Colegio de San Juan de Letran – Calamba Bucal, City of Calamba, 4027, Laguna

School of Nursing

A Case Study on

Hemophilia A

Prepared and presented

Montesur Mark Niko N.3BSN3 – Group 11

As a partial requirement inRelated Learning Experience (RLE)

Conducted atMedicine Forbes Ward

University of Santo Tomas HospitalEspaña, Manila

Presented and Submitted to:

Mrs.Cabudol

Name of Patient: Joaquin Gliceria BartolomeAge and Sex: 70 year old femaleBirthday: May 13, 1939Present Address: Obando, BulacanCivil Status: MarriedReligion: CatholicOccupation: Unemployed

I. CHIEF COMPLAINT: Altered Sensorium

II. PRESENT ILLNESS: Patient is a known diabetic, poorly controlled since 20 years ago on Glimepiride 500mg OD; claimed to be compliant but with poor CBG monitoring.A few hours PTA, patient became stuporous, still unable to talk, unable to feed because of inability to chew and difficulty of swallowing, hence admission

III. ADMITTING DIAGNOSIS: T/C starvation ketosis; DM type 2 poorly controlled; sepsis probably secondary to sacral ulcer; AKI secondary to dehydration secondary to sepsis.

IV. PAST HEALTH HISTORYA. General Health: Patient is known diabetic for 20 years on Glimepiride 500 mg OD and no known allergiesB. Childhood Illness: The patient has no known childhood illness.C. Accident and Injuries: No accidents and injuries known.D. Hospitalization: April (2010) CVA; Right Hemiparesis with facial asymmetry and dysarthriaE. Immunization: Unrecalled.F. Allergies: Patient has no food or medication allergiesG. Surgeries: S/P appendectomy (1960); S/P Hip surgery (2005); s/p cataract surgery (2000)H. Geographic Location: The patient lives in Obando, Bulacan a busy urban community.

V. FAMILY and HEALTH HISTORYA. Gonogram/Family Tree

(+) asthma - Daughter(-) DM (-) Hypertension (-) Heart disease(+) cancer – son and father

B. Personal Habitsa. Use of Tobacco: N/Ab. Alcohol: N/Ac. Prohibited Drugs: Does not use drugs.d. Hygiene: Patient has good hygiene but is partially assisted when taking baths due to right hemiparesise. Elimination Patterns: Voids 5-6 times a day and has a bowel of 1 per day.

C. Sleep and Wake Patterns: The client usually wakes up 6am in the morning while her sleeping time varies per day.

D. Exercise and Activity: Sedentary lifestyle due to effects of aging.E. Recreation: Patient enjoys watching TV.F. Nutrition: The patient controls intake of rice due to DM.G. Stress and Coping Patterns: Watching TVH. Socio-economic Status

a. Educational Level: b. Financial Status: Patient is dependent on son

I. Occupational Health Problems

1. Nature of Work: N/A

VI. LIFESTYLE PRACTICES

A. Activities of Daily Living: Patient wakes up early to eat breakfast. The rest of the day is spent watching TV.B. Ability to Care for Self and Family: Before hip surgery, client was able to take care of self. After surgery patient constantly needs assistance.C. Client’s Preferred Lifestyle: Patient prefer to stay at home and watch TV.D. Home and Neighborhood Environment: Patient lives near the street. Environment is noisy and slightly polluted.

VII. HEALTH PROMOTION AND MAINTENANCE ACTIVITY

A. Health Belief1. Promotive, Preventive, and Restorative Practices: The patient takes medications and seeks consult for serious illnesses. Self-medicates for common

illnesses.2. Role and Relationship Patterns:

A. Cultural Influences: The patient does not believe In any hilot/albularyos.B. Spiritual and Religious Influences: Does not go to church.

