diabetes mellitus rizza (repaired) (1)

7/30/2019 Diabetes Mellitus Rizza (Repaired) (1)

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A Case Study about

DIABETES MELLITUS LEFT FOOT

Patio, Patrick Jazzen P.

Paz, Rizza Marie P.

Poquita, Sienna Rose C.

Ricafranca, Reylin Shalimar M.

Sakaluran, Nurmina B

Salazar, Kimberly P.

Samatra, Troy A.

Umayam, Cherry Ann D.

Velarde, Arnel T.

Adviser:

Ms. Susan C. Espadon, R.N MAN

Clinical Instructor


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TABLE OF CONTENTS

Acknowledgement

Abstract

I. INTRODUCTION

II. OBJECTIVES

1. General

2. Specific

III. SCOPE AND LIMITATIONS

IV. PATIENTS HEALTH INFORMATION

1. Patients Personal Profile

a. Name

b. Sex

c. Age

d. Height and weight

e. Marital/Family Status

f. Children

g. Residential Address

h. Admitting Diagnosis

i. Final Diagnosis

2. Chief Complaint or Presenting Complaint

3. History of Present Illness

3.1 Location and radiation of complaint

3.2 Severity of complaint

3.3 Timing or onset

3.4 Situation of onset

3.5 Duration of complaints

3.6 Previous similar complaints

3.7 Exacerbating and relieving factors

3.8 Associated symptoms patients

3.9 Explanation of complaint

4. Past Medical History

5. Family History /

6. Drug History

7. Genogram

8. Lifestyle History / Gordons Functional Pattern


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TABLE OF CONTENTS

V. GROWTHS DEVELOPMENT / MILESTONE


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TABLE OF CONTENTS

VI.

VII. PHYSICAL ASSESSMENT

VIII. VITAL SIGNS

IX. ANATOMY AND PHYSIOLOGY

X. SIGNS AND SYMPTOMATOLOGY

XI. PATHOPHYSIOLOGY

XII. COLLABORATIVE / MEDICAL MANAGEMENT

1. Symptomatic Approach

2. Laboratories / Diagnostic Proceeds

3. Drug Study

4. IV Therapy

5. Diet Therapy

6. Surgical Intervention/s

XIII. NURSING MANAGEMENT

a. NCP

b. Algorithm of Care

XIV. GLOSSARY

XV. BIBLIOGRAPHY

XVI. APPENDICES

1. Communication Letter

2. GCP Consultation Sheet

3. GCP Monitoring Sheet4. Researchers Profile


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ACKNOWLEDGEMENT

The members of this case study would like to extend their warmestgratitude to all the people who made the success of this case presentation areality.

First and foremost, to the Almighty Father, for His unceasing love and blessings,

for giving us enough power and fortitude to face all the hardships in the making of this

work. To Him, be all glory and praise!

Dean, Ms. Iris C. Castillon RN, RM, MAN, MaEd, for her vital encouragement

and support.

GCP adviser, Ms. Susan C. Espadon, RN MAN, thank you very much for being

there at all times and pushing us so hard beyond our limits, for her invaluable time,

knowledge and effort rendered to us. Most of all, for giving us the inspiration to finish this

seemingly impossible task.

Mr. Paul Obispo, RN MAN, III-2 class adviser, thank you for sharing your books

to us, and for encouraging us to be eager with our studies and for being supportive at all

times.

Clinical Instructors, thank you for extending your patience and imparting the

knowledge that we need.

Ms. Menchie P. Palmejar RN MAN, GCP Chairman, thank you for the inspiration

you extended, we will never forget you for the constant reminders and much needed

motivation.

To all the nurses and staff of Pasay City General Hospital, especially in the

Surgical Ward for giving us the opportunity to complete this endeavor.

To our dear parents, for their never ending support and understanding;

for always being there to guide us and care for us.

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The patient who marked a part of our hearts, for challenging us to do more to

maintain his normal condition.

To the group, we would like to recognize each other for our own radical efforts

in order to complete this case study, for sticking together through thick and thin and for

simply being there.

Lastly, to each and every one who helped us realize the importance of this case

presentation, may it be direct or indirect, no matter how minimal, the gratitude and

pleasure for the achievement of this task is ours to share.

ACKNOWLEDGEMENT II | P a g e


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CASE ABSTRACT

This is a case of patient N.L. 42 years old Male, Single, residing at Taft Avenue,

Pasay City. The patient was admitted at Pasay City General Hospital last January 18,

2013 at 9:25 pm with a chief complaint of 1 week fever with unrecalled Body Temp and

(+) pus on wound at left foot. Initial vital signs were taken Temp 38.2 C, PR 90 bpm, RR

20 cpm, BP 120/70. Initial medical diagnosis was diabetes mellitus left

foot. The patient was subjected for Urinalysis, Hematology, FBS Creatinine,

and Anterior Posterior Radiologic Exam on Left Foot.

Some complications that were displayed by the patient were infection, imbalance

nutrition more than body requirements, management includes; daily wound care,

continuous monitoring of the patients blood sugar and condition through laboratory test

results and assessment of symptoms as demonstrated by the patient.

In his 1 week of confinement in the hospital, the patients condition has improved.

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INTRODUCTION

Diabetes mellitus is a condition in which the pancreas no longer produces

enough insulin or cells stop responding to the insulin that is produced, so that glucose in

the blood cannot be absorbed into the cells of the body. Symptoms include frequent

urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet,

oral medications, and in some cases, daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset

or adult-onset diabetes, and this form of diabetes occurs most often in people who are

overweight and who do not exercise. Type II is considered a milder form of diabetes

because of its slow onset (sometimes developing over the course of several years) and

because it usually can be controlled with diet and oral medication. The consequences of

uncontrolled and untreated Type II diabetes, however, are the just as serious as those

for Type I. This form is also called noninsulin-dependent diabetes, a term that is

somewhat misleading. Many people with Type II diabetes can control the condition with

diet and oral medications, however, insulin injections are sometimes necessary if

treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear; however, there seem to be both

hereditary (genetic factors passed on in families) and environmental factors involved.

Research has shown that some people who develop diabetes have common genetic

markers. In Type I diabetes, the immune system, the bodys defense system against

infection, is believed to be triggered by a virus or another microorganism that destroys

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cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and

family history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells

have become resistant to the insulin produced and it may not work as effectively.

Symptoms of Type II diabetes can begin so gradually that a person may not know that

he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other

symptoms may include sudden weight loss, slow wound, urinary tract infections, gum

disease, or blurred vision. It is not unusual for Type II diabetes to be detected while a

patient is seeing a doctor about another health concern that is actually being caused by

the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include people

who:

are obese (more than 20% above their ideal body weight)

have a relative with diabetes mellitus

belong to a high-risk ethnic population (African-American, Native American,

Hispanic, or Native Hawaiian)

have been diagnosed with gestational diabetes or have delivered a baby

weighing more than 9 lbs (4 kg)

have high blood pressure (140/90 mmHg or above)

have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL

and/or a triglyceride level greater than or equal to 250 mg/dL

have had impaired glucose tolerance or impaired fasting glucose on previous

testing.

INTRODUCTION 2 | P a g e
http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/gestational-diabetes/http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/gestational-diabetes/


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Diabetes mellitus is a common chronic disease requiring lifelong behavioral and

lifestyle changes. It is best managed with a team approach to empower the client to

successfully manage the disease. As part of the team the, the nurse plans, organizes,

and coordinates care among the various health disciplines involved; provides care and

education and promotes the clients health and well being. Diabetes is a major public

health worldwide. Its complications cause many devastating health problems.

The major goal in treating diabetes is to minimize any elevation of blood sugar

(glucose) without causing abnormally low levels of blood sugar. Type 1 diabetes is

treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is treated first with

weight reduction, a diabetic diet, and exercise. When these measures fail to control the

elevated blood sugars, oral medications are used. If oral medications are still insufficient,

treatment with insulin is considered.

