FINAL CASE STUDY of Diabetes Mellitus
FINAL CASE STUDY of Diabetes Mellitus
FINAL CASE STUDY of Diabetes Mellitus
COLLEGE OF NURSING
City of Malolos, Bulacan
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SUBMITTED TO:
LEVEL THREE INSTRUCTORS
I.
INTRODUCTION
This case study is all about L.V, a 56 year old patient who diagnose with a Type 2 Diabetes Mellitus along with a
urinary tract infection at Bulacan Medical Center on December 19, 2012, with a chief complain of dizziness, weakness
and difficulty in breathing.
Diabetes Mellitus or simply diabetes, is a group of metabolic diseases characterized by increased levels of
glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Diabetes has its
major classification which varies in cause, clinical course, and treatment. These are the type 1 DM, type 2 DM,
gestational diabetes, and diabetes mellitus associated with other conditions or syndromes.
Type 2 diabetes mellitus or commonly known as Non- insulin dependent or an adult onset type described as a
relative deficiency of insulin production and a decreased insulin action and/or increased insulin resistance. It occurs
more commonly among people who are older than 30 years of age and obese although its incidence is rapidly
increasing in younger people that is because of the growing epidemic of obesity in children, adolescence and young
adults.
The clinical manifestations are depending on the patients level of hyperglycemia. It includes polyuria (increased
urination) and polydipsia (increased thirst) occurs as a result of excess loss of fluid associated with osmotic dieresis.
Patients also suffers polyphagia (increased appetite) that is the results from the catabolic state induced by insulin
deficiency and the breakdown of proteins and fats. Other manifestations such as fatigue, weakness, sudden vision
changes, tingling or numbness in hands or feet, dry skin and recurrent infections are noted.
Several procedures like fasting plasma glucose, random plasma glucose and glucose level two hours after
receiving glucose (2- hour postload) may indicate an abnormally high blood glucose level which is considered to be the
basic criterion for the diagnosis of diabetes. The major goal of the diabetes treatment is to normalize the insulin activity
and blood glucose level to reduce the development of vascular and neuropathic complications without patient
experiencing hypoglycemia: nutritional therapy, exercise, monitoring, pharmacologic therapy and education which are
the essential components of diabetic regimen.
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The incidence of diabetes is growing around the world. It is in the top ten leading causes of deaths. Filipinos are
not an exemption to this incidence as more and more Filipinos are affected by the disease. According to the survey
conducted by the Philippine Cardiovascular outcome study on Diabetes Mellitus in 2007 found out that 20.6 percent of
adults aged 30 and above were found to be diabetic. In 1998 only 3.9 percent of Filipinos living in the Philippines had
diabetes. On the other hand, the prevalence of diabetes according to the NNHES (National Nutrition Health Survey)
study is 4.8%.
REASONS OF STUDY
The group chose type 2 diabetes mellitus as our case study because aside from it is still fresh in our minds; our
group was interested in studying this. We are willing to do this case to challenge our own minds in analyzing the
problem and to enhance our knowledge, as well as to gain new experiences which could bring new learnings for the
group. This case study will also help the group in understanding the disease process of the patient. It would also help
the group in identifying the primary needs of the patient with a type 2 Diabetes Mellitus. By identifying such needs
and health problems arise the group can now formulate an individualized Nursing care plan for the patient that
would address these needs and problems effectively. Management of the identified problem will help the patient to
recover faster and maintain holistic sense of wellness. This will also equip the group with knowledge, skills and
attitude on how to manage future patient with the same disease.
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II.
OBJECTIVES
STUDENT- CENTERED
GENERAL OBJECTIVES
The purpose of this case study is to give the much needed knowledge and awareness to the nursing students who have or
might have handled cases of Type II Diabetes Mellitus associated with Urinary Tract Infection.
SPECIFIC OBJECTIVES
(STUDENT-CENTERED)
KNOWLEDGE:
To be able to have a better understanding at the case of the patient having a type 2 Diabetes Mellitus
associated with Urinary Tract Infection and the occurrence of its signs and symptoms.
To be able to know the disease process through its pathophysiology.