INTRODUCTIONDIABETES MELLITUS TYPE 2

Diabetes mellitus type 2 or Type 2 Diabetes (formerly called non - insulin-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a metabolic disorder that is primarily characterized by insulin resistance, relative insulin deficiency, and hyperglycemia. It is often managed by increasing exercise and dietary modification, although medications and insulin are often needed, especially as the disease progresses. It is rapidly increasing in the developed world and there is some evidence that this pattern will be followed in much of the rest of the world in coming years. CDC has characterized the increase as an epidemic. In addition, whereas this disease used to be also seen primarily in adults over age 40, in contrast to Diabetes mellitus type 1, it is now increasingly seen in children and adolescents, an increase thought to be linked to rising rates of obesity in this age group, although it remains a minority of cases.

Unlike Type 1 diabetes, there is little tendency toward ketoacidosis in Type 2 diabetes, though it is not unknown. One effect that can occur is nonketonic hyperglycemia which also is quite dangerous, though it must be treated very differently. Complex and multifactorial metabolic changes very often lead to damage and function impairment of many organs, most importantly the cardiovascular system in both types. This leads to substantially increased morbidity and mortality in both Type 1 and Type 2 patients, but the two have quite different origins and treatments despite the similarity in complications.

CAUSES

Type 2 diabetes is caused by a complicated interplay of genes, environment, insulin abnormalities, increased glucose production in the liver, increased fat breakdown, and possibly defective hormonal secretions in the intestine. The recent dramatic increase indicates that lifestyle factors (obesity and sedentary lifestyle) may be particularly important in triggering the genetic elements that cause this type of diabetes.

RISK FACTOR

Obesity and Metabolic Syndrome Family History Ethnicity Low Birth Weight

TREATMENT

Diabetes mellitus type 2 is a chronic, progressive disease that has no established cure, but does have well-established treatments which can delay and sometimes avoid most of the formerly inevitable consequences of the condition.

Self monitoring of blood glucose Dietary management Exercise Antidiabetic drugs Insulin preparations

DIAGNOSIS

The diagnosis of type 1 diabetes, and many cases of type 2, is usually prompted by recent-onset symptoms of excessive urination (polyuria) and excessive thirst (polydipsia), often accompanied by weight loss. These symptoms typically worsen over days to weeks; about a quarter of people with new type 1 diabetes have developed some degree of diabetic ketoacidosis by the time the diabetes is recognized. The diagnosis of other types of diabetes is usually made in other ways. These include ordinary health screening; detection of hyperglycemia during other medical investigations; and secondary symptoms such as vision changes or unexplainable fatigue. Diabetes is often detected when a person suffers a problem that is frequently caused by diabetes, such as a heart attack, stroke, neuropathy, poor wound healing or a foot ulcer, certain eye problems, certain fungal infections, or delivering a baby with macrosomia or hypoglycemia.

Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following: fasting plasma glucose level at or above 126 mg/dL (7.0 mmol/l). plasma glucose at or above 200 mg/dL (11.1 mmol/l) two hours after a 75 g oral glucose load as in a glucose tolerance test. random plasma glucose at or above 200 mg/dL (11.1 mmol/l).

SIGNS AND SYMPTOMS

The early symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine. High amounts of glucose in the urine can cause in -creased urine output and lead to dehydration. Dehydration causes increased thirst and water consumption.

The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein.

A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite. Some untreated diabetes patients also complain of fatigue, nausea and vomiting. Patients with diabetes are prone to developing infections of the bladder, skin, and vaginal areas.

OBJECTIVES OF THE STUDYThe objectives of the study are the following:

General Objectives:

To give background knowledge about diabetes mellitus presented in the study

Specific Objectives: To know the clinical manifestations of the diseases included in the study To know the assessment and diagnostic procedures used to diagnose the diseases To identify the suitable management (medical, surgical and nursing) and pharmacologic regimen to be used for the disease of the client

To provide appropriate nursing care plan and health teachings to manage the disease of the client

NURSING THEORY

DOROTHEA OREM’S SELF-CARE DEFICIT THEORY

THE CONCEPTUAL FRAMEWORK

Orem's work can be separated into a conceptual model and three theories. Orem’s conceptual model is constituted from six central or core concepts and one peripheral con-cept. The central concepts are self-care, self-care agency, therapeutic self-care demand, self-care deficit, nursing agency, and nursing system. The peripheral concept is basic conditioning factors.