Adherence to a diabetic diet is an important aspect of controlling elevated blood

sugar in patients with diabetes. The American Diabetes Association (ADA) has provided

guidelines for a diabetic diet. The ADA diet is a balanced, nutritious diet that is low in

fat, cholesterol, and simple sugars. The total daily calories are evenly divided into three

meals. In the past two years, the ADA has lifted the absolute ban on simple sugars.

Small amounts of simple sugars are allowed when consumed with a complex meal.

Weight reduction and exercise are important treatments for diabetes. Weight reduction

and exercise increase the body's sensitivity to insulin, thus helping to control blood sugar

elevations.

http://www.medicinenet.com/script/main/art.asp?articlekey=47883http://www.medicinenet.com/script/main/art.asp?articlekey=320http://www.medicinenet.com/script/main/art.asp?articlekey=47883http://www.medicinenet.com/script/main/art.asp?articlekey=320


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According to the world health organization the 10 top death causes in the world

diabetes mellitus rank 9th disease of death in the middle income and 8 th on the the high

income countries and rank 9th around the world updated last June of 2011.

Fact sheet N310Updated June 2011

The 10 leading causes of death by broad income group (2008)

Low-income countries Deaths in millions % of deaths

Lower respiratory infections 1.05 11.3%

Diarrhoeal diseases 0.76 8.2%

HIV/AIDS 0.72 7.8%

Ischaemic heart disease 0.57 6.1%

Malaria 0.48 5.2%

Stroke and other cerebrovascular disease 0.45 4.9%

Tuberculosis 0.40 4.3%

Prematurity and low birth weight 0.30 3.2%

Birth asphyxia and birth trauma 0.27 2.9%

Neonatal infections 0.24 2.6%

Middle-income countries Deaths in millions % of deaths



Chronic obstructive pulmonary disease 2.79 7.2%



HIV/AIDS 1.03 2.7%

Road traffic accidents 0.94 2.4%


Diabetes mellitus 0.87 2.3%



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Middle-income countries Deaths in millions % of deaths

Hypertensive heart disease 0.83 2.2%

High-income countries Deaths in millions % of deaths



Trachea, bronchus, lung cancers 0.54 5.9%

Alzheimer and other dementias 0.37 4.1%



Colon and rectum cancers 0.30 3.3%


Hypertensive heart disease 0.21 2.3%

Breast cancer 0.17 1.9%

World Deaths in millions % of deaths






HIV/AIDS 1.78 3.1%

Trachea, bronchus, lung cancers 1.39 2.4%



Road traffic accidents 1.21 2.1%



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OBJECTIVES

GENERAL OBJECTIVES

We, the student nurses chose diabetes mellitus wagner left foot 4rth digit for our

Grand Case Presentation because it is a very interesting topic. In line with influenza,

bronchitis, diarrhea, and hypertension, diabetes is one of the common problems in the

country. In 2011, it ranked as 8th leading causes of mortality in the world as stated by

the world health organization. The objectives of this case study are the following:

1. Gain knowledge and deeper understanding of the disease process itself.

2. Provide the best nursing care for the client, and impart health teachings

regarding the clients condition to maintain an optimum level of functioning.

Specific objectives

Cognitive

Formulate an appropriate nursing care plan for the clients current condition.

Relate the present state of the client with her personal and pertinent family

history

Analyze and interpret vital signs and laboratory procedures to determine the

underlying cause of the clients condition.

Identify treatment modalities and its importance like drugs, diet and exercise.

Psychomotor

Give nursing care to our client; importance of proper hygiene, proper diet, and

proper wound care.

Gather a comprehensive assessment of the client.

Monitor and analyze laboratory values along with signs and symptom

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Apply and demonstrate what we have learned that may improve and help the

client to do her daily routines with her condition.

Affective

Gain camaraderie to our fellow students while learning.

Exchange knowledge to fellow students in providing care through discussions.

Develop our sense of unselfish love and empathy in rendering our nursing care

to our patient so that we may be able to serve our future clients with higher level

of holistic understanding as well as individualized care.

Gain cooperation with fellow students for mutual benefit to achieve a shared

goal.

Respect our differences so that we may be able to make this case presentation

possible.

OBJECTIVES 7 | P a g e


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SCOPES and LIMITATIONS

The scope of this study includes the collection of information specifically the

patients health condition. The study also includes the assessment of the physiological

and psychological status, adequacy of support systems and care given by the family as

well as health care providers and medical records. The patients actual problems for 7 days

including the initial assessment and its appropriate nursing intervention applied within his

stay at Pasay City General Hospital. And for the limitations of this case study includes that

we are not able to handle the patient from the time he came in the emergency room and

to his admission January 18, 2013 and to his operation. We only have the chance to

handle him on the 5 th day of his hospital confinement which was last January 23-24

2013. Daily monitoring was done until he was discharge last January 31 at the surgical

isolation ward. The patient was admitted again after a week February 7 during his opd

follow up to have further observation. The data we gathered is from the patient and to his

live in partner.

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PATIENTS PERSONAL PROFILE

Patients Personal Profile

Name: N.L.

Sex: Male

Age: 42 years old

Height: 54

Weight: 80 lbs

Marital Status: Single

Children: 0

Occupation: Driver

Residential Address: Taft Avenue, Pasay City

Admitting Diagnosis: DM Left foot

Final Diagnosis: DM Left foot

Surgical Intervention: (DM foot Left) E Disarticulation 4th digit left foot

Chief Complaint or Presenting Complaint

2 weeks remittent fever

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History of Present Illness

1 month PTA client had symmetrical swelling on his left and right foot up to hisknee. Client ignores it, no medication taken, no consultation was made.

3 weeks PTA, swelling was still present, according to the patient sloughing of

skin between the third, fourth and fifth digit of his Left foot occurs, he describe it similarto an athletes foot and foul odor was noted. He used to put cotton in between the third,fourth and fifth digit of his Left foot, when he remove the cotton, client noticed thepresence of pus so he cleaned it with Betadine and took antibiotic Amoxicillin 500 mg for7 days 2x a day. (Self medication) still no consultation was done.

2 weeks PTA patient N.L. experienced fever unrecalled body temp. MedicationParacetamol 500 tablet was taken whenever patient feels he has fever, still noconsultation was made.

One day PTA patient sought consultation at Zapote Community Hospital becauseof 2 weeks fever He was given medication Metformin 500 mg O.D., Tempra Tablet 500

mg and Clindamycin 300 mg 1 cap TID for his wound and was advice to come back aftera week.

Two hours PTA he sought consult at PCGH E.R. due to 2 weeks continuousfever accompanied by dizziness and was subsequently admitted.

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Past Medical History

According to our patient, Patient N.L. had fever, cough and colds during his

childhood and adult days. He doesnt experience any accident / injury / hospitalization

nor undergone any operation.

Social history

Patient is the fourth child among his 6 siblings, a College undergraduate of Patts

Aeronautics. He is single but is living with his live in partner for 7 years and they have no

children. The Ppatient is a Driver of a van with a route of Paliparan to Molino.

Personal History

He had no history of allergy to any food or dust. He started smoking when he

was 16 years old, consumes about 1-3 sticks per day and stop on his 21 years of age.

The patient also stated that he drinks alcohol occasionally and consumes 500 ml of

brandy. Patient N.L. is single but is living with his live in partner for 7 years and has no

children. Patient NL is a Driver of a van with a route of Paliparan to Molino. They have a

monthly income of 8000 per month. Due to insufficient financial problem, his eldest

brother who is working abroad helps him in his hospital needs. The patient includes

meat as part of his diet, he loves to eat hamburger and tapsilog. He drinks 8 glasses of

water a day and can consume 1 liter of soft drink a meal and prefers to drink energy

drink whenever he is on work. He goes to work every 5:00 pm 3:00 am. He usually

sleeps whenever he is at home. He stated that he has no active exercise. According to



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patient NL, he is a legitimate resident of Taft Avenue, Pasay City. Their community is set

in an urban environment. He lives in a two storey house, rented by him and his live in

partner, their house is situated in a neighborhood with peace and order maintained by

the Homeowners. The house is made of concrete. It is well ventilated provided with two

windows and the main door. It also comes with a bathroom. They get water from the

NAWASA as their water supply. Taking van and scooter is their means of transportation

and cellular phones are their means of communication.

