2pm
>received awake on mod high back rest
>afebrile
>with NGT
>on OF 300cc q 4
>with embolic stockings
>on berodual nubulization
>seen and examined by Dr Aquino
>needs attendded
>endorsed
2pm-10pm
>received patient asleep lying on bed
>With ngt
>afebrile
>not in respiratory distress
>OF prepared and given
>monitored VS and recorded
>Monitored I&O
>due meds given
10pm-6am
>received patient on bed
>conscious and afebrile
>not in respiratory distress
>with NGT silicon
>on OF 1800 kcal/day
>CBG monitored and recorded
>Neb with berodual done
>with embolic stockings
>VS taken and recorded
>I&O monitored
>needs attended
>endorsed
3/2/07
6am-2pm
>received pt asleep on bed, conscious and coherent
>(-) IVF
>with NGT
>CBG monitored and recorded
>on Neb with berodual Q8
>with Embolic stockings
>On OF DM 1800kcal/day 300cc every hour
>due meds given
>VS motired and recorded
>afebrile
>not in respiratory distress
>kept comfy
>endorsed
2pm-10pm
>received patient on bed on a semi high fowler posn
>afebrile
>VS checked and monitored
>CBG monitored and recorded
>with embolic stockings
>suction scretion orally
>for fleet enema tom
>needs attended
>endorsed
10pm-6am
>received patient on bed , conscious
>not in respiratory distress
>with NGT silicon
>neb performed by pulmo
>VS taken and recorded
>needs attended
>endorsed
3/3/07
6am-6pm
>Received pt asleep on semi high fowler posn
>with NGT
>on OG 1800kcal/day
>for fleet enema
>Due meds given
>CBG taken
>endorsed
6pm-6am
>received patient on bed
>with NGT
>afebrile
>on OF 1800kcal/day
>CBG taken
>Suction secretion PRN
>Due meds given
>Keep pt comfy
>endorsed
3/4/07
6am-6pm
> received patient asleep
>with siliconized NGT
>on OF of 1800kcal/day
>VS monitored and recorded
>CBG 121mg/dl
>endorsed
3/5/07
10pm-6am
>received patient half asleep
>no IVF
>with NGT
>hx teaching done such as properhandling of NGT
>practiced aseptic technique such as handwashing
>ensure that the tube is covered tightly
>Place the tube above the head of the client when not in use
>due meds given
6am-2pm
>received patient on asleep
>not in respiratory distress
>restless
>due meds given
>CBG monitored
>provided comfort
>side rails are raised for security
>provided enough rest
>Seen by Dr Espirito
2pm-10pm
>Received patient lying on bed awake
>with clean patent NGT
>dry lips noted
>dry skin and poor skin turgot
>flaking skin in the forehead noted
>immobile
>in OF feeding
>VS taken and recorded
>monitored I&O
>positioned client to left lateral
>due meds given
10pm-6am
S>No verbal cues
O>Received patient asleep
>With NGT
>W/O IVF
A> Risk for impaired skin integrity r/t physical immobility
P>After 8hrs of shift px will not manifest signs of impaired
Skin integrity
I> Reposition client every 2 hrs
>hx teaching done such as:
>proper skin care
>proper hygiene
>wound care
E> Goal met, after 8 hrs shift, px did not manifest any
Signs of impaired skin integrity
3/06/07
6am-2pm
O> Recvd pt awake lying on bed WO IVF
>Conscious and coherent
>DM diet
>(+) Body weakness
>(+) Poor skin turgor
>Dry hard formed stool
A> Constipation related to irregular defecation habits as manifested
By dry hard formed stool
P> After 8hrs of shift, the pt will be able to establish normal pattern
Of bowel function