SELF-CARE is defined as action directed by individuals to themselves or their environments to regulate their own functioning and development in the interest of sustaining life, maintaining or restoring integrated functioning under stable or changing environmental conditions, and maintaining or bringing about a condition of well-being.

SELF-CARE AGENCY is defined as a complex capability of maturing and mature individuals to: (1) determine the presence and characteristics of specific requirements for regulat-ing their own functioning and development, (2) make judgments and decisions about what to do, and (3) perform care measures to meet specific self-care requisites.

THERAPEUTIC SELF-CARE DEMAND is defined as the action demand on individuals to meet some complex of universal, developmental, and health deviation self-care requisites. Universal self-care requisites are associated with life processes and maintenance of the integrity of human structure and function. Developmental self-care requisites are associ-ated with human developmental processes and conditions and events that occur during various stages of the life-cycle, as well as with events that may adversely affect develop-ment. Health deviation self-care requisites are associated with genetic and constitutional defects and human structural and functional deviations and their effects, as well as with medical diagnostic and treatment measures prescribed or performed by physicians.

SELF-CARE DEFICIT is defined as the expression of a relationship of inadequacy between self-care agency and the therapeutic self-care demand.

NURSING AGENCY is defined as a complex property or attribute of nurses developed through specialized education and training in the theoretical and practical nursing sciences and through their development of the art of nursing in reality situations.

NURSING SYSTEMS is defined as a dynamic action system produced by nurses as they engage in the diagnostic, prescriptive, and regulatory operations of nursing practice. The wholly compensatory nursing system is selected when the patient cannot or should not perform any self-care actions. The partly compensatory nursing system is selected when the patient can perform some, but not all, self-care actions. The supportive-educative nursing system is selected when the patient can and should perform all self-care actions.

BASIC CONDITIONING FACTORS reflect features of individuals or their living situations, such as age, gender, health state, developmental age, sociocultural, health care system variables, family system elements, and patterns of living. Basic conditioning factors influence self-care and self-care agency.

THE THREE THEORIES

The three theories derived from Orem's conceptual model are the theory of self-care deficit, the theory of self-care, and the theory of nursing systems.

The central idea of the THEORY OF SELF-CARE DEFICIT is that individuals can benefit from nursing because they are subject to health-centered or health-derived limitations that render them incapable of continuous self-care or that result in ineffective or incomplete care.

The central idea of the THEORY OF SELF-CARE is that self-care is a learned behavior that purposely regulates human structural integrity, functioning, and development.

The central idea of the THEORY OF NURSING SYSTEMS is that nursing systems are formed when nurses use their abilities to prescribe, design, and provide nursing for legitimate patients by performing discrete actions and systems of actions that regulate the value of or the exercise of individuals' capabilities to engage in self-care and meet the self-care requisites of the individual therapeutically.

PHYSICAL ASSESSMENT

A. General Survey: no activity

B. Integument: Warm, dry skin, 3x3cm sacral grade 3 ulcer and 2x1 cm grade 2 left ischial tuberosity ulcer.

C. Head: no vertigo, no headaches

D. Eyes: Pink palpebral conjunctiva, anicteric sclera, cloudy cornea

E. Ears: normal hearing, no discharges, with slight earwax

F. Nose & Sinuses: no pain on the sinuses, no discharge on the nose, NGT inserted in Left nostril

G. Mouth: no sore throat, no bleeding gums, not dry buccal mucosa

H. Neck & Lymph Nodes: not enlarged lymph nodes, no stiff neck

I. Cardiovascular: tachycardia ( 96bpm), no chest pains, normal BP (110/60)

J. Breast: no nodules palpated, no discharge

K. Respiratory: no cough, dyspnea (35cpm), clear breath sounds

L. Gastrointestinal: Flat abdomen, NABS, tympanitic on percussion, no masses, no abdominal tenderness

M. Renal and Urinary: with FIC

N. Musculoskeletal: decreased muscle tone

O. Neurological: GCS score of 6 E1V1M4

ANATOMY AND PHYSIOLOGY OF THE PANCREAS

The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail).