Family History

The Patients family on his mother side has (-) history of asthma, (+)

Hypertension, (+) Diabetes Mellitus, (-) Thyroid Disorders, (-) Heredofamilial diseases

and has (-) history of asthma, and fathers side has (+) Hypertension, (-) Diabetes

Mellitus, (-) Thyroid Disorders, (-) Heredofamilial diseases.

Drug History

No previous drugs taken



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Family Genogram

(1925 1992) (1928 2000)Car Accident Cervical Spondylosis

(+) Hypertension (+) Hypertension(+) Diabetes

(+) Diabetes (+) Hypertension) (+) Diabetes(+) Hypertension

Male Female

Patient

Death

Unmarried Legends:

Married

PATIENTS PERSONAL PROFILE 13 | P a g


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Lifestyle History / Gordons Functional Health Pattern

Gordons Functional

Health Pattern

Before Hospitalization During Hospitalization

Activity-Exercise Pattern 1 month before

hospitalization patient can

still go to his work as a driver

but has hindrances on

walking because of his

bilateral edema below his

knee up to his foot

Ater operation patient can

stand but with the help of his

live in partner.

Health Perception-Health

Management Pattern

He is able to groom his self

independently, he doesnt

requires assistance in

bathing and dressing.

He is able to groom his self

independently. He doesnt

requires assistance in bathing

and dressing but requires

assistance in cleaning his

wound. Client regularly

follows physician order of

taking his medication alone.

His live in partner is very

supportive in taking care of

his needs.

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Elimination Pattern The patient can go to the

bathroom and defecates

every day usually in the

morning.

The patient can go to the

bathroom and defecates

every day usually in the

morning.Nutritional-Metabolic

Pattern

The patient can eat

independently and loves to

eat. The patient includes

meat and rice as part of his

daily diet, he loves to eat

hamburger and tapsilog. He

drinks 8 glasses of water a

day and can consume 1 liter

of softdrink a meal and

prefers to drink energy drink

whenever he is on work.

The patient is now aware of

his disease and now monitors

what he eats. He now prefers

to eat fruits.The patient still

can consume 8 glasses of

water a day and stops

drinking softdrinks and

energy drinks

Sleep-Rest Pattern He goes to work every 5:00

pm 3:00 am. He usually

sleeps whenever he is at

home. He sleeps around 4:00

am 12:00 pm and the 2:00

pm- 4:00 pm.

The patient can sleep at

around 10 pm and wakes up

early at 5 am. He takes 1 2

hours of nap in the afternoon.

He usually wakes up for

medication and when taking

his vital signs.

Cognitive-Perceptual

Pattern

He is able to express his self

verbally and is willing to

share what he feels and his

ideas.

He is able to express his self

verbally and is willing to

share what he feels and his

ideas.

Coping-Stress Pattern The patient makes himself Patient can now cope with his



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busy in his work and he loves

to watch television or

listening to the radio.

condition because of the

support of his partner and his

siblings.

Value-Belief Pattern Patient has not manifested

conflict between treatment

and his personal belief.

Patient and his family believe

in medical treatment. The

patient is just a normal

Roman Catholic Person that

knows God and just going to

church occasionally:

Birthdays, Christmas and

New Year with his family. He

also believed in superstitious

beliefs. His family believes in

GOD and his son Jesus

Christ and knows the

importance in his well being.

The patient and his family

are willing to cooperate to the

health care provider by

providing necessities and

assuring that the patient has

undergone the requested

laboratory examination. Still

patient has not manifested

conflict between treatment

given and he also can no

longer go to church to attend

mass but can just offer a

prayer.

Self-Perception-self-

Concept Pattern

The patient describe as an

industrious person. he used

to socialized with his friends

by drinking brandy

occasionally. His live I

partner and relatives is

always there to give support.

The patient is now aware of

his disease/condition and is

now open to maintain his

blood sugar level within

normal limit and is now ready

to have a healthy lifestyle.



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Sexual-Reproductive

Pattern

The patient had no children. The patient had no children.

Role-Relationship Pattern The patient is known as a

snob, strict and good person

but knows how to get along

with different types of people.

Patient's family is with him

during his confinement. They

are supportive in giving the

necessary needs and wishing

the patient to be well and to

recover soon.



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GROWTH and DEVELOPMENT / MILESTONE

Erik Eriksons Developmental Stage

Adapted and expanded to Freuds theory of development to include the life span,believing that people continue to develop throughout life.

Erickson envisions life as a sequence of levels of achievement. Each stagesignals a task that must be achieved. The resolution of the task can be complete, partial,or unsuccessful, Erickson believes that the greater the task achievement, the healthierthe personality of the person; failure to achieve the next task. These developmentaltasks can be viewed as a series of crises and successful resolution of these crises issupportive to the persons ego. Failure to resolve the crises is damaging to the ego.

Stage

Competence:

Industry vs.

Inferiority

(Latency, 5-12

years)

Children start recognizing their

special talents and continue to

discover interests as their

education improves. They may

begin to choose to do more

activities to pursue that interest,

such as joining a sport if they

know they have athletic ability,

or joining the band if they are

good at music. If not allowed to

discover own talents in their own

time, they will develop a sense

of lack of motivation, low self-

esteem, and lethargy. They maybecome couch potatoes" if they

are not allowed to develop

interests.

At this stage the client had

been encourage making and

doing things and had been

praised for his accomplishments.

At this stage also the client starts

his studies at Elementary and

High School at Misamis,

Mindanao. The client began to

demonstrate industry by being

diligent, persevering at tasks until

finished and putting work before

pleasure. At the age of 7 the

client start to plays Filipino

games like Patentero, Luksongbaka and Tumbang preso with

his friends. And in this stage he

starts to learn different house

hold chores.

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Fidelity: Identityvs. RoleConfusion(Adolescence,13-19 years)

Superego identity is the

accrued confidence that the

outer sameness and continuity

prepared in the future are

matched by the sameness and

continuity of one's meaning foroneself, as evidenced in the

promise of a career. The ability

to settle on a school or

occupational identity is pleasant.

In later stages of Adolescence,

the child develops a sense

of sexual identity. As they make

the transition from childhood to

adulthood, adolescents ponder

the roles they will play in the

adult world. Initially, they are apt

to experience some role

confusion mixed ideas and

feelings about the specific ways

in which they will fit into society

and may experiment with a

variety of behaviors and

activities (e.g. tinkering with

cars, baby-sitting for neighbors,

affiliating with certain political or

religious groups. Identity Crisis.This turning point in human

development seems to be the

reconciliation between 'the

person one has come to be' and

'the person society expects one

to become'. This emerging

sense of self will be established

by 'forging' past experiences

with anticipations of the future.

In relation to the eight life stages

as a whole, the fifth stage

corresponds to the crossroads.

In this stage of his life the

patient starts to be independent

and at this time the client is

studying at PATTS College of

Aeronautics. In this stage the

client also start experiencinggreat body changes

accompanying puberty, the

ability of the mind to search

ones own intensions and the

intentions of the others, the

suddenly sharpened awareness

of the role society has offered for

later life. At this stage the client

enjoys his teenage life. At the

age of 15 the client had his

girlfriend at the same age. He

had explore his life same like

what a teenagers did. He drinks

occasionally with his friends, go

some party and all the alike.

Love: Intimacyvs. Isolation(Youngadulthood, 20-24, or 20-35

Once people have established

their identities, they are ready to

make long-term commitments to

others. They become capable of

In this stage the client had his

live in partner but they dont have

child since they have been

together. They decided to be

GROWTH and DEVELOPMENT / MILLESTONE 19 | P a g e


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years) forming intimate, reciprocal

relationships (e.g. through close

friendships or marriage) and

willingly make the sacrifices and

compromises that such

relationships require. If peoplecannot form these intimate

relationships perhaps because

of their own needs a sense of

isolation may result.

independent so that they prefer

to rent a house. The client had

his job as a driver of Public VAN

(Paliparan-Molino) while his

housewife is a plain housewife.