To be able to be knowledgeable about the patient drug study.
SKILLS:
ATTITUDE:
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To be able to formulate nursing care plans based on the prioritized health needs of the client.
To be able to discuss about the pathophysiology of the disease process.
To be able to familiarize on the aggravating factors and specific interventions to prevent complications
of Type 2 diabetes Mellitus and Urinary Tract Infection.
To be able to change any misconception about the said disease of the patient.
To be able to develop awareness in the proper care management for type 2 diabetes mellitus and urinary
tract infection.
To be able to serve our future clients with a higher level of holistic understanding as well as
individualized care.
(CLIENT-CENTERED)
GENERAL OBJECTIVES
This case study implies knowledge and awareness to people who have or might be at risk of the said
disease regarding its fatality and detection.
SPECIFIC OBJECTIVES
KNOWLEDGE:
To be able to impart knowledge regarding type 2 Diabetes Mellitus and Urinary Tract Infection.
To be able to determine signs and symptoms and its complications.
To be able to familiarize on the appropriate interventions with its rationale to improve patients condition.
SKILLS:
To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own.
To be able to explain the different factors that may cause type 2 diabetes mellitus and Urinary Tract
Infection and its danger.
To be able to participate in her plan of care.
ATTITUDE:
To help the patient in motivating her to continue the health care provided by the health workers.
To be able to complies with the treatment protocol and prevention strategies.
To be able to identify different measures to prevent further aggravation of the condition.
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Upon seeing the patient last March 5, 2013, he was able to communicate to us, has no manifestation of hyperglycemia
nor hypoglycemia. During our clinical rotation we seen our client with the following drugs Humulin 70/30, Lantus 16 units,
VAsalat 10mg, Micardis Plus 80mg and Catapress her blood pressure reaches 150.
D. Past Health History
According to the client, he experienced common diseases like fever, cough and colds. She also had Urinary Tract
infection last December and was given medication like Bactrim Forte. According to client she was also confined in the ICU for
1 week because of hyperglycemia associated by hypertension. He is also a hypertensive patient.
E. Family Health History
According to the patient, her family has a history of Asthma, diabetes Mellitus and Hypertension on the paternal
side.
According to the client she feels ill and weak whenever her sugar
level increased. She also added that she feels sad because she
wasnt able to do things that he used to do before like doing chores
in a longer period of time but the client has a positive outlook in life,
she stated that kahit na may diabetes ako at maraming bawal,
pagpapatuloy ko ang aking buhay.
Nutritional-Metabolic Pattern
With Diabetes Mellitus
BREAKFAST
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LUNCH
DINNER
TOTAL
INTAKE
March
2,
2013
1 bowl
Lugaw(275
ml)
1 cup
tea(250mL)
March
3,
2013
1 bowl of
lomi(275mL
)
1 glass of
water(250
mL)
March
4,
2013
bowl of
Quaker
oats(125mL
)
1 glass of
water(250
mL)
1 pc. Of fish
fillet
cup of
rice
1 glass of
water(250m
l)
bowl of
binagoonga
ng
baboy(150
mL)
cup rice
1 glass of
water(250m
L)
cup of
rice
serving
of adobong
manok
1 glass of
water(250m
L)
1 pc. Of
fish fillet
cup of
rice
1 cup
tea(250mL)
Approximat
ely:
1050mL
bowl of
binagoonga
ng
baboy(150
mL)
1 cup rice
1 glass of
water(250
mL)
1 pc Indian
mango
1 sachet of
skyflakes
1 cup
tea(250mL)
Approximat
ely:
1350mL
Approximat
ely:
1325mL
According to the client she has restriction on his diet. If we noticed her intake
in the span of 3 days, she limits her carbohydrates intake as well as fat
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intake. She also added that she was also limiting herself in eating sweet
foods. Our client stated that she drinks a lot everyday approximately 1
liters, she verbalized uhaw
uhaw akoMellitus
palagi. According to the
Withna
Diabetes
approximate Total intake per day it is normal, because the normal Total
ELIMINATION
intake is 2500mL per day. URINATION
And in the 72-hour diet recallBOWEL
it is shown
that her
intake isFREQUEN
minimal, compare
to her statement
prior to
her condition. COLO
COLOR/TR
DISCOMFO
FREQUENCY
CY
Elimination Pattern
Marc
h 2,
2013
Marc
h 3,
2013
Marc
h 4,
2013
9times(ap
prox.