The pancreas is made up of two types of tissue, the exocrine tissue, secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas and endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

The endocrine part of pancreas consists of pancreatic islets dispersed among the exocrine portion of the pancreas. The islets secrete two hormones, insulin and glucagon which function to help regulate blood nutrient levels, especially blood glucose. Alpha cells of the pancreatic islets secrete glucagon, and beta cells of the pancreatic islets secrete insulin.

The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum.

It is very important to maintain blood glucose levels within a normal range of values. A decline in the blood glucose level below its normal range causes the nervous system to malfunction because glucose is the nervous system’s main source of energy. When blood glucose decreases, fats and proteins are broken down rapidly by other tissues to provide an alternative energy source. As fats are broken down, some of the fatty acids are converted by the liver to acidic ketones, which are released into the circulatory system. When blood glucose levels are very low, the breakdown of fats can cause the release of enough fatty acids and ketones to cause the pH of the body fluids to decrease below normal, a condition called acidosis. The amino acids of protein are broken down and used to synthesize glucose by the liver.

If blood glucose levels are too high, the kidneys produce large volumes of urine containing substantial amounts of glucose. Because of the rapid loss of water in the form of urine, dehydration can result.

Insulin is released from the beta cells primarily in response to the elevated blood glucose levels and increased parasympathetic stimulation that is associated with digestion of meal. Increased blood levels of certain amino acids also stimulate insulin secretion. Decreased insulin secretion results from decreasing blood glucose levels and from stimulation by the sympathetic division of the nervous system. Sympathetic stimulation of the pancreas occurs during physical activity. Decreased insulin levels allow blood glucose to be conserved to provide the brain with adequate glucose and to allow other tissues to metabolize fatty acids and glycogen stored in the cells.

The major target of the insulin are the liver, adipose tissue, muscles, and the area of the hypothalamus that controls appetite, called satiety center. Insulin binds to membrane-bound receptors and, either directly or indirectly, increases the rate of glucose and amino acid uptake in these tissues. Glucose is converted to glycogen, or fat, and the amino acids are used to synthesize protein.

PRECIPITATING FACTOR:

- diet- lifestyle- trauma

Alteration of functioning by alpha & beta cells of the pancreas

Production of excess glucagon

Production of glucose from protein and fats stores

Wasting of lean body mass

↑ Ketones

Acidosis Acetone breath

Weight loss

Fatigue

Failure to produce insulin and/or insulin resistance

Elevated BG

Chronic Elevation of Blood Glucose

Glycoprotein cell wall deposits

Decrease circulation to the small vessels

MacroVascular Problems

Impaired Immune Function

Infection Delayed wound healing

Accelerated atherosclerosis

HPN

↓ Circulation on the kidneys

↑ Osmolality due to glucose

Polyphagia

Polyuria

Polydipsia

Weight loss

Diabetic nephropathy

Chronic Kidney Disease↓ GFR

↑ Creatinine Level and BUN

PATHOPHYSIOLOGY PREDISPOSING FACTOR:- Age- Heredity- Race- gender

LABORATORY ANALYSIS

HEMATOLOGY (May 01, 2010)

Test Result Normal Value Clinical SignificanceHemoglobin 117 120-170 g/dl Normal

Hematocrit .37 0.37-0.54 Normal

Platelet count 388 250-450 x 10 g/L Normal

Segmented neutrophils .92 0.5-0.7 Increased due to acute infectionLymphocytes 0.08 0.2-0.4 Increased due to acute infection

WBC 18.1 4.5-10x10g/L Leukocytosis may be due to infection and tissue damage

CLINICAL CHEMISTRY (May 01, 2010)

CLINICAL CHEMISTRY (May 05, 2010)

ECG (May 01, 2010)