Care:Generativity vs.Stagnation(Middleadulthood, or35-64 years)

Generativityis the concern of

guiding the next generation.

Socially-valued work and

disciplines are expressions of

generativity. Simply having or

wanting children does not in andof itself achieve generativity.

The adult stage of generativity

has broad application to family,

relationships, work, and society.

Generativity, then is primarily

the concern in establishing and

guiding the next generation...the

concept is meant to include.

productivity and creativity

By this time they cant provide

all their hospital needs and asks

help to the patients elder brother.

They spent more time taking

care of his condition thats why

they are more intact to eachother. At the age of 42 the client

still works as a driver but since

he is hospitalized he cant go to

work.

GROWTH and DEVELOPMENT / MILLESTONE 20 | P a g e
http://en.wikipedia.org/wiki/Generativityhttp://en.wikipedia.org/wiki/Generativityhttp://en.wikipedia.org/wiki/Generativity


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PHYSICAL ASSESSMENT

Affected Part

Wound Assessment - Diabetes Mellitus ( Left Foot)

Part

Assessed

Assessment

Findings

Actual

Findings

Implication

Neuropathic

pain

Burning, stinging,

shooting and

stabbing (non-

stimulus

dependent)

Stinging May take place at the central level

after peripheral nerve damage.

Local pain Deep infection or

Charcot joint

Deep

infection

Theres a new areas of break-

down Probes to bone (increased

risk in the presence of

osteomyelitis)

Size Length, width,

depth and location,

preferably with

clinical photograph

Length: 12

cm

Width: 5 cm

Location:

left foot

It implicates that theres a deep

infection occurs.

Wound Bed Appearance

Black (necrosis)

Yellow, red, pink

Undermined

Black

(necrosis)

due to the disruption of cells.

Source: Pocket Guide improved Patient Outcomes For Diabetic Foot

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PHYSICAL ASSESSMENT

Infection

Signs

Odor

Be aware that

some signs (fever,

pain, increased

white blood count/

ESR) may be

absent. Evaluate

the ulcer for signs

of infection,

inflammation and

Edema

(+) foul

odor

(+) edema

(+) redness

Infected wounds replicating

organisms exist and tissue is

injured and lead to poor healing.

Exudate Copious,

moderate, mild,

none

Copious Consistent with more severe

infections, and is commonly

referred to as pus.

Wound edge Callus and scale,

maceration,

erythema, edema

(+) callus

and scale

(+)

maceration

(+)

erythema

(+) edema

a sign that the newly

formed epithelial cells have

migrated down and

around the wound edge because

they could not

connect to moist, healthy,

granulation tissue in the

wound bed.

PHYSICAL ASSESMENT 22 | P a g e
http://en.wikipedia.org/wiki/Pushttp://en.wikipedia.org/wiki/Pus


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PHYSICAL ASSESSMENT

Physical Examination and Health Assessment(NANDA ASSESSMENT TOOL)

Pathologic AssessmentDate Performed: January 26, 2013

Circulation

Part Assessed Normal Actual Implication

Color

Skin Color depends on race,

can be whitish, pink,

brown shade to black

Pale This is due to decrease

blood circulation

B. Mucous

Membrane

Mucous is pinkish and

moist

Pale This is due to decrease

blood circulation

C. Lips Pink, moist and smooth Pale This is due to decrease

blood circulation

D. Nail bed Nail bed is pinkish Pale This is due to decrease

blood circulation

E. Conjunctiva Conjunctiva is pink, clear,

moist and has small

blood vessels

Pale

conjunctiva

This is due to decrease

blood circulation

F. Sclera Color is white few visible

small vessels

Color is white

few visible

small vessels

Normal

Blood Pressure

A. Lying N: 90/60-130/90mmhg R: 120/80

L: 130/90

Blood pressure is within

normal



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PHYSICAL ASSESSMENT

Pulses

A. Carotid:

B. Temporal

C. Jugular

D. Radial

E. Popliteal

F. Post-tibial

G. Dorsalis pedis

Pulse quality

0= pulse not palpable or

absent

+1= weak, thread pulse,

difficult to palpate,

obliterate with pressure

+2= diminished pulse,

cannot be obliterate

+3= easy to palpate, full

pulse:cannot be

obliterate

+4= strong, bounding

pulse: maybe abnormal

+3

+3

+3

+3

+3

+3

+1

Pulses are within normal

except the pulse in dorsalis

pedis, it is weak, thready

pulse, difficulty to palpate

obliterated with pressure.

Heart Sound

A.Rate 60-100 bpm 80 Normal

B. Rhythm Regular Regular Normal

C. Murmur No murmur No murmur Normal

Jugular Vein

A. Jugular vein

distention

None None Normal

Breath sound

Breath sounds Bronchial or tubular

(trachea part)

Bronchovesicular (1st

and 2nd interspaces

anteriorly and scapula

posteriorly)

No presence of

breath sound on

the lungs

Normal



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PHYSICAL ASSESSMENT

Vesicular (lung

periphery)

Extremities

A. Temperrature Warm to touch Warm to touch Normal

B. Capillary Refill Blanch test results to

nail that returns to its

color instantly upon

release


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PHYSICAL ASSESSMENT

VARIATIONS IN NORMAL VITAL SIGNS

AGE TEMPERATURE(Celsius andFahrenheit)

PULSE(Average andRanges)

RESPIRATION(Average andRanges)

BLOODPRESSURE(mmHg)

Newborns 36.8(98.2)(axilliary)

130(80-180) 35(30-80) 73/55

1 year 36.8(98.2)(axilliary)

120(80- 140) 30(20-40) 90/55

5-8 years 37(98.6) 100(75-120) 20(15-25) 95/57

10 years 37(98.6) 70(50-90) 19(15-25) 102/62

Teen 37(98.6) 75(50-90) 18(15-20) 120/80

Adult 37(98.6) 80(60-100) 16(12-20) 120/80

OlderAdult(>70

years)

37(98.6) 70(60-100) 16(15-20) Possibleincreaseddiastolic

Source: (KOZIER, FUNDAMENTALS OF NURSING, SEVENTH EDITION 2004

26 | P a g e


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BODY TEMPERATURE

On Jan 18 client was brought to PCGGH with a chief complaint of fever (remittent) that last for 2 weeks with a Temperature of38.5. The temperature comes down but not reaching the normal 37.8 38. 5.

Implications: Lifted from patients cart an indication of infection due to presence of wound on his Left foot

Intervention: Paracetamol 500 mg. tab for fever was given as ordered.

January 19, 2013 (Lifted from patients chart) at temp ranges from 38.2 38. Still febrile

Intervention: TSB given by the relative

Jan 20, 2013 clients temp is within normal

VITAL SIGNS 27 | P a g e


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Jan 23 (duty days we handled the client P op disarticulation of the 4 th digit of left foot. Clients temp ranges from 36.1 to 36.7.

Despite of the patient post op procedure clients temp is within normal



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CARDIAC PULSE

All cardiac and pulse rate were within normal limit



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RESPIRATORY RATE

All respiratory rate were within normal



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BLOOD PRESSURE

Increse Bp is due to viscosity of blond because of infection that the pstientcant give.



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ANATOMY and PHYSIOLOGY

a. Normal

Pancreas is an organ situated in the upper part of ones abdomen. It is about

6 inches or 15 cms long and has a flattened bulbous head that is surrounded by part of the

intestine called duodenum, a narrow body that lies behind the stomach and a tapered tail

that rests on the front of the left kidney.

Pancreas is one of the organs in the body that has both exocrine and

endocrine functions.