625mL)
6times(ap
prox.
530mL
per shift)
8times(ap
prox.600)
ANPAREN
CY
Dark
Yellow
RT
NONE
once
Dark
Yellow
NONE
once
Dark
Yellow
NONE
once
NOT
RECAL
L
NOT
RECAL
L
NOT
RECAL
L
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0- BED MOBILITY
0- BATHING
0- COOKING
0- GROOMING
1- GENERAL
LEGEND:
Level 0- Full self Care
Level I- Requires Use of Equipment
Level II- Requires assistance or supervision from another
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person
Level III- Requires assistance from another person and
device
Level IV- Is Dependent and doesnt participate
The Client feels sad and happy. Sad because she was not able to
things that may trigger her condition and happy because her family
is very supportive and concern about her present condition.
Cognitive-Perceptual Pattern
With Diabetes Mellitus
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Sexuality/ReproductivePattern
With Diabetes Mellitus
We dont ask about this topic to him.
STAGES
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Freud's Psycho-sexual
Theory
Erickson's Psycho-social
Theory
Kohlbergs Theory of
Moral
GENITAL
Puberty-Death
Generativity vs.
Stagnation
Middle Adulthood: 35 to 55 or 65
Formal Operational
12 - Adulthood
Post Conventional
-Universal Ethics
Orientation
DEFINITION
Adults need to
create/nurture things that
will outlast them, often by
having children/creating a
positive change that
benefits other people.
Success leads to feelings
of usefulness and
accomplishment, while
failure results in shallow
involvement in the world.
RESOLUTION
V. THEORY
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THEORY
THEORIST
1. Health Promotion
Model
Nola J. Pender
2. Self-Care Deficit
Theory of Nursing
Dorothea E. Orem
Lydia Hall
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DESCRIPTION
APPLICATION OF THEORY TO
THE PATIENT
PHYSICAL ASSESSMENT
ASSESSMENT
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS/INTERPRET
ATION
GENERAL APPEARANCE
BODY BUILT
INSPECTION
Proportionate ( mesomorph )
Normal
POSTURE
INSPECTION
Normal
OVER-ALLHYGIENE
BODY AND
BREATH ODOR
INSPECTION
Normal
INSPECTION
Normal
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SIGNS OF
DISTRESS
INSPECTION
No signs of distress
Weak in appearance
OBVIOUS SIGN
OF HEALTH OR
ILLNESS
INSPECTION
INSPECTION
Normal
INSPECTION
Normal
MENTAL STATUS
LEVEL OF
CONSCIOUSNE
SS
ORIENTATION
BODY
PART
INTEGUMENTARY
a.) SKIN
b.)
NAILS
TECHNIQUE
INPECTION
PALPATION
INSPECTION
PALPATION
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NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS
SKULL
SCALP
INSPECTION
Normal
PALPATION
INSPECTION
Normal
PALPATION
Smooth
No presence of dandruff or
lesions
Smooth
Color is lighter than facial skin
No tenderness
HAIR
INSPECTION
Normal
FACE
INSPECTION
Symmetric/slightly asymmetrical
facial features
Symmetrical facial movements.
Normal
a. Eyebrows
INSPECTION
EYES
b. Eyelashes
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Normal
INSPECTION
slightly outward.
Normal
Skin is intact
c. Eyelids
NSPECTION
Skin is intact
Normal
d. Conjunctiva
Red or pink.
e. Cornea
INSPECTION
Pink in color
Normal
g. Pupils
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Normal
Transparent, shiny and smooth.
Details of iris are visible
INSPECTION
No edema or tearing
No edema or tearing
PALPATION
Normal
INSPECTION
j. Visual
Acuity
h. Visual
Fields
i. Ocular
movements
INSPECTION
INSPECTION
Normal
Normal
Moves in unison.