Normal sinus rhythm 2.) Low voltage QRS in limb leads 3.) Prolonged QT intervals

ABG

May 01, 2010 pH 7.527 pCO2 44.6 pO2 123.1 HCO3 36.9 O2 Sat 98.9%May 01, 2010 pH 7.527 pCO2 44.6 pO2 123.1 HCO3 36.9 O2 Sat 98.9%

CHEST X-RAY (May 01, 2010)Atheromatous Aorta

Test Result Normal Value Clinical SignificanceSodium 155.71 137-147meq/L May be due to dehydration or diabetic acidosis

Potassium 2.66 3.8-5 meq/L May be due to dehydration or diabetic acidosis

Test Result Normal Value Clinical SignificanceSodium 139.00 135-155mmol/L Normal

Potassium 4.40 3.4-5.3mmol/L Normal

DRUG STUDY

Generic Name MeropenemBrand Name TienamClassification Anti-infectivesIndication Treatment of susceptible infections including intra-abdominal infections, meningitis, resp. tract infections, septicemia, skin in-

fections & UTI in immunocompromised patients.

Contraindication Hypersensitivity to amide type local anaesthesia Severe shock/heart block

Side Effect Thrombophlebitis, pain, induration, erythema, & tenderness following injection Rash, urticaria, pruritus GI disturbances, pseudomembranous colitis, hematological disturbances, confusional states Hearing loss, taste perversion

Client Teaching Advise breast feeding patient of risk of drug transmission to infant Instruct patient to report adverse reactions

Generic Name AllopurinolBrand Name AlluraseClassification Hyperuricemia and Gout preparation (Musculoskeletal)Indication Treatment of gout either primary or secondary to the hyperuricemia associated with blood dyscrasias & their therapy. Primary or

secondary uric acid nephropathy; recurrent uric acid stone formation.

Contraindication Children except those with hyperuricemia secondary to malignancy. Pregnancy and lactation, Idiopathic HemochromatosisSide Effect Skin rash; exfoliative rashes, Stevens-Johnson syndrome, toxic epidermal necrolysis may occur.

Fever, chills, leucopenia or leukocytosis, eosinophilia, arthralgia & vasculitis, GI disturbances, peripheral neuritis, alope-cia, headache, drowsiness & vertigo.

Client Teaching Advise patient to refrain from driving or performing hazardous tasks requiring mental alertness Advise patient taking allopurinol for recurrent calcium oxalate stones to reduce intake of animal protein, Na, refined

sugars, oxalate-rich foods, and calcium Tell patient to stop drug at first sign of rash. Which may precede severe hypersensitivity or other adverse reaction. Advise patient to avoid alcohol use during drug therapy.

Generic Name RanitidineBrand Name Zantac HClClassification AntacidIndication Adult duodenal & benign gastric ulcer

NSAID-associated peptic ulceration Duodenal ulcer associated with H. Pylori infection Post op ulcer Acute reflux esophagitis Symptomatic relief of GERD Chronic episodic dyspepsia Relief of heartburn, dyspepsia and hyperacidity

Contraindication Children below 16 yrs old Hypersensitivity to drug

Side Effect Vertigo. Malaise Blurred vision Reversible leucopenia, pancytopenia, thrombocytopenia Jaundice

Client Teaching Remind patient taking drug once daily to take it h.s. Instruct patient to take drug without regard to meals Urge patient to avoid cigarette smoking because it may increase gastric acid secretion and worsen disease

Generic Name Isophane Insulin suspensionBrand Name InsulatardClassification Antidiabetic drugsIndication Diabetes when prolonged action is required

DKA Hyperglycemia

Contraindication Hypoglycemia Side Effect Hypoglycemia, hyperglycemia (rebound or Somogyi effect)

Urticaria, itching, swelling, redness, stinging, warmth at injection site, rash Lipoatrophy, lipohyperthropy, hypersensitivity reactions, anaphylaxis, rash

Client Teaching Tell patient that insulin relieves symptoms but doesn’t cure disease Inform patient about nature of disease: importance of following therapeutic regimen; adherence to specific diet, weight re-

duction, exercise, and personal hygiene programs; and ways of avoiding infection. Review timing of injections and eating, and explain that meals must not be skipped.