I>Establish rapport
>VS taken
>Due meds given
>OF given
>CBG done 179mg/dl
>administered 2 units of insulin
E> Goal partially met after 8hrs of shift the pt was able to
Have a normal bowel functioning but with small hard formed stool
2pm-10pm
O> Recevd pt awake and coherent but unable to speak clearly
>With clean NGT for gavage
>Dry skin and poor skin turgor
>Flaking skin on the forehead noted
>Scaring on the vesicle on the reght forearm noted
>Diaper rashes on the buttocks noted
>Immobile
A>Impaired skin integrity related to immobility and alteration of fluid and
Electrolyte status
P>After 8hrs of nursing intervention the pt will be able to
>Display an improvement of skin moisture
>have an alternative container for urine collection
>Maintain dryness of the buttocks area
>Minimize flaking skin in the forehead
>Have a comfortable safe envt
I>VS maintained and documented
>I&O monitored and recorded
>Reposition client
> monitored pt for wet underpads
>Instructed guardian to keep pt buttocks clean and dry
E> Goal met, the px displayed improvement in skin moisture
Minimized flaking skin in the forehead, has a comfortable and safe
Envt maintained buttocks and perinneal area dry and now has a
Alternative container for urine
10pm-6am
>Received pt awake lying on bed
>noIVF
>with NGT
>Dysphasia
>After 8hrs of nursing intervention pt will be able to communicate thru
clean gestures
>Establish rapport by
>Touch therapy
>communicating nice and in a friendly manner
>attending pts needs
>V/S monitored and recorded
>Kept pt comfortable by fixing
>Linens
>Pillows
>Gown
>CBG done
>OF done
>Goal met pt was able to communicate thru clear gestures like nodding
03/07/07
6am-2pm
>Rcved pt awake
>(-) dyspnea
>(+) Dry cough
>(+) Body weakness
>(+) Diaper rash
>reposition client q2
>Always keep area dry
>CBG taken
>Monitored for signs of hypoglycemia
>Seen by Dr Espirito
2pm-10pm
>Pt is awake and conscious not in respiratory distress
>T=38.8 celsius
>with NGT
>Skin is warm to touch
>VS taken and monitored
>TSB done
>PRN meds given
>CBG done
>with nebulization done
>monitored for SS of hypoglycemia
10pm-6am
>Rcved pt on bed awake
>- IVF
>Febrile
>VS taken and monitored
>Paracetamol given
>CBG taken
>TSB advised
>For repeat Na,CBC,K serum ammonia
>endorsed
03/08/07
6am-2pm
>VS taken
>Uncooperative
>With NGT
>With dry wound at R arm area
>Impaired speech
>Skin warm to touch
>Place on semi high fowler posn
>I&O recorded
>Meds given thru NGT
>Establish rapport thru touch therapy
>TSB done
2pm-10pm
>Rcved client awake on bed with IVF PNSS 1l X 12
>uncooperative
>Irritable
>With NGT
>Impaired speech
>monitored VS
>Advice to do TSB
>OF done
>Due meds given
10pm-6pm
>Recvd pt on bed on a semi high fowler posn
>with IVF PNSS X 12
>Febrile
>VS checjed and recorded
>OF given
>NPO except meds
>CBG monitored
>Due meds given
>IVF regulated
>TSB done
>PRN meds given
>Kept pt comfortbale
>Needs attended
>endorsed
03/09/07
6am-2pm
>With IVF 0.9NaCl X 8
>Recvd pt awake in supine posn
>VS taken and recorded
>With NGT
>With Foley catheter
>uncooperative
>(+) cataract in both eyes
>OF done
>I&O checked and monitored
>Established rapport thru touch therapy
>endorsed
2pm-10pm
>Recved pt awake in bed with IVF PNSS 1L X 8hrs
>uncooperative