Exocrine Pancreas

Secretion of water and electrolytes originates in the centroacinar and intercalated

duct cells

Pancreatic enzymes originate in the acinar cells

Final product is a colorless, odorless, and is osmotic alkaline fluid that contains

digestive enzymes (amylase, lipase, and proteases)

500 to 800 ml pancreatic fluid secreted per day

Alkaline pH results from secreted bicarbonate which serves to neutralize gastric acid

and regulate the pH of the intestine

Enzymes digest carbohydrates, proteins, and fat

ANATOMY and PHYSIOLOGY 32 | P a g e


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Enzymes

Amylase

o only digestive enzyme secreted by the pancreas in an active form

o functions optimally at a pH of 7

o hydrolyzes starch and glycogen to glucose, maltose, maltotriose, and

dextrins

Lipase

o function optimally at a pH of 7 to 9

o emulsify and hydrolyze fat in the presence of bile salts

Proteases

o essential for protein digestion

o secreted as proenzymes and require activation for proteolytic activity

o duodenal enzyme, enterokinase, converts trypsinogen to trypsin

o Trypsin, in turn, activates chymotrypsin, elastase, carboxypeptidase, and

phospholipase

Within the pancreas, enzyme activation is prevented by an antiproteolytic

enzyme secreted by the acinar cells.

Endocrine Pancreas

Accounts for only 2% of the pancreatic mass

Nests of cells - islets of Langerhans

It secretes two important hormones namely - Insulin and Glucagon which are

essential for regulation of glucose in the blood.

Four major cell types



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Alpha (A) cells secrete glucagon

Beta (B) cells secrete insulin

Delta (D) cells secrete somatostatin

F cells secrete pancreatic polypeptide

Insulin

o Synthesized in the B cells of the islets of Langerhans

o 80% of the islet cell mass must be surgically removed before diabetes

becomes clinically apparent

o Proinsulin, is transported from the endoplasmic reticulum to the Golgi

complex where it is packaged into granules and cleaved into insulin and a

residual connecting peptide, or C peptide.

o Major stimulants:

Glucose, amino acids, glucagon, GIP, CCK, sulfonylurea

compounds, -Sympathetic fibers

o Major inhibitors:

somatostatin, amylin, pancreastatin, -sympathetic fibers

Glucagon

o Secreted by the A cells of the islet

o Glucagon elevates blood glucose levels through the stimulation of

glycogenolysis and gluconeogenesis

o Major stimulants

Aminoacids, Cholinergic fibers, -Sympathetic fibers

Major inhibitors

Glucose, insulin, somatostatin, -sympathetic fibers



42/88

Somatostatin

Secreted by the D cells of the islet

Inhibits the release of growth hormone

Inhibits the release of almost all peptide hormones

Inhibits gastric, pancreatic, and biliary secretion

Used to treat both endocrine and exocrine disorders



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SIGNS AND SYMPATOLOGY

THEORETICAL PATHOGNOMONIC

Polyuria (increased urination) (+)

Polydipsia (increased thirst) (+)

Polyphagia (increase appetite) (+)

Fatigue (+)

Weakness (+)

Sudden vision change (+)

Tingling, numbness in hands (-)

Tingling, numbness in feet (+)

Dry skin (+)

Skin lesion (+)

Wound that are slow in healing (+)

Weight loss (+)

Nausea (-)

Vomiting (-)

Abdominal pain (-)

36 | P a g e


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PATHOPHYSIOLOGY

37 | P a g e

Predisposing factor:

Heredity

Age: 42 years old

Gender: male

Precipitating factor:

Obesity

Excessive intake of carbonated drinks

Beta cell dysfunction from islet of langerhans

Insufficient insulin secretion

Insulin resistant (insulin receptor defect)

Impaired process of glucose to glycogen to enter inside the cell

hyperglycemia

Increased insulin demand

Decreased protein synthesis

polyphagia

fati ue

Cellular starvation

Intracellular:hypoglycemia

polydipsia

Increased blood viscosity

Decrease renal thresholdDehydration of cells

Hyperosmotic plasma

Extracellular:hyperglycemia

glucosuria


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PATHOPHYSIOLOGY 38 | P a g e

Decrease gammaglobulins,

susceptibility to infection

Impaired wound healing

Osmotic diuresis

-polyuria

nephropathy

angiopathyneuropathy

DM type 2

Impaired sensation

of the feet

motorsensory

Altered oxygen distribution

Muscle wasting

Cell injury

Increase creatinineleve of

151.3 normal value 58.0-96.0

Decrease circulation inperipheral area

peripheral

Venous insufficiency

ischemia

Tissue damage

DM foot

Gangrene (local death of soft tissues

(+) pus

blood streak

change in skin color

due to loss of blood supply)

(+) swelling

+ wounds

inflammation

infection

hypoxia


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LABORATORIES

COLLABORATIVE / MEDICAL MANAGEMENT

URINALYSIS

Patient Name: NLWard: ER

Date: January 18, 2013

URINALYSIS

Procedure Actual

Values

Normal

Values

Interpretation

Color Dark Yellow

to amber

Pale yellow

to amber

Normal

Character cloudy Clear to

slightly hazy

Normal

Reaction /pH

3.0 4.5-8.0 Normal

SpecificGravity

1.030 1.015-1.025 Normal

Sugar +2 Negative Increase Blood

Sugar l

Indicates Increasedlevels withhyperglycemia mayindicate diabetesmellitus

Protein +1 Negative Increased

Protein

If protein is found in yoururine, diabetic kidneydisease is likely to bepresent

Blood +1 Negative

Leukocytes +1 Negative Increased

leukocytes

A positive leukocyteesterase test resultsfrom the presence of

white blood cells eitheras whole cells or aslysed cells.

Nitrate +2 Negative Increased

Nitrate

A positive nitrite testindicates that bacteriamay be present insignificant numbers inurine

39 | P a g e


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Pus cells 10 15 /hpf 0-8 Increased Pus

Cells

Kidney stones: Stonescause irritation andinflammation in theurinary tract which canlead to pus cells in urine.Kidney stones nearly

always also cause theappearance of red bloodcells (RBCs) in urine

RBC 8 12 / hpf 0-5 Increased RBC Hematuria is thepresence of abnormalnumbers of red cells inurine

MucusThreads

Few Few Normal threads may beoccasionally present innormal personsespecially whendehydrated.and this

indicates to some sort ofinfection, irritation

EpithelialCells

moderate Few Epithelial cells are liningcells, no big deal

Bacteria abundant Few Presencce of bacteria.

Urates /Phosphate

many Few Occasional uratecrystalsand oxalate crystals maybe present in normalindividuals dueto dehydrationand there

by leading toconcentrated urine.Presence of Bacteriumis suggestive ofinfection.

LABORATORIES 40 | P a g e
http://www.healthcaremagic.com/topics/oxalate/4356http://www.healthcaremagic.com/topics/dehydration/91http://www.healthcaremagic.com/topics/oxalate/4356http://www.healthcaremagic.com/topics/dehydration/91


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January 18, 2013Ward: ER

HEMATOLGY

Procedure ActualValues

NormalValues

Interpretation Implication

RH Typing positive

Hemoglobin 147 140-180g\l

normal

HCT 0.40 0.40-0.54 normal

RBC 4.98 4.5-6.5x10/L

normal

WBC 8.6 5-10x10/L

Normal

Segmenters 0.73 0.55-0.65 Increased

segmenters

Increasedsegmenters

indicates patienthas signs ofinfection

Lymphocytes

0.22 0.25-0.35 Decreased

lymphocytes

Low lymphocytescount (LLC), asurrogate forinflammation.

Monocytes .10 0.02-0.06 Increased

monocytes

The high and lowresponderphenomenon ofmonocytes tissuefactor (MTF)

activity has beenattributed toeffects onmonocytes bygranulocytes,Platelets andLipopolysaccharide(LPS)

PlateletCount

304 Induction ofhyperglycemia hasbeen shown toincrease platelet P-

selectin expression (asurface adhesionmolecule) in patients

with DM.



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January 18, 2013 Blood Typing O - POSITIVE

X-Ray: -left foot

Patient: NLAge: 42 y.oDate: January 18, 2013Ward: ER

Results: Single AP view of the Left foot shows no fracture or dislocation.

Diffuse soft tissue swelling seen.