Stress that accuracy of measurement is very important Advise patient not to alter order of mixing insulins or change model or brand of syringe needle. Tell patient that glucose monitoring and urine ketone tests are essential guides to dosage and success of therapy Stress the importance of recognizing hypoglycemic symptoms because insulin-induced hypoglycemia is hazardous and may

cause brain damage if prolonged.

NURSING MANAGEMENT

Blood glucose monitoring. The patient self monitoring of blood glucose enables the patient to make self management decision regarding exercise, diet, and meditation.

Foot care. Proper care of the feet is crucial for the patient with DM.

Exercise. Regular consistent exercise is considered an essential part of diabetes management.exercise contributes to weight loss, reduces triglycerides and cholesterol, increases muscle tone and improves circulation.

Effects of stress. Emotional and physical stress can increase blood glucose levels and result in hyperglycemia. Common stress-evoking situations include acute illness and the stress of surgery. The patient with diabetes who has minor illness such as cold or the flu should continue drug therapy and food intake.

HEALTH TEACHINGS

DO DON’TBLOOD GLUCOSE Monitor your blood glucose at home and record

results in a log Take insulin as prescribed Instruct family members in the use of glucagon

administration in the case of emergencies due to hypoglycemia

Skip doses of insulin especially when sick Run out of insulin Enroll in a fad diet Rub the area where insulin was administered

EXERCISE Learn how to exercise and food affect your blood glucose levels

Forget that exercise will lower glucose level Exercise if blood glucose levels are very elevated

this may lead to a temporary worsening of blood glucose level

DIET Follow diet, eating regular meals at regular times

Eat slowly and chew food thoroughly Choose foods low in saturated fats Limit the amount of alcohol intake Learn your cholesterol level

Eat fried foods Drink excessive amounts of alcohol because this

may lead to unpredictable low blood glucose reactions

OTHER GUIDELINES Obtain annual eye examination and urine testing for protein

Examine feet at home Wear comfortable fitting shoes to prevent foot

injury. Break in new shoes gradually Always carry identification of a diabetic patient Have other medical problems treated especially

high BP Know the symptoms of hypo and hyperglycemia Quit smoking

Smoke Apply hot or cold directly on the feet Go barefoot Ignore the symptoms of hypo and

hyperglycemia Put baby oil or lotion between toes

DISCHARGE GOALS

1. Homeostasis achieved.2. Causative/precipitating factors corrected/controlled.3. Complications prevented/minimized.4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.5. Plan in place to meet needs after discharge.

PROBLEM LIST

1. Ineffective airway clearance related to neuromuscular dysfunction as evidenced by GCS score of 6 E₁V₁M₄2. Impaired swallowing related to decreased strength or excursion of muscles involved in mastication3. Impaired physical mobility related to neuromuscular impairment as evidenced by GCS score of 6 E₁V₁M₄4. Hyperthermia related to infection as evidenced by increased WBC count (CBC dated 05/01/2010)5. Impaired skin integrity related to physical immobilization

Problems Nursing Diagnosis Rank JustificationHigh Blood GlucoseCBG >300

Unstable Blood Glucose related to inadequate blood glucose monitoring evidenced by elevated serum glucose levels

1

Diabetes Mellitus is the main problem. All other problems are complications of the disease.

Right hemiparesisFacial asymmetryInability to masticate

Impaired swallowing related to decreased strength or excursion of muscles involved in mastication 2

Food is one of the basic needs. Impairment of swallowing prevents intake of food orally which could lead to hypoglycemia, dehydration and malnutrition.

3x3cm sacral grade 3 ulcer Impaired skin integrity related to physical immobilization 3

High glucose levels impede wound healing therefore any type of wound should be given immediate attention.

GCS score E₁V₁M₄No activity

Impaired physical mobility related to neuromuscular impairment as evidenced by GCS score.

Non-ambulation may lead to serious complications such as pneumonia, pressure ulcers and bed sores. It may also aggravate problem number three.