In parallel alignment.
Moves in unison.
In parallel alignment.
INSPECTION
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Normal
Distance vision:
EARS
Normal
a. Auricles
INSPECTION
PALPATION
Symmetrical
Symmetrical
Uniform color.
Uniform color.
No tenderness or lesions.
No tenderness or lesions.
Mucosa is pink.
Mucosa is pink.
Nasal patency:
Nasal patency:
Normal
b. External ear
INSPECTION
NOSE
INSPECTION
PALPATION
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Normal
Normal
Normal
Normal
MOUTH
a. Lips and
buccal
INSPECTION
PALPATION
mucosa
INSPECTION
b. Teeth and
gums
PALPATION
32 adult teeth
Pink gums
No retraction of gums
Normal
Normal
Central position
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Central position
Normal
c. Tongue
INSPECTION
Pink color
Pink color
PALPATION
No lesions
No lesions
Moves freely
Moves freely
No tenderness
No tenderness
PALPATION
Normal
Normal
INSPECTION
d. Mouth floor
and roof
Normal
Soft palate: light pink
INSPECTION
e. Hard and
soft palate
f. Uvula
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e. Tonsils and
oropharynx
Normal
Present
Present
INSPECTION
PALPATION
Equal strength
Equal strength
Not palpable
INSPECTION
f. Gag reflex
NECK
a. Lymph nodes
b. Trachea
INSPECTION
Normal
Normal
PALPATION
c. Thyroid
gland
INSPECTION
PALPATION
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Normal
POSTERIOR THORAX
a. Posterior
thorax
b. Respiratory
excursion
c. Vocal tactile
fremitus.
INSPECTION
PALPATION
INSPECTION
PALPATION
INSPECTION
PALPATION
Anteroposterior to transverse
diameter in ratio of 1:2
Anteroposterior to transverse
diameter in ratio of 1:2
No tenderness
No tenderness
No masses
No masses
3-5cmThumb separate at
inspiration.
Normal
Normal
Normal
Deviation from Normal
due to mucus
secrtions.
Normal
d. Percussion
e. Auscultation
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PERCUSSION
ANTERIOR THORAX
a. Anterior
Thorax
AUSCULTATIO
N
INSPECTION
Uniform temperature
Uniform temperature
No tenderness
No tenderness
PALPATION
INSPECTION
b. Respiratory
excursion
PALPATION
Normal
Normal
Normal
Symmetrical chest expansion
PERCUSSION
c. Percussion
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Normal
d. Auscultation
AUSCULTATIO
N
stomach
CARDIOVASCULAR
a. Heart
AUSCULTATIO
N
PALPATION
INSPECTION
Normal
S1 all sites
S2 all sites
S3- in children/young adults
S4 older adults
b. Carotid
artery
AUSCULTATIO
N
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Normal
Normal
Normal
Veins are not visible
INSPECTION
Rounded shape
Rounded shape
PALPATION
Slightly assymetric
Generally symmetric
Normal
Normal
No tenderness, masses or nodules.
No tenderness, masses or
nodules.
Normal
No discharge, tenderness, or
masses
No discharge, tenderness, or
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Normal
ABDOMEN
INSPECTION
Uniform in color
Rounded (convex)
Symmetric contour
Symmetric movements caused by
respirations
Normal
Symmetric contour
Symmetric movements caused by
respirations
PERCUSSION
PALPATION
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Liver size:
Normal
Normal
Normal
MCL: 6 12cm
MSL: 4 8cm
Normal
Normal
Liver: no enlargement may not be
palpable
Gall bladder:
UPPER EXTREMITIES
a. Shoulders,
arms, elbows,
wrists hands
and fingers
b. Shoulders and
arms:
movement and
force
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No distention
Symmetrical
Symmetrical
Normal
Normal
Normal
c. Elbows:
movement and
force
Normal
d. Wrists:
movement and
force
Normal
e. Hands and
fingers:
movement and
force
LOWER EXTREMITIES
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Normal
a. Hips, knees,
ankles and
feet:
b. Hips:
movement and
force
Symmetrical, No redness,
swelling, deformity
Normal
Normal
Normal
Normal ranges:
20 degrees dorsiflexion of ankle
and foot; 45 degrees plantar flexion
of ankle and foot
20 degrees of eversion 30 degrees
of inversion
10 degrees of abduction; 20
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Normal
degrees of adduction
40 degrees of flexion; 40 degrees of
extension
Full ROM against resistance.