>With NGT
>Pain scale of 5 out of ten
>Impaired speech
>irritable
>VS taken and recorded
>Maintained bedrest
>Reduced metabloic demands
>OF done
>Due meds given
6pm-6am
>Recvd pt on MHBR with IVF PNSS 1L X 8
>Afebrile
>On O2 @ 2 lpm
>With NGT
>with FC intact
> VS taken and recorded
> Monitored I&O
>CBG taken
>Kept rested and comfy
>Endorsed
03/10/07
6am-2pm
>Recvd patient awake in supine position
>On going IVF PNSS 1L X 8
>(+) swelling on R aram
>With NGT
>With Foley Cath
>(+) Skin sores
>VS taken
>Meds given
>OF done
>Place pt on semi high fowler
>CBG checked
>Applied hot compress on affected arm
>I&O checked
>Reposition client Q2
>endorsed
2pm-10pm
> Recvd pt awake on bed IVF hooked PNSS 1L X 8
>Cooperative
>With NGT
>With dry wound on R arm
>Impaired speech
>Pain scale of 4 out of 10
>With Foley cath
>VS monitired
>OF done
>Kept client comfy
>Due meds given
>Endorsed
10pm-6am
> Received awake on MHBR posn
>With NGT intact
>CBG monitored
>on Nebulization done
>afebrile
>Endorsed
03/11/07
6am-6pm
>Received awake lying on bed
>Afebrile
>With Foley cath
>With NGT
>Kept moderate high back
>Turn pt side to side
>Seen and examined by Dr Grino
>Kept monitored for any untoward S/S
>needs attended
>Endorsed
6pm-6am
>Received patient awake in moderate high back
>With ongoing IVF PNSS
>afebrile
>Not in respiratory distress
>O2 Inhalation 2 L/min
>CBG taken HS
>With berodual nebulization
>turned side to side
>With NGT
>endorsed
03/12/07
6am-2pm
>recved patient awake on bed
>With IVF 9 PNSS 1L X 12
>Conscious and coherent
>Weakness noted
>With Chopped lips
>with Poor skin turgor
>With foley cath
>(+) Bed sores
>CBG taken
>Due meds given
>OF given
>IV regulated
>I&O monitored
2pm-10pm
>Received patient sleeping with IVF D5nm 1LX 12
>With NGT for gavage
>Immobile
>Dry skin and poor skin turgor
>with indwelling foley cath
>With 02 2L/min via NC
>Monitored recorded VS
>monitored and recorded I&O
>Encouraged guardian to reposition
>CBG taken
>Kept dry and comfy
>Endorsed
10pm-6am
>Recvd pt on bed conscious awake
>with IVF of PNSS 1l X 12
>with CBG taken
>Ongoing O2 @ 2L/min
>with siliconized NGT
>with IFC
>OF given
>VS taken and recorded
>Kept comfy and safe
>Turned patient side 2 side
>Due meds given
>IVF regulated
>Needs attended
3/13/07
6am-2pm
>IVF PNSS
>afebrile cnscious restless
>uncooperative
>With Foley catheter
>with NGT
>with dry skin and poor skin turgor
>On CBG
>(+) body weakness
>VS taken and monitored
>Allow the pt to verbalize the instruction
>Provided rest periods
>Provided rest periods
>I&O recorded and taken
2pm-10pm
>Recvd pt lying on bed in right lateral posn, awake
>with O2 via NC 2L/min
>With clear NGT
>Poor skin turgor
>Dry and flaking skin
>Immobile
>Monitored and recorded V/S
>Monitored and recorded I&O
>OF given
>IVF regulated
>CBG taken
>Gastric lavage done
>Kept dry and comfy
>Due meds given
10pm-6am
>With NGT
>With O2 via NC
>both hands are tied on side rails
>With IVF PNSS 1L X 12
>With Foley cath
>With complain sleeping
>Raised side rails
>Checked NGT placement
>Checked placement of NC
>Pt kept comfy
>IVF regulated
>VS monitored
>OF done
>CBG done
>Due meds given
Medications
1. Kalium durule 2 tabs TID
- to treat his electrolyte imbalance and to prevent hypokalemia