GCS score E₁V₁M₄DroolingNGT inserted in left nostril

Risk for Aspiration related to presence of NGT 5

This is a risk diagnosis therefore, more immediate problems should be addressed first.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

S:“Hindi namin masyado namomonitor ung blood sugar nya. Minsan nakakalimutan,” as verbalized by patients son.

O:CBG results <300 mg/dL

Unstable Blood Glucose related to inadequate blood

glucose monitoring as evidenced by elevated serum glucose levels

After the nursing interventions, the

client will:

Maintain glucose in satisfactory range.

Relatives will:

Verbalize understanding on the importance of accurate CBG monitoring.

IndependentMonitor CBG regularly.

Monitor I&O accurately.

Observe for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness.

Collaborative

Give the right amount of feedings on time and according to dietary restrictions.

Administer prescribed insulin dosages on time.

Educate relatives on proper and accurate CBG monitoring, insulin administration and feeding.

To identify and manage glucose variations.

Increased urine output may be a sign of increased serum glucose levels.

Once carbohydrate metabolism resumes (blood glucose level reduced) and as insulin is being given, hypoglycemia can occur.

A diabetics diet is computed according to her needs to manage blood glucose levels

Insulin administration will help control glucose levels especiallly during feeding times

To identify and manage glucose variations at home.

The goal not met:

Patient’s serum glucose levels still above satisfactory range.

Goal met:

Relatives verbalized understanding on the importance of accurate CBG monitoring.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

O:Right hemiparesis

Facial asymmetry

Inability to masticate

Impaired swallowing related to decreased strength or excursion of muscles involved in mastication

After the nursing interventions, the

client will:

Maintain adequate hydration as evidenced by good skin turgor, moist mucous membranes, and individually appropriate urine output.

Achieve and maintain desired body weight.

Independent

During feedings, raise head of bed as upright as possibel with head in anatomic alignment and slightly flexed forward. Keep HOB elevated 30-45 mins after feeding, if possible.

Suction oral cavity PRN.

Monitor intake, output and body weight.

Provide oral hygiene at least three times a day.

To reduce the risk of regurgitation/aspiration.

Promotes airway safety.

To evaluate adequacy of fluid and caloric intake.

To prevent bacterial growth and halitosis.

The goal is met as manifested by:

Good skin turgor, moist mucous membranes and appropriate urine output.

Maintained body weight.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

O:No activity and ambulation

3x3 cm sacral grade 3 ulcer

2x1 cm grade 2 left ischial tuberosity ulcer

Impaired skin integrity related to physical immobilization secondary to starvation ketosis

After the nursing interventions, the client will:

Display timely healing of pressure sores without complications.

Independent

Assess blood supply and sensation in affected area.

Measure length, width, depth of ulcers. Note extent of tunneling/undermining if present.

Inspect surrounding skin for erythema, induration, maceration.

Periodically remeasure wound and observe for complications

Keep the area clean/dry, carefully dress wounds, prevent infection, manage incontinence, and stimulate circulation to surrounding areas

Use appropriate skin-protective agents for open wounds.

Reposition client every 2 hours.

Collaborative

Assist in wound debridement

To evaluate actual/potential for impairment of circulation.

To document status/provide baseline data for future comparisons.

To document status/provide baseline data for future comparisons.

To monitor progress of wound healing.

To assist body’s natural process of repair.

To protect wound and surrounding tissues.

To reduce pressure on compromised tissues.

To remove non-viable, contaminated, or infected tissue.

The goal is partially met:

Pressure ulcers are unchanged but without complications.

BIBLIOGRAPHY

Books:

Medical and Surgical Nursing 11th edition by Brunner and Suddart Essential of Anatomy and Physiology 5th edition by Kevin Patton Pharmacology 5th edition by Kee, Hayes, McCuistion Nurses pocket guide 10th edition by Doenges, Moorhouse, Murr Nursing Care Plans 6th edition by Doenges, Moorhouse, Geissler Clinical Companion to Medical Surgical Nursing 3rd Edition by Dirksen, Lewis Heithemper

Internet Sources: (Date Visited: August 8, 2009)

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