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VIII. DRUGS/MEDICATIONS
DRUG NAME
MECHANISM OF
ACTIONS
Generic Name:
HUMULIN 70/30
Classification:
Antihyperglycemic /
Antidiabetic
Route/Dosage:
Subcutaneous;
10ml
Decreases blood
glucose by
transport of glucose
into cells;
conversion of
glucose to glycogen
.
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INDICATION
Management of
type 2 Nondependent
diabetes mellitus
CONTRAINDICATI
ON
Hypoglycemia and
hypersensivity
reactions
SIDE EFFECTS
NURSING
RESPONSIBILITIE
S
Lipodystrophy;
insulin resistance;
allergic reactions;
hypoglycemia
Obtain patience
history, including
drug history and
any known
allergies.
Monitor fasting
blood glucose, 2hrs
after meals.
Monitor urine
ketones during
illness.
Monitor body
weight
Monitor for
hypoglycemic
/hyper glycemic
reactions.
Generic Name:
Simvastatin
Classification:
Antihyperlipidemic
agent/HMG-CoA
reductase inhibitor
Route/Dosage:
40mg/tab OD
Inhibits HMG-CoA
reductase enzyme,
which reduces
cholesterol
synthesis
Generic Name:
Telmisartan
(micardis)
Classification:
Angiotensin II
antagonist/
Antihypertensive
Route/Dosage:
80mg/tab OD
Blocks the
Treatment for
vasoconstrictive
Hypertension
and aldosteronesecreting effects of
angiotensin II by
selectively
blocking the
binding of
angiotensin II to the
AT1 receptor in
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Treatment of
Hyprlipidemias
Pregnancy and
Hypersensitivity to
any components of
preparation.
Abdominal pain;
constipation;
headache;
dizziness
Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Pregnancy and
lactation. Biliary
obstructive disorder.
hypersensivity
Diarrhea;
headache; fatigue;
Urinary tract
infection
Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
many tissues
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Generic Name:
Amlodipine
Classification:
Antihypertensive
agent
Route/Dosage:
10mg/tab OD
sublingual
Decreases
pheripheral
vascular resistance
of smooth muscle
(decrease blood
pressure)
Treatment for
hypertension
Generic Name:
Blocks the
Treatment for
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Hypersensivity to
Palpitations;
headache;
dizziness; fatigue;
Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Headache;
Prior:
Valsartan
Classification:
Angiotensin II
receptor blocker /
Antihypertensive
agent
Route/Dosage:
80mg OD
Generic Name:
Clonidine
Classification:
AntiHypertensive
agent
Route/Dosage:
750mcg/Tab BID
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vasoconstrictive
Hypertension
and aldosteronesecreting effects of
angiotensin II by
selectively
blocking the
binding of
angiotensin II to the
AT1 receptor in
many tissues.
the components
Stimulates central
alpha-adrenergic
receptors to inhibit
symphatetic
cardioaccelerator
and vasoconstrictor
centers
Hypersensitivity to
clonidine
Management of all
grades of
hypertension
dizziness; fatigue
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Drowsiness, dry
mouth, headache,
urinary retention
hypotension
Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Date
Indication/ purposes
Analytes
ordered/
date
result
Hematology December
White Blood
I t provides
19, 2012
Cell
valuable
information
about the blood
and some
extent the bone
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Result
Normal
Interpretation
Nursing responsibilities
14.7
4.1-11.1
Prior to examination:
Check the doctors order.
Explain the procedure to the
client.
Assess for the presence of
hematophobia.
marrow, which
is the blood
forming tissue.
It is used for
the following
purposes:
To ensure both
adequate
oxygen
carrying
capacity and
hemostasis.
To identify
persons who
may have an
infection.