2. Solosa ½ tab OD 3 mg
- this drug was given to him to control his blood sugar
3. Aminoleban N x 12 BID
- to prevent having liver impairment because he was taking too many medications
4. Ranitidine 150 mg
- to block daytime and nocturnal basal gastric acid secretion stimulated by histamine and
reduces gastric acid release in response to food, and insulin.
5. Mupirocin cream / ointment (Foskina)
- it is an anti infective drug applied to the patient’s wound at the right arm to prevent
infection
6.
Vit. B Complex 500 mg BID
- to prevent cell membrane and protein damage and is essential to the digestion and
metabolism of polyunsaturated fats. Maintains the integrity of cell membranes, protects against
blood clot formation by decreasing platelet aggregation, enhances vitamin A utilization, and
promotes normal growth, development, and tone of muscles.
7.
Lipitor 10 mg HS
- his maintenance to lower his blood pressure
8.
Fibrosine Sachet OD HS
- since the patient has decreased peristalsis, he needs more fiber to help in digestion
9. Metronidazole 500 mg tab TID
- used as a prophylaxis agent to avoid infection
10. Lactulose 30 cc TID
- to avoid constipation
11. Nootropil 1-2 gm tabs TID
- his maintenance to lower his blood pressure
12. Avandamet 4 mg / 500 mg 1 tab OD (breakfast)
- to improve glycemic control
13. Sodium chloride 2 tabs TID
- to maintain fluid and electrolyte balance and for neuromuscular functioning
FEBRUARY 18, 2007
CHEST X-RAY PORTABLE ADULT
Patch of Haze is noted in the right suprahilar region
Heart is not enlarged
Thoracic Aorta is atheromatous
Diaphragm and Sulci are normal
Osteodegenerative changes of the dorso-lumbar spine is seen
IMPRESSION:
KOCH’S PNEUMONIA VS Newgrowth Right atheromatous Aorta
REMARK:
CT SCAN SUGGESTED FOR FURTHER EVALUATION
FEBRUARY 19, 2007
-9:37 AM
TEST
Glucose
Ldlc
Cholesterol
Triglycerides
Holc
Uric acid
FEBRUARY 19, 2007
-4:47 PM
ammonia
249.umol/L
FEBRUARY 21, 2007
-5:45
HBS AG-AB
ANTI-HAV IGG
ANTI HAV IGM
ANTI HBC IGG
ANTI HBC IGM
ANTI HBE
ANTI HCV
HBE AG
HBS AB
RESULT
5.8mmol/L
7.21mmol/L
2.8mmol/L
0.63mmol/L
1.3mmol/L
175umol/L
NORMAL VALUE
4.2-6.1
0.00-3.90
0.0-5.2
0.0-2.26
1.0-1.6
208-506
9-33
IMMUNOLGY SECTION
NON REACTIVE
REACTIVE
NON REACTIVE
REACTIVE
NR
NR
NR
NR
REACTIVE
FEB. 19, 2007
CT SCAN
Exam: CT SCAN of the brain with contrast
Non-contrast and contrast enhanced cranial CT SCAN revealed the following findings:
1.
2.
3.
4.
5.
6.
7.
hypodensity is seen on the right frontal, periventricular white matter region
the ventricle, sulci and scistern are dilated
the interfoliae spaces are prominent
midline structures in place
posterior fossa structures are unremarkable
no abnormal enhancement noted
the visualized petromastoids, orbits, and paranasal sinuses are unremarkable
IMPRESSION
Ischemic right frontoparietal white matter changes cortical, cerebral and cebellar atrophy.
FEBRUARY 23, 2007
EXAMINATION: chest x ray portable adult
Follow up since 2-18-07 show adequate pulmonary vascularity at this time. The previously noted
suprahilar haze is still seen. No other significant findings of note.
ULTRASOUND REPORT
2/21/07
EXAMINATION: whole abdomen
Liver is relatively small and high-lying with smooth surface. Echopattern is homogenous
