case fonte
TRANSCRIPT
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INTRODUCTION
Diabetes mellitus, often simply referred to as diabetesis 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:
Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also
referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.)
Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined
with an absolute insulin deficiency. (Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short,
and adult-onset diabetes.)
Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during
pregnancy. 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 type 1 and 2 are chronic conditions that usually 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 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.
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I. Biographic DataName: Patient K
Age: 57 y/o Gender: Male
Religion: Catholic
Marital status: Single Occupation: Private Guard
Room and Bed no.: PS 2
Chief Complaint: wound that does not heal
Diagnosis: DM II gangrene right foot; uncontrolled
Attending Physician: Dr. Bathan
II. Nursing HistoryA. Past Health History
1. Childhood Illness:Cough and colds
2. Immunizations:The client stated that he had completed his childhood immunization
3. Allergies:The client stated that he had no food and drug allergies.
4. Accidents:The client stated that he had previous accidents in motor vehicle
5. Hospitalizations:The clients last hospitalization was due to his motor vehicle accident
Medications currently taken:
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Ceftriaxone
Ketorolac
6. Foreign Travel (when, length of stay)The client had no previous foreign travel
B. History of Present Illness:1 day prior to admission the client feels severe pain on his right gangrenous foot, he decided to choose BRH for his
treatment.
C. Family History/Genogram:
Legend:
w/ HPN
w/ DM
Mother Father
Patient K Sister Brother
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III. Activities of Daily Living
ADL Before Hospitalization During Hospitalization
1. Nutrition Patient stated that he eat vegetables especially
root crops.
He usually eat foods with soup like sinigang & nilaga.
2. Elimination Hindi naman ako hirap sa pag-ihi; siguro, mga
limang beses ako umiihi sa isang araw as
verbalized by the patient
According to the patient, he voids atleast 3-4 times a
day.
3. Exercise Naglalakad-lakad ako minsan saka ngjajogging
as stated by the patient.
The patient cannot perform exercise due to his present
condition.
4. Hygiene Patient stated that he takes a bath everyday. punas-punas laang dahil sa kalagayan ko ngayon as
verbalized by the patient.
5. Substance
use
The patient stated: wala akong iniinom na kahit
anong gamot
--Ketorolac
-Ceftriaxone
6. Sleep and
Rest
Nakakatulog naman ako ng maayos sa bahay
as stated by the patient.
The patient cannot sleep well in the hospital due to the
pain he feels.
7. Sexual
Activity
matanda na ako ey! Hindi na to natayow! No sexual activity
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Steps Normal findings Findings
1. General Appearance
1.1 Observe body built,height and weight
1.2 Observe the clientsposture and gait
1.3 Observe the clientsover all hygiene and
grooming
-The client is cooperative and responds to questions
nicely.
-Speech is clear and understandable.
-The size of the body is proportion with the size of
the head.
-Slouched
-slightly groomed
2. Skin
2.1.Inspect skin color
2.2.Assess edema
2.3.Inspect, palpate anddescribe skin lesions
2.4.Observe and palpateskin moisture
2.5.2.6.Note the skin turgor
In white skin: light to dark
pink
In dark skin: light to dark
brown, oliveEdema: no swelling, pitting
or edema.
Skin lesion: none
Skin moisture: warm dry.
Skin texture: smooth, soft.
Skin turgor: pinched up
skin returns immediately to
original position
The skin complexion is brown.
No presence of edema or swelling.
No skin lesion
The skin is warm to touch
Skin returns immediately to its original position
when pinched.
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deposits, streak, freckles
5. Skull and face
5.1.Inspect the skull for sizeshape and symmetry
5.2.Palpate the skull fornodules or masses and
depressions
5.3.Inspect facial features5.4.The eyes for edema or
hollowness
5.5.Note symmethry offacial movements
Size, shape, symmetry:
rounded, smooth skull
contour
Smooth, uniform
consistency, absence of
nodules and masses
Facial features:
Symmetric/slightly
asymmetrical facial
features, palpebral fissures,
equal in size; symmetric
nasolabial folds
The skull is symmetrical in shape.
Elicit facial features
Theres a symmetry of facial features
6. Eye structure and Visual
Acuity
6.1.Inspect the eyebrows,eyelashes and eyelids
Eyebrows: Hair evenly
distributed; curled slightly
outward. Eyebrows
symmetrically aligned;
Equal movement
Eyelashes: Equally
Eyebrows hair were evenly distribution,
symmetrically aligned
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6.2.Inspect the bulbar andpalpebral conjunctiva
6.3.Inspect and palpate thelacrimal gland, lacrimal
sac and nasolacrimal
duct
6.4.Perform the cornealsensitivity reflex test
6.5.Inspect the pupils forcolor, shape symmetry
of size
distributed; curled slightly
outward
Eyelids: Lid margins moist
and pink. Skin intact; no
discharge; no discoloration
Bulbar conjunctiva: Shiny.