To identify
acute and
chronic illness,
bleeding
tendencies.and
number of
circulating
white blood
cells.
Lymphocytes% 14.1
16.0-46.0
Monocytes %
Granulocytes
%
2.9
83.0
2.3-8.5
48.7-81.2
Red Blood
Cells
Hemoglobin
4.53
3.90-5.20
127
120-151
Hematocrit
0.377
0.364-0.460
MCHC(Mean
377
318-342
14.7
11.9-14.4
corpuscular
hemoglobin
concentration)
RDW(red
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blood cell
distribution
width)
Laboratory
procedure
Urinalysis
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Date ordered/
date result
December
19,2012
Indication/
purpose
It is an
essential
procedure
for
patients
undergoin
g hospital
admission
or
physical
examinati
on.
Platelet
402
169-418
MPV(mean
platelet
volume)
6.7
7.0-10.5
Analytes
Result
Color
Light yellow
Transparency
Slightly
turbid
normal it indicates:
That the
patient
develop
cardiovascular
disease.
The result is within
normal.
The result is below
normal it indicates
that :
The patient
may develop
leukemia.
Normal
Pale
yellow
to
amber
clear to
slightly
hazy
Interpretation
Nursing
consideration
Normal
Prior:
1. Review
Normal
2. Gather all
the
necessary
materials
CHEMICAL
EXAMINATION:
Glucose
+1
Negative
physicians
order.
Positive result of
glucose in the urine
may indicate:
needed.
3. Explain the
procedure to
It is a
useful
indicator
of a
healthy or
diseased
state and
Specific gravity
has
remained
an
integral
part of the MICROSCOPIC
patient
EXAMINATION:
examinati
on.
Amorphous urate
Bacteria
1.030
Faint aromatic
Rare
1.010-1.025
Rare
Negative
high blood
glucose level
undiagnosed or
uncontrolled
diabetes
mellitus
The result is above
normal level it
indicates that:
Urine is concentrated
The result is abnormal
it indicate that:
the patient eats
food cause
musty odor.
Infected urine
Urine that have
glucose.
Abnormal result
indicates:
Infection
process.
the patient.
4. 4 .Instruct
the patient
to void
directly into
a clean, dry
container.
Sterile,
disposable
containers
are
recommend
ed. Women
should
always have
a cleancatch
specimen if
a
microscopic
examination
is ordered.
Feces,
discharges,
vaginal
secretions
and
menstrual
blood will
contaminate
the urine
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specimen.
After:
1. Cover all
specimens
tightly, label
properly and
send
immediately
to the
laboratory.
2. If a urine
sample is
obtained
from an
indwelling
catheter, it
may be
necessary
to clamp the
catheter for
about 15-30
minutes
before
obtaining
the sample.
Clean the
specimen
port with
antiseptic
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The
process of
urinalysis
determine
s the
abnormal
constituen
ts
revealed
by
microsco
pic
examinati
on of the
urine
sediment.
before
aspirating
the urine
sample with
a needle
and a
syringe.
3. Observe
standard
precautions
when
handling
urine
specimens.
4. If the
specimen
cannot be
delivered to
the
laboratory or
tested within
an hour, it
should be
refrigerated
or have an
appropriate
preservative
added.
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X. NURSING PRIORITIZATION
NURSING PROBLEM
1. Altered Tissue Perfusion
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JUSTIFICATION
We consider this problem as our first priority because diabetes
mellitus has a primary feature of constricted blood vessels which
caused by an inadequate oxygenated blood circulate in the body
which is the reason of having a fatigue in relation to the decrease
muscle strength
2. Fatigue
3. Deficient Knowledge
ASSESSMENT
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NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTION/S
RATIONALE
EVALUATION
OBJECTIVE CUES:
Verbalization
of the
problem
Statement of
misconception
Vital Signs:
BP: 130/70 mmHg
RR: 29cpm
Ineffective tissue
perfusion related
to weakening due
to vasoconstriction
of blood vessels
After 8 hours of
nursing
intervention, the
patient will be
able to achieve a
normal circulation
in the peripheral.
drug use
vasoconstriction.