w/ evidence of mass. Intrahepatic bile ducts are not dilated. Portal venous system is normal.
Gallbladder measures 6.5x2.1cm. no evidence of stone. Vesicle wall is not thickened. Commen
bile duct measures 0.4cm. pancreas and spleen are unremarkable.
Right kidney: 10.2x4.1 cm
9.6 x 4.2 cm.
No evidence of renal stone or mass. Bilateral pelvocalectesia and hydroureter are seen.
Corticomedullary borders are well-defined. Urinary bladder shows thickening and irregularity of
the posterior wall. No stone seen. Indwelling catheter is seen.
Prostate gland measures 2.9x3.3x3.7cm w/ an approximate volume of 18.4ml. paranchymal
calcifications are noted.
IMPRESSION
-A tropyhing; no evidence of mass.
- normal gallbladder, pancreas and spleen
- normal sized of kidney with bilateral hydronephrosis, associated with hydroureter.
- Cystitis, likely chronic
- Indwelling foley catheter in place
- Normal sized prostate gland w/ calcifications noted.
CT SCAN OF THE CHEST
2/21/07
contrast enhance chest CT w/ settongs optimized for the visualization of the ling parenchyma and
mediastinum were taken and revealed the ff. Findings:
inhomogenous opacities are seen in the anterior segment of the left lower lobe.
Pulmonary fibrosis is noted in the left apex.
Pleural effusion is noted bilaterally w/ subsegmentally calcified.
No mediastinal or hilar lymphadenopathies noted.
Hyperthropic spurs are seen in the visualized thoracic vertebral bodies.
IMPRESSION
Pneumonia, anterior segment of upper the right upper lobe and posterior segment of the left
lower lobe.
Pulmonary fibrosis, left apex.
Pleural effusion, bilateral.
Subsegmental atelactasis, right lower lobe
Atheroscleroti aorta, spleenic artery, and coronary arteries.
Degenarative chances of the thoracic spine.
CARDIVASCULAR DIAGNOSTIC
ACHOCARDIOGRAM REPORT
2/19/ ICU
M-MODE
LVEDD
LVESD
LVEDV
LVESV
EF
CO
FS
HR
DIMENSIONS
58mm
39mm
168cc
65cc
62
6.81
34%
Bpm
AORTA
LA
RVEDD
IVST
IVST
PWT
PWT
EPSS
35mm
44mm
13mm
10mm
12mm
8mm
14
7
REMARKS
Dilated left ventricle w/ hypokinesia of the anterior interventicular septum from mid to base w/
preserved overall left ventricular systolic function
Normal right ventricular function of thrombus. Normal atrial dimension.
Structurally normal mitral aortic.
Fluid: serum
Priority: routine
Test unit time: 10:27:03
Test unit date: march 3,07
TEST
CREATININE
SODIUM
POTASSIUM
RESULT
128UMOL/l
129mol/L
4-6mmol/L
NORMAL RANGE
71-133
137-145
3.6-5.0
Fluid: serum
Priority: routine
Test time: 18:54:34
Test date: march 1,07
TEST
ammonia
RESULT
Inc. 32.4umol/L
NORMAL RANGE
9-33
Fluid: serum
Priority: routine
Test time: 10:21:38
Test date: feb. 26,07
TEST
Creatinine
Sodium
Potassium
RESULT
91umol/L
Decreased 132mmol/L
Decreased 3.3mmol/L
NORMAL RANGE
71-133
137-145
3.6-5.0
Electrocardiogram report
Date: feb. 20, 07
Interpretations- regular rythmn w/ frequent premature ventricular contraction
Old inferior myocardial infarction
To consider lateral wall ischemia
ECG report
Date: feb. 19, 07
Interpretation- sinus ryhtmn w/ premature ventricular contractions
Incomplete right bundle block
T/c lateral wall ischemia
ECG report
Date: feb. 18, 07
Interpretation- sinus rythmn
Old inferior wall myocardial infarction complete right bundle branh block
Lateral wall ischemia