Smooth and pink or red
Lacrimal gland: no edema
or tenderness
Lacrimal sac and
nasolacrimal duct: no
edema or tearing
Client blinks when the
cornea is touch, indicating
that the trigeminal nerve is
intact
Color: Black
Equal in size, normally 3-7
mm diameter; round,
smooth border iris flat and
round
Elicit corneal sensitivity reflex test
Pupils color were black
Equal in size
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6.6.Assess the pupils directconsensual reaction to
light and
accommodation
6.7.Assess peripheral visualfields
6.8.Assess six ocularmovements
6.9.Assess visual acuity
Illuminated pupil
constricts.
Non illuminated constricts
When looking straight
ahead, client can see the
objects in the periphery.
Both eyes coordinated,
move in unison, with
parallel alignment
Able to read newsprint
When light passes through the pupil, it constrict
7. Ears and hearing
7.1.Inspect and palpateauricles
Color; same as facial skin
Symmetry of size is
symmetrical.
The auricle aligned with
outer canthus of eye, about
10 from vertical
Mobile, firm, and not
tender, pinna recoils after
Pinna recoils when folded
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7.2.Inspect the external earcanal for cerumen skin
lesions, pus and blood
and the tymphanic
membrane for color
and gloss
7.3.Palpate the maxillaryand frontal sinuses for
tenderness
it is folded
Distal third contains hair
follicles and glands. Dry
cerumen, grayish-tan
color; or sticky wet
cerumen in various shades
of brown
No masses in maxillary and
frontal sinuses.
No presence of masses in maxillary or frontal
sinuses
8. Nose
8.1.Inspect and palpate theexternal nose
8.2.Determine the patencyof both nasal cavities
Symmetric and straight, no
discharge or flaring
Color is uniform; not
tender and no lesions
Air moves freely as the
client breaths through the
nares
Theres no discharge
No lesions
9. Mouth and Oropharynx
9.1.Inspect and palpate lips Color of outer lids is Color of lips were slightly pink
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9.2.Inspect the teeth andgums
9.3.Inspect and palpate thetongue, mouth floor and
frenulum
9.4.Inspect the tongue
uniform, pink, (darker in
dark skinned clients)
Texture is soft, moist and
smooth.
Symmetry of contour
Inner lips color is uniform
(Freckled brown
pigmentation in dark skin
client)
32 adult teeth
smooth, white, shiny tooth
enamel
Pink gums
Moist, firm texture to gums
No retraction of gums
Central position; pink
color; the mouth floor is
moist; slightly rough; thin
whitish coating. Smooth,
lateral margins; no lesions
Raised papillae or taste
buds
Texture is slightly rough
Tooth were no longer complete
Has pink gums
The tongue is pink in color
Tongue moves freely
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movement
9.5.Inspect the hard andsoft palate
9.6.Inspect the ovula forcolor, discharge and
mobility
9.7.Inspect the tonsils forcolor, discharge and
size
9.8. Elicit the gag reflex
Moves freely
Light pink, smooth, soft
palate. Lighter pink hard
palate, more irregular
texture
Positioned in midline of
soft palate
Tonsils color is pink and
smooth
No discharge and normal
size or not visible
Present
Elicit the gag reflex test
10. Neck
10.1.Assess head movementand muscle strength
10.2.Palpate the neck forenlarge lymphnodes
10.3.Palpate the thorax forbulges and tenderness
10.4.Inspect and palpate
Coordinated, smooth
movements with no
discomfort
No enlarge lymph nodes
Central placement in
Can move freely without discomfort
No presence of enlarge lymph nodes
Thorax were in the midline of neck
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the thyroid gland midline of neck
Not visible on inspection
11. Thorax and lungs
11.1.Inspect the shape andsymmetry of the
thorax
11.2.Inspect the spinalalignment for
deformities
11.3.Palpate the thorax forbulges and tenderness
11.4.Palpate the chest forrespiratory excursion
11.5.Palpate the chest forvocal or tactile
fremitus
11.6.Percuss for
Anteroposterior to
transverse diameter in
ratio 0f 1:2
Chest symmetric
Spine vertically aligned
Spinal column is straight,
right and left shoulders and
hips are at the same height
Skin intact; uniform
temperature
Full and symmetric chest
expansion
Bilateral symmetry of vocal
fremitus
Fremitus is heard most
nearly at the apex of the
Theres no spinal deformities
Theres symmetry of chest expansion when the
patient inhales.
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diaphragmatic
excursion
11.7.Auscultate the chest
lungs
Excursion is 3-5 cm (11/2to
2 in.) bilaterally in woman
in 5-6 cm (2-3 in.) in men
Diaphragm is usually
slightly higher on the right
side
Vesicular and
bronchovesicular breathe
sounds.