SUBJECTIVE:
OBJECTIVE:
generalized
weakness
increased
respiratory
rate of 25cpm
body
weakness
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Fatigue
related to
decrease
muscle
strength
Assess
response to
activity
Response to an
activity can be
evaluated to achieve
weight loss
fatigue
-limited ROM
inability to
perform ADL
altered VS
altered
sensorium
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Asses
muscle
strength of
patient and
functional
level of
activity.
Discuss with
patient the
need for
activity
Alternate
activity with
periods of
rest/
uninterrupte
d sleep.
Monitor
pulse,
respiration
rate and
blood
pressure
before/after
activity
Perform
activity
slowly with
desired level of
tolerance.
To determine the
level of activity
Education may
provide motivation
to increase activity
level even though
patient may feel too
weak initially
Prevents excessive
fatigue.
Indicates
physiological
levels of tolerance.
Interventions should
be directed at
delaying the onset of
fatigue and
optimizing muscle
efficiency.
Symptoms of fatigue
frequent rest
periods
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Promote
energy
conservation
techniques
by
discussing
ways of
conserving
energy while
bathing,
transferring
and so on.
Provide
adequate
ventilation
Provide
comfort and
safety
Instruct
patient to
perform
deep
breathing
exercises
Instruct
client to
increase
For proper
oxygenation
To be free from
injury
Promotes relaxation
For muscle strength
and tissue repair
To prevent weakness
and paleness
To provide proper
ventilation
ASSESSMENT
OBJECTIVE CUES:
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Verbalization
NURSING
DIAGNOSIS
Deficient knowledge
related to the
disease process due
to lack of
PLANNING
After 8 hours of
nursing
intervention, the
patient will be able
Vitamins A, C
and D and
protein in
her diet.
Instruct also
patient to
increase iron
in diet
Administer
oxygen as
ordered.
NURSING
INTERVENTION/S
Encourage client to
do self monitoring of
her glucose level.
RATIONALE
EVALUATION
of the
problem
Statement of
misconception
Vital Signs:
BP: 130/70 mmHg
RR: 29cpm
information or
information
misinterpretation
to verbalize
accurate
information, report
understanding of
condition and
discuss process and
treatment.
Provide explanations
of reasons for the
procedure and the
preparation needed.
Identify individual
restrictions such as
too sugar in the
food.
Information can
decrease the
anxiety of the
patient.
XII. CONCLUSION
At the end of our case study, our group learned things about Type II Diabetes Mellitus and Urinary Tract Infection that are
needed for us to know. We therefore conclude that we, as nursing students must give time in knowing disease or illness like our
case. These things would help us further in giving or disseminating information to people who are concerned or involved in this
condition.
On the other hand, this case study is not only for nursing student but this can be also helpful to other professionals and
ordinary people. We studied about the risk factors, its sign and symptoms, treatment, medication for Type II Diabetes Mellitus
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and Urinary Tract Infection. Hence, we learned that any individual is prone to this condition if their lifestyle puts them to a higher
risk. Thats why we must all be well-informed to prevent its occurrence.
Lastly, at the end of our case study we, student nurses apprehend all essential things about Type II Diabetes Mellitus and
Urinary Tract Infection. Avoid exposure, proper lifestyle, proper hygiene and proper nutrition is the best way to prevent the
acquiring of Type II Diabetes Mellitus and Urinary Tract Infection and any other diseases.
XII. BIBLIOGRAPHY
-
Kozier B. et al: Fundamentals of Nursing 10th edition Pearson education Inc. New jersey Copyright 2004
p.434
Moorhouse , Doenges, M.: Nurses Pocket Guide: Nursing Diagnoses with Interventions
Brunner and Suddart: textbook of Medical and Surgical Nursing 12 th edition, hippincott, Williams & Wilkins
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-http://www.justmommies.com/articles/anemia-during-pregnancy.shtml#ixzz1lN1GVpZL
http://en.wikipedia.org/wiki/Pain#Management
http://www.livestrong.com/article/202712-a-nursing-diagnosis-of-limited-mobility/
http://nurseslabs.com/d5w-iv-fluid-study/\
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