Blood Chemistry

Patient Name: NLWard: SurgicalDate: January 19, 2013

TEST NORMAL

VALUE

RESULT Implication Analysis

GlucoseFBS

4.10mmol/L

5.90mmol/L

13.40 increase Indicates

hyperglycemia

Bloodureanitrogen

2.80mmol/L

7.20mmol/L

12.03 Increase kidneysare not

able to remove

urea from

the blood normally

Creatinine 58.0umol/L

96.0umol/L

151.3 Increase may mean

kidneys are not

working properly

http://www.webmd.com/urinary-incontinence-oab/picture-of-the-kidneyshttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/urinary-incontinence-oab/picture-of-the-kidneyshttp://www.webmd.com/heart/anatomy-picture-of-blood


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Blood Chemistry

Patient Name: NLWard: SurgicalDate: January 20, 2013

TEST NORMALVALUE

RESULT Implication Analysis

HBA1C 4.2 6.2 % 5.2 normal This indicates that the patient had

normal glucose in the past 3 months.

January 22, 2013Ward: Surgical

HEMATOLGYProcedure Actual

ValuesNormalValues

Interpretation Implication

RH Typing positive

Hemoglobin 100 140-180g\l

decreased Decreased redblood cell count:Anaemia- a lack ofred blood cells, whichcan lead to adeficiency inoxygen-carrying

ability.HCT 0.30 0.40-0.54 decreased Lowered hematocrit

can simplysignify hemorrhage

Post Operative Findings:

January 22, 2013Necrotic Tissue, plantar aspect less edematous tissue up to ankle

http://en.wikipedia.org/wiki/Hemorrhagehttp://en.wikipedia.org/wiki/Hemorrhage


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HGT Monitoring

5 am 6 am 5 pm

01-20-13 271 mg/dl

01-21-13

01-22-13 155 mg/dl - 198mg/dl

01-23-13 - 134 mg/dl -

01-24-13 refused - -

01-25-13 - - refused

01-26-13 134 mg/dl - -

01-27-13 refused - -

01-28-13 147 mg/dl - -

01-29-13 127 mg/dl - -



52/88

DRUG STUDY

Paracetamol 500 mg PRN

Started: January 18, 2013 (8:00 pm) at ER

Generic Name Mechanism ofAction

Indication Side effects NursingResponsibilities

Acetaminophen(APAP, Paracetamol)

Tempra, Tylenol

Unknown.Thought to produceanalgesia byblocking painimpulses byinhibiting synthesisof prostaglandin inthe CNS or of othersubstances thatsensitize painreceptors tostimulation. Thedrug may relievefever throughcentral action in the

hypothalamic heat-regulating center.

Mild pain or fever Hematologic: hemolyticanemia neutropenia,leukopenia, pancytopeniaHepatic: jaundiceMetabolic: hypoglycemiaSkin: rash urticaria

Monitor for S&S of:hepatotoxicity, even withmoderateacetaminophen doses,especially in individuals

with poor nutrition orwho have ingestedalcohol over prolongedperiods; poisoning,usually from accidentalingestion or suicideattempts; potentialabuse frompsychologicaldependence (withdrawal

has been associatedwith restless and excitedresponses).

45 | P a g e


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TT 0.5 SQ




Tetanus Toxoid Promotes

immunity to tetanusby inductingantitoxin

Primary immunization to

prevent tetanus

CNS: slight fever,headache, seizures,malaise, encelopathyCV: tachycardia,hypotension, flushingMusculoskeletal: aches,painSkin: erythema,induration, nodule atinjection site, urticaria,pruritusOther: chills, anaphylaxis

Obtain history of

allergies and reaction toimmunizationKeep epinephrine1:1000 available to treatanaphylaxis

DRUG STUDY 46 | P a g e


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ATS 6,000 TIM (-) ANST



Generic Name Mechanism of Action Indication Side effects Nursing responsibilities

GENERIC NAME:Anti-tetanus serum

GENERAL

CLASSIFICATION:

EPI vaccine, Anti-

tetanus

The toxin appears toact by selective

cleavage of a protein

component of synaptic

vesicles, synaptobrevi

n II, and this prevents

the release of

neurotransmitters by

the cells.

Tetanus Toxoid isto prevent an

individual from

contracting tetanus.

This medication is

given to provide

protection

(immunity) against

tetanus

CNS: Mild fever, joint pain,muscle achesGI: nausea, vomiting,abdominal pain, diarrheaHematologic:transientleukopenia, easinophiliaHepatic: jaundiceSkin:maculopapular rash,urticaria

Shake well the vial beforewithdrawing each dose

Special care should be

taken to ensure that the

injection does not enter

the blood vessel
http://en.wikipedia.org/wiki/Tetanushttp://www.medicinenet.com/script/main/art.asp?articlekey=8142http://www.medicinenet.com/script/main/art.asp?articlekey=361http://en.wikipedia.org/wiki/Tetanushttp://www.medicinenet.com/script/main/art.asp?articlekey=8142http://www.medicinenet.com/script/main/art.asp?articlekey=361


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Drugs given at the Ward

Ketorolac 50 mg Q8

Started: January 18, 2013

Ended: January 22, 2013 (13 doses)


Indication Side effects Nursing Responsibilities

KetorolacTromethamine

Toradol

CLASSIFICATION:Nonsteroidal anti-inflammatory agents,nonopioidanalagesics

May inhibit

prostaglandinsynthesis toproduce antiinflammatory,analgesic, andantipyretic effects.

Pain CV: thrombophlebitisGI: nausea, vomiting,abdominal pain, diarrheaHematologic:transientleukopenia, easinophiliaHepatic: jaundiceSkin:maculopapular rash,urticariaOther: anaphylaxis

Assess pain (note type, location,

and intensity) prior to and 1-2 hrfollowing administration Ketorolactherapy should always be giveninitially by the IM or IV route. Oraltherapy should be used only as acontinuation of parenteral therapy.- Caution patient to avoid concurrentuse of alcohol, aspirin, NSAIDs,acetaminophen, or other OTCmedications without consultinghealth care professional.- Advise patient to consult if rash,itching, visual disturbances, tinnitus,

weight gain, edema, black stools,persistent headche, or influenza-likesyndromes (chills,fever,musclesaches, pain) occur.



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Co Amoxiclav 1.2 g TIV Q6



Generic Name Mechanism of

Action

Indication Side effects Nursing

ResponsibilitiesAmoxiclav

Brand NameAmoclav

Classification:Bactericidal

Inhibits enzymes

involved informationof peptidoglycanlayer of bacterialcell wall. No effecton human cell walls

skin & soft tissue

infections, post-surgical procedures,

Skin: itching, rashes,CNS: Hepatic: jaundiceSkin: Erythema, dermatitisGI: Diarrhea, vomiting

before giving drug ask

patrient about allergicreactions to drug.

Instruct patient to take

food to prevent GI upset

Watch out for rash

occurring that willindicate allergic reaction.



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Sitaglipin 50 mg / tab i tab P.O.




Action


Responsibilities

Sitaglipin

Brand NameJanuvia

helps control

blood sugar levels.It works byregulating the levelsof insulin your bodyproduces aftereating.

Sitagliptin is for people

with type 2 diabetes.Sitagliptin is sometimesused in combination withother diabetesmedications, but is not fortreating type 1 diabetes.

Skin: hivesRespiratory: difficultybreathingImmunology: swelling ofyour face, lips, tongue, orthroatHepatic: pancreatitisGI: nausea and vomiting,loss of appetite;GU: urinating less thanusual or not at all;

Monitor Blood Glucose



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Clindamycin300 mg / tab 1 cap TID P.O.




Action


Responsibilities

ClindamycinHydrochloride

Brandname:Dalacin C

inhibits bacterial

protein synthesis bybinding to the 50ssubunit of theribosimes

infections caused by

sensitive staphylococci,streptococci,pneumococci, bacteroidesand other sensitiveaerobic and anerobicorganisms.

CV: thrombophlebitisGI: nausea, vomiting,abdominal pain, diarrheaHematologic:transientleukopenia, easinophiliaHepatic: jaundiceSkin:maculopapular rash,urticariaOther: anaphylaxis

monitor renal, hepatic

and hematopoieticfunctions duringprolonged

Observe patient for

signs and symtoms ofsuperinfection



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Metformin 500 mg / tab P.O. O.D.