12. Heart
12.1.Auscultate the heart inall four anatomic sites:
aortic, pulmonic,
tricuspid and mitral
12.1.Palpate the peripheralpulses both sides of the
body
Usually louder at base of
heart.
Systole: silent interval;
slightly shorter duration
than diastole at normal
heart rate (60-90 beats per
minute)
Diastole: silent interval;
slightly longer duration
than systole at normal
heart rate
Heart rhythm were above normal
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Symmetric pulse volume;
full pulsations
13.Sensory function13.1.Light touch sensation13.2.Pain sensation
13.3.Position or kinestheticposition
13.4.Tactile discriminationstereognosis
Light tickling or touch
sensation
Able to discriminate
sharp and dull
sensations
Can readily determine the
position of fingers and toes
Recognizes common
objects
Can feel light touch
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I. Physical Assessment
T: 39.1
P: 110 bpm
R: 24
BP: 120/80
II. Laboratory and Diagnostic Examination results
CBG
CBG RESULTS NORMAL VALUES INTERPRETATION &
ANALYSIS
450 mg/dl 80-120 mg/dl
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III. Medication
Drug Name Dosage Classification Indication Side Effect Contraindications Nursing Responsibility
Ketorolac 30mg/amp1
amp IM
Nonsteroidal
anti-
inflammatory
agents, nonopioid
analagesics
Inhibits
prostaglandin
synthesis, producing
peripherally
mediated analgesia
- Also has
antipyretic and anti-
inflammatory
properties.
- Therapeutic
effect:Decreased
pain
dizziness Hypersensitivity
- Cross-sensitivity
with other NSAIDs
may existPre- or
perioperative use
- Known alcohol
intoleranceUse
cautiously in:
-cardiovascular
disease.
- Ketorolac therapy should
always be given initially by
the IM or IV route. Oral
therapy should be used only
as a continuation of
parenteral therapy.
-Caution patient to avoid
concurrent use of alcohol,
aspirin, NSAIDs,
acetaminophen, or other
OTC medications without
consulting health care
professional.
- Advise patient to consult
if rash, itching, visual
disturbances, tinnitus,
weight gain, edema, black
stools, persistent headche,
or influenza-like syndromes
(chills,fever,muscles aches,
pain) occur.
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Etoricoxib 120mg
OD
NSAIDS ARCOXIAselectively
inhibits
cyclooxygenase
(COX)-2, the
isoform associated
with pain and
inflammation
Relief of acute
pain
The patient should
tell the doctor his
medical history,
especially of: angina,
heart attack or a
blocked artery in the
heart, narrow or
blocked arteries of
the extremities
kidney disease, liver
disease, heart failure,
high blood pressure
-Check if the patient have a
history of stoke.
- If the patient have any
allergies to any other
medicines or any other
substances, such as foods,
preservatives or dyes.
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Pathophysiology
Heredity
Age
Food Eating habit
(Rich in glucose)
Blurred visionIncreased thirst
FatigueFrequent urination
Slow wound healing
Since the body cells and tissues are non responsive to insulin,
lucose remains in the bloodstream.
There is normal production of insulin
hormone but the body cells are
resistant to insulin
Leads to hyperglycemia
Predisposing Precipitating
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IV. Nursing Care Plan
Cues Analysis Goal/objective Nursing
Intervention
Rationale Evaluation
S: ang sakit ng
sugat ko as
verbalize by the
client.
O: restlessness
Facial
Grimace
Guarding
Behavior
Pain scale: 7/10
Temp:37.5
PR: 100 bpm
RR: 24
Acute pain
related to right
knee amputation
After an hour of
nursing
intervention the
clients pain will
be lowered downfrom 7-4.
>assist patient to
assume position of
comfort
>monitor painclosely
>administer
analgesics as
ordered by the
physician
>to obtain some
pain relief
>to assessincreases in
severity
>to maintain
acceptable level
of pain
After an hour of
nursing
intervention
GOAL WAS
MET; the clientspain was lowered
down from 7-4.
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V. Discharge PlanMedication
Take etoricoxib once pain was felt.
Exercise
Encourage Passive Range Of Motion exercises on the unaffected leg.
Treatment
HCG monitoring and insulin therapy.
Health teaching
The patient should watch for what he eats. Should take the prescribed medications to help him in his early recovery andfollow the suggested diet.
Out Patient Follow Up
The patient needs to go back in the outpatient department after 1 week of being discharged in the hospital.
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Diet
You can keep your blood glucose at a healthy level if you:
y Every day, choose foods from these food groups: starches, vegetables, fruit, meat and meat substitutes, and milk and yogurt.
y Limit the amounts of fats and sweets you eat each day.
Spiritual Counseling
The patient should have faith inGod and try to go to church every Sunday and attend the mass. And never stop praying.