Fluid: serum
Priority: routine
Test time: 9:9:50
Test date: feb. 24, 07
TEST
UREA
CREATININE
AMMONIA
SODIUM
POTASSIUM
RESULT
6.7mmol/L
97umol/L
Inc. 355umol/L
Dec.134
3.1mmol/L
NORMAL RANGE
3.2-7.1
71-133
9-33
17-145
3.6-5
TEST
Ammonia
Pottasium
Sodium
RESULT
NORMAL RANGE
9-33mol/L
3-6-5.0mmol/L
137-145mmo/L
4.3
138
CBC
Test requested: February 28, 2007
TEST
RESULT
RBC
4.20
Hematocrit
0.39
WBC
12.2.00-170.00g/L
NORMAL RANGE
4.50-6.0x1012/L
0.40-0.54
132
TEST
NORMAL RANGE
RESULT
CAPILLARY BLOOD GLUCOSE
Date
Time
CBG result
2/18
5:30 pm
11:30 pm
5:30 am
11:30 am
5:30 am
11:30 pm
5:30 am
11:30 am
5:30 pm
11:30 pm
5:30 am
11:30 am
5:30 pm
11:30 pm
5:30 am
11:30 am
5:30 pm
11:30 pm
5:30 am
11:30 am
5:40 pm
11:30 pm
5:30 am
11:30 am
5:30 pm
11:30 pm
7:30 am
11:30 am
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
264 mg/dl
117 mg/dl
120 mg/dl
181 mg/dl
174 mg/dl
207 mg/dl
99 mg/dl
243 mg/dl
180 mg/dl
240 mg/dl
131 mg/dl
136 mg/dl
130 mg/dl
174 mg/dl
91 mg/dl
228 mg/dl
185 mg/dl
139 mg/dl
145 mg/dl
126 mg/dl
145 mg/dl
165 mg/dl
124 mg/dl
153 mg/dl
194 mg/dl
124 mg/dl
129 mg/dl
152 mg/dl
151 mg/dl
161 mg/dl
224 mg/dl
254 mg/dl
194 mg/dl
168 mg/dl
265 mg/dl
221 mg/dl
204 mg/dl
161 mg/dl
241 mg/dl
265 mg/dl
151 mg/dl
2/19
2/20
2/21
2/22
2/23
2/24
2/25
2/26
2/27
2/28
Amount of insulin
given
6 “u” HR
--------------------2 “u” HR
2 “u” HR
4 “u” HR
-----------4 “u” HR
2 “u” HR
4 “u” HR
----------------------------------2 “u” HR
-----------SQ 4 “u” HR
SQ 2 “u” HR
----------------------------------------------2 “u” HR
-----------------------2 “u” HR
-----------------------------------------------2 “u” HR
4 “u” HR
6 “u” HR
2 “u” HR
2 “u” HR
8 “u” HR
2 “u” HR
4 “u” HR
2 “u” HR
4 “u” HR
6 “u” HR
-------------
3/1
3/2
3/3
3/4
3/5
3/6
3/7
3/8
3/9
3/10
3/11
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
2:15 am
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
161 mg/dl
205 mg/dl
246 mg/dl
171 mg/dl
140 mg/dl
265 mg/dl
280 mg/dl
91 mg/dl
136 mg/dl
251 mg/dl
212 mg/dl
182 mg/dl
121 mg/dl
276 mg/dl
122 mg/dl
148 mg/dl
273 mg/dl
260 mg/dl
119 mg/dl
179 mg/dl
201 mg/dl
283 mg/dl
68 mg/dl
137 mg/dl
225 mg/dl
above 500 mg/dl
171 mg/dl
146 mg/dl
209 mg/dl
194 mg/dl
245 mg/dl
125 mg/dl
211 mg/dl
198 mg/dl
196 mg/dl
208 mg/dl
174 mg/dl
257 mg/dl
267 mg/dl
70 mg/dl
228 mg/dl
258 mg/dl
209 mg/dl
2 “u” HR
4 “u” HR
4 “u” HR
2 “u” HR
2 “u” HR
6 “u” HR
6 “u” HR
----------------6 “u” HR
4 “u” HR
2 “u” HR
-----------6 “u” HR
----------------------6 “u” HR
6 “u” HR
----------2 “u” HR
4 “u” HR
6 “u” HR
-----------------4 “u” HR
12 “u” HR
2 “u” HR
------------4 “u” HR
2 “u ”HR
6 “u” HR
-----------4 “u” HR
2 “u” HR
2 “u” HR
4 “u” HR
2 “u” HR
6 “u” HR
6 “u” HR
----------4 “u” HR
6 “u” HR
2 “u” HR
3/12
3/13
3/14
3/15
3/16
11:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
7:30 pm
7:30 am
11:30am
7:30 pm
7:30 am
11:30am
7:30 pm
11:30 pm
7:30 am
11:30am
137 mg/dl
162 mg/dl
211 mg/dl
169 mg/dl
195 mg/dl
128 mg/dl
148 mg/dl
182 mg/dl
254 mg/dl
146 mg/dl
191 mg/dl
225 mg/dl
269 mg/dl
244 mg/dl
167 mg/dl
151 mg/dl
270 mg/dl
---------2 “u” HR
4 “u” HR
2 “u” HR
2 “u” HR
---------------2 “u” HR
6 “u” HR
-------------------------------------------------------------------------
ASSESSMENT
S- no verbal cues
O-