Action


ResponsibilitiesMetforminHydrochloride

Brandname:Fortamet,Glucophage

Decreases hepatic

glucose productionand intestinalabsorption ofglucose andimproves insulinsensitivity(increasesperipheral glucoseuptake and use)

adjunct to diet to lower

glucose level in patientswith type 2 (non insulindependent) diabetes.

GI: diarrhea nausea,vomiting, abdominalbloating, flatulence,anorexia, taste perversion.Hematologic:megaloblastic, anemiaMetabolic: lactic acidosis,hypoglycemia

Give with meals.

Maximum does may bebetter tolerated if totaldose is divided in thricea day dosing and given

with meals.

Monitor patients

glucose level regularly toevaluate effectiveness oftherapy.

Notify prescriber if

glucose level increasesdespite therapy



60/88

Metronidazole 500 mg TIV Q6




Action


ResponsibilitiesMetronidazole

Brand Name:Flagyl, Metrogyl

Classification:Anti Bacterial

Direct-acting

trichomonocide andamebecide that

works inside andoutside theintestines. \Itsthought to entercells ofmicroorganismsthatcontainnitroeductase,forming unstablecompounds thatbind to DNA and

inhibit synthesis,causing cell death

Bacterial infections

caused by anaerobicmicroorganismTo prevent postoperativeinfection in contaminatedor potentiallycontaminated surgery

CNS: fever, vertigo,headache, ataxia,dizziness, syncope,incoordination, confusion,irritability depression,

weakness, insomniaseizures, peripheralneuropathyCV: flattened T wave,edema, flushing,thrombophlebitis after IVinfusionEENT: rhinitis, sinusitis,pharyngitisGI: abdominal crampingorpain, stomatitis, vomitingGU: darkened urine,polyuria, dysuria, cystitisHematologic:transientleukopenia, neutropeniaMusculuskeletal: fleeting

joint painsRespiratory: URTISkin: rash

give oral form with

meals.

Observe patient for

edema, especially if hisreceiving corticosteroids;Flagyl IV may cause Naretention.

Tell patient to avoid

alcohol and alcoholcotaining drugs duringfor atleast 3 days aftertreament course.

Tell patient he may

experience a metalictaste and dark or redbrown urine.



61/88

Humulin r 10 units


Generic Name Mechanism Action Indication Side Effects NursingResponsibilities

Insulin

Humulin R Regular

Increases glucosetransport acrossmuscle and fat cellmembranes toreduce glucose level,promotes conversionof glucose to itsstorage form.Glycogen: triggersamino acid uptakeand conversion toprotein in musclecells and inhibits

release of free fattyacids from adiposetissue; andstimulates lipoproteinlipase activity; whichconverts circulatinglipoprotein lipaseactivity, whichconverts circulatinglipoproteins to fatty

Controlhyperglycemia withhumalog andsulfonylureas inpatients with type 2diabetes mellitus

Methabolic:hypoglycemia,hyperglycemia,hypomagnesemia,

hypokalemia

Skin: Rash, urticaria,pruritus, swelling,redness, stinging,warmth, at injectionsites.

Others: Lipoatrophy,lipohypertrophy,hypersensitivityreaction,anaphylaxis,

Make sure patientknows that drugrelieves symptomsbut doesn't curedisease

Stress that accuracyof measurement isimportant, especiallywith concentratedregular insulin, aids,such as magnifying

sleeve or dosemagnifier, mayimprove accuracy,show patient andcaregivers how tomeasure and giveinsulin



62/88

acid Advise patient toavoid vigorousexercise immediatelyafter insulin injection,especially of the areawhere injection wasgiven, because itincrease absorptionand risk of highglucose episodes



63/88

Fusidate sodium 5 grams, topical ointment


Generic Name mechanism ofaction


Generic

Name : Sodium

Fusidate

Therapeutic

Classification

: Antibiotics

Trade Name(s):

India- Dicfu, Fucidin

This medication is a

bacteriostaticantibiotic,prescribed forosteomyelitis, boils,folliculitis, sycosis,and other skininfection

Solcoseryl gel andointment:

Radiation

dermatitis Trauma(wounds)

Badly healing

wounds

Bed sores

Chemical and

thermal burns

Freezings

mild irritation, burning, orredness. swelling, rash.

Most Common - Jaundiceand liver

Caution should be

exercised in patientswith history of liverproblems, jaundice, anyallergy, duringpregnancy andbreastfeeding.* For external use only.* Monitor liver functionregularly while using thismedication.
http://www.medindia.net/drugs/therapeutic-classification/antibiotics.htmhttp://www.medicinenet.com/script/main/art.asp?articlekey=1992http://www.medindia.net/drugs/therapeutic-classification/antibiotics.htmhttp://www.medicinenet.com/script/main/art.asp?articlekey=1992


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Salcoseryl jell 10% For weeping wounds and burns

Generic name Mechanism ofaction

Indications Side rffrcts Nuring responsibilities.

Salcoseryl jellSolcoseryl

enhances reparativeand regenerative

processes,contributes to

activation of aerobicmetabolic

processes andoxidative

phosphorylation,increases oxygen

consumption in vitroand stimulate the

transport of glucoseinto the cells

Allergy

Treatment Antibiotics Antif

ungal Antivirals Skin

Problem

Solcoseryl representsdeproteinized

hemodialysate containinga broad spectrum of lowmolecular components ofcellular mass and blood

serum obtained from vealcalfs. Solcoseryl

possesses the followingproperties:

improves the transport ofoxygen and glucose to the

cells being in hypoxicconditions

increases the synthesis ofintracellular ATP and

contributes to increase theproportion of aerobic

glycolysis and oxidativephosphorylation

activates the reparative

Burns, scalds, skinulcers, bed sores,

prevention & treatmentof radiation dermatitis,traumatic & ischaemic

wounds. Start treatmentw/ jelly until formation of

granulation tissue,continue w/ oint until

complete epithelization.

What should a patient

know before using

Solcoseryl?

The Solcoseryl should

not be used in cases of:

Known

hypersensitivity to

any of the

medication

ingredients

Children and

adolescents under

18 years of age (for

solution for injections

and solution for

infusion)

Make sure to consult

http://www.rxpharmacy.md/allergy.htmlhttp://www.rxpharmacy.md/allergy.htmlhttp://www.rxpharmacy.md/antibiotics.htmlhttp://www.rxpharmacy.md/antimycotic.htmlhttp://www.rxpharmacy.md/antimycotic.htmlhttp://www.rxpharmacy.md/antiviral-agents.htmlhttp://www.rxpharmacy.md/skin-problems.htmlhttp://www.rxpharmacy.md/skin-problems.htmlhttp://www.mims.com/Singapore/diagnoses/Info/2751http://www.mims.com/Singapore/diagnoses/Info/2729http://www.mims.com/Singapore/diagnoses/Info/637http://www.rxpharmacy.md/allergy.htmlhttp://www.rxpharmacy.md/allergy.htmlhttp://www.rxpharmacy.md/antibiotics.htmlhttp://www.rxpharmacy.md/antimycotic.htmlhttp://www.rxpharmacy.md/antimycotic.htmlhttp://www.rxpharmacy.md/antiviral-agents.htmlhttp://www.rxpharmacy.md/skin-problems.htmlhttp://www.rxpharmacy.md/skin-problems.htmlhttp://www.mims.com/Singapore/diagnoses/Info/2751http://www.mims.com/Singapore/diagnoses/Info/2729http://www.mims.com/Singapore/diagnoses/Info/637


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and regenerativeprocesses in tissuesstimulates fibroblast

proliferation and collagenvascular wall.

your doctor if you are

pregnant or

breastfeeding

Solcoseryl injectable

solutions should be used

with caution in patients

with heart failure,

pulmonary edema,

oliguria, anuria,

hyperhydration

For the treatment of

trophic skin damages itis recommended to

combine parenteral and

local forms of Solcosery



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DISCHARGE PLAN

Medications:

Advised patient to take home medications in right time and proper dosage.