with NGT in
proper
placement
with each
hand tied on
side rails
with low left
side rails
DIAGNOSIS
Risk for injury
RATIONALE
 Due to
presence of
risk factors
to injury
such as:
- altered
mobility
PLANNING

At the end
of 8 hours
shift the
patient’s
environment
will be
modified to
enhance
safety
enhancers.

At the end
of 8 hours
shift the
patient will
be free from
any injury.

At the end
of 8 hours
shift the
patient’s
companion
will be able
to protect
the patient
from injury
INTERVENTION

Raise and
secured side
rails.

Check both
hand if tied
properly.




Patient kept
comfortable in
bed.
Checked the
placement of the
NGT.
Re-position the
client PRN
Health Teaching
to relatives done
such as:
- WOF any signs of
patient’s discomfort
RATIONALE

To prevent
falls and
injury

To avoid
pressure that
may cause
discomfort

To ensure
comfort

To prevent
aspiration

To promote
circulation
and prevent
pressure
sores

To provide
further
education to
the patient’s
relatives
EVALUATION

Goal met.
Patient’s
environment
was modified
to enhance
safety.

Goal met.
Patient After 8
hours shift the
patient was
able to be free
from any
injury.

Goal met.
Patient’s
companion
was able to
protect the
patient from
injury.
2
ASSESSMENT
S- no verbal cues
O-


Patient is
hesitant to
some nursing
intervention
Dysphasia
DIAGNOSIS
Impaired social
interaction
RATIONALE
due to
communication
barriers
PLANNING

After 8
hours of
nursing
intervention
the patient
must gain
trust and
must be at
ease.

After a
week of
nursing
intervention
s patient
will be able
to
communicat
e through
clear
gestures
INTERVENTION

Established rapport
by touch therapy

Communicated in a
nice and friendly
manner

Attended to patients
needs

Kept patient
comfortable by
fixing linens,
pillows and
blankets

Adjusted position
to patients comfort
RATIONALE

To gain
patient’s
trust


To catch
the
patient’s
soft side
To help
patient

To attain
the highest
level of
comfort
possible

To
maintain
proper
blood
circulation
and lung
epansion
EVALUATION

3
ASSESSMENT
S- no verbal cues
O-

DIAGNOSIS
Impaired skin
integrity related to
mechanical factors as
manifested by
wound at the right
arm.
RATIONALE
Due to
disruption of
skin surface
PLANNING

After series
of nursing
interventions
for 2 weeks
the patient
will be able to
display timely
healing of
skin lesions


patient will be
able to
maintain
optimal
nutrition
patients
relative/comp
anion will be
able to gain
knowledge in
maintaining
skin integrity
INTERVENTION

Raise and
secured side
rails.

Check both
hand if tied
properly.

Patient kept
comfortable in
bed by fixing
linens and
blankets

Checked
wound



Health
teaching to
companion
such as:
-
frequent
wound check
wound
cleaning
-
RATIONALE

To prevent
falls and
injury.

To prevent
further injury
to oneself.

To ensure
comfort
For possible
purulence
and infection
To help them
gain
knowledge
and to help
them in their
independent
care
EVALUATION