Co Amoxiclav 625 mg/tab TID x 1 week

Clindamycin 300 mg/tab q6 x 1 week

Diclowal 100 mg/tab BID for pain

Evaluate the importance of checking the expiration dates of medication.

Exercise:

Encouraged patient to do ROM exercise

Encouraged patient to ambulate and do active and passive ROM exercises at patients tolerance to promote circulation and reduce

risks associated with immobility.

Treatment:

Instructed patient to comply with home medications.

Advised patient and relative to support leg when moving and use assistive device, such as clutches walker within reach.

Monitor blood sugar using glucometer with strip at proper time. 1 hour before meal

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DISCHARGE PLAN

Health:

Instructed patient and relative to practice aseptic technique in cleaning and dressing of wounds.

Advised patient and relative in doing hand washing technique before and after cleaning of wound to reduce risk of infection and cross

contamination.

Instructed patient and relative to use sterile gauze pad, bandage scissor, micropore using aseptic technique during wound dressing to

protect the wounds and the surroundings tissues.

Encouraged patient to eat nutritious foods for promoting wound healing

Encouraged patient to take a bath regularly to reduce risk for infection and bacterial contamination.

OPD Follow up

Advised patient about follow up check up after 1 week of discharge due on February 07, 2013

Diet (DM DIET)

Instructed patient to limit intake of sweet, salty foods and soda drinks.

Encouraged patients to read labels and choose foods described as having a low glycemic content, low fat and higher fiber content, this

foods produce lower rise in glucose.

DISCHARGE PLAN 61 | P a g e


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IV THERAPY

August 21- 28, 2012 ( 7 days)

NAME OF IVF NO. of IVBOTTLES

FORMULATION/CONCENTRATION

INDICATION NURSING CONSIDERATION

PNSS(Plain NormalSaline

Solution)

12 0.9% sodiumchloride

Classification:Isotonic Table Salt(Sodium Chloride)

Usede to giveintravenous fluids topatients suffering fromsalt and waterdeprivation

Used in bloodtransfusions,hyponatremia andburn victims

Used for irrigationduring surgery, todilute medications.And to clean woundsout

Used because it haslittle to no effect onthe tissues and maketheperson feelhydrated preventinghypovolemic shockorhypotension

Monitor patient frequently for:

a. Signs of infiltration/sluggishflow

b. B. sign of phlebitis/infectionc. C. dwell time of catheter and

need to be replacedd. D. condition of catheter

dressinge. Check the level of the IVFf. Correct solution, medication

and volumeg. Check and regulate the drop

rateh. Change the IVF solution if

neededd

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DIET THERAPY

Date Diet Food consumed Rationale

January 18 21, 2013DM Diet - A diabetic diet is a special way of

eating for people who have type (1) or type

two(2) diabetes, or have been told they are at

high risk of developing diabetes. A diabetic

diet can range in calories from 1,200 to 2,000calories per day.

Read

more: http://www.livestrong.com/article/40710

-definition-diabetic-diet/#ixzz2KTDgLSTf.

1,200 to 2,000 calories

per day

37,800 kcal was

consumed by the patient

in her whole stay in the

hospital.

DM Diet- The mainpurpose of the diabetic dietis to eat specific portions ofcarbohydrates andproteins at specific timesthroughout the day to keepblood sugar levels normal.

Blood glucose (sugar)levels need to continuallymonitored throughout theday by a diabetic person tomake sure that the diet isstabilizing blood sugarlevels. If a diabetic goes offthe diabetic diet or eats toomuch sugar, they may beat risk of healthcomplications such asneuropathy and strokes.

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http://www.livestrong.com/article/40710-definition-diabetic-diet/#ixzz2KTDgLSTfhttp://www.livestrong.com/article/40710-definition-diabetic-diet/#ixzz2KTDgLSTfhttp://www.livestrong.com/article/40710-definition-diabetic-diet/#ixzz2KTDgLSTfhttp://www.livestrong.com/article/40710-definition-diabetic-diet/#ixzz2KTDgLSTf


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SURGICAL INTERVENTIONS

z

Operative Record

Pre Op Dx DM Foot Left

Post Op Dx Dm Left Foot

Operation Performed Disarticulation Left Foot Wagner III

Time began: 2:40 pm

Time Finished: 3:00 pm

Surgeon: Dr. Putera

Sterile Nurse: V. Conel

Non Sterile Nurse: R. Putera

Aneesthesiologist: Mr. Zamudio

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Date Performed: Operation: Indication:

January 22, 2013 E disarticulation of 4th digit

Left foot

Incision made on 3rdand 4th

webspace

Disarticulation and

debridement done

Betadinepack inserted

webspace. Wet to drydressing done.

removel of dead, damaged,or infected tissue to improvethe healing potential of theremaining healthy tissue
http://en.wikipedia.org/wiki/Deadhttp://en.wikipedia.org/wiki/Infecthttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Deadhttp://en.wikipedia.org/wiki/Infecthttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Health


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SURGICAL INTERVENTIONS

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NURSING MANAGEMENT

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective:

Wound @sole of Lfoot,purulentdischarge,bloodstreaked

Woundsize: length-15.24 cmwidth

10.16 cm

depth 0.5 cm

Numbnesso L foot

Toenails-

Impairedskinintegrityrelatedto largevesseldestruction asevidenced bydrainingwoundon L footsecondary toDiabetesMellitus

type 2(NIDDM)

Short-term

After 8 hours ofnursing intervention,

the client will:

1. Verbalizeknowledge andunderstandingregarding hisillness

2. Participate intreatmentregimen suchas properwound care,balanced dietand regularexercise

3. Be free ofpurulentdischarge

Long-term

After 1 week of

- Irrigatethewound inroom

temperature usingsolution#3 (30mlvinegar,30mlzonroxand1liter ofPNSS) asprescribed

- Assessbloodsupply

andsensation ofaffectedarea

- Assesswound

Cleans thewoundwithoutharming

thedelicatetissues

Toevaluatepotentialforimpairmen

t ofcirculationtoo lowerextremities

Providesinformation abouteffectiveness oftherapy

Short-term

After 8 hours ofnursing intervention,

the client was able to:

1. Verbalizedknowledge andunderstandingregarding hisillness

2. Participated intreatmentregimen such asproper woundcare, balanceddiet and regularexercise

3. free of purulent

discharge

Long-term

After 1 week ofnursing intervention,the client was able to:

Minimized

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NURSING MANAGEMENT

crackednail beds

Scaly onthesurrounding skin of Lfoot

Blister 5cm width

nursing intervention,the client will:

1. Achieve timelywound healing

2. Minimizeswelling

3. Display signs

of healing withwound edgesclean

witheachdressingchange

- Keepsthe areacleanand dry,bycarefullydressingthewound,preventstheinfectionandstimulatecirculation tosurrounding areas

- Assistwith the

andidentifiesadditionalneeds

To assistthe bodysnaturalprocess of

repair

To removeinfectedtissue

To protectthe woundand thesurrounding tissues

Promotescirculationandreducesrisksassociatedwith

swelling1. Displayed signs

of healing withwound edgesclean

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NURSING MANAGEMENT

debridement

- Useappropriatedressingsandwound

coverings

- Timelyelevationon lowerextremities andmobility

mobilityand edemaformation

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NURSING MANAGEMENT

Assessment Diagnosis Planning Intervention Rationale Evaluation

ctive:

walaakongmar

amdamansakaliwangpaako asverbalize by theclient

Objective:

Numbness felt onL foot

Diminishedperipheral pulses:Popliteal:2

Posterialtibial- 1

Dorsalisp

Ineffectiveperipheraltissue perfusionrelated todecreased

arterial bloodflow asevidenced bydecreasedperipheralpulses,paleness of Lfoot, numbnessand brittletoenailssecondary toprolongedwound healing

Short-term

After 8 hours ofnursingintervention, the

client will:

1. Verbalizeunderstanding ofrelationshipbetweendiabetesmellitusandcirculatorychanges

2. Demonstrateawareness ofsafetyfactorsandproperfoot care

Long-term

- Elevate feetwhenup inchair.Avoidlongperiods ofstanding orsitting

- Monitorintakeandoutput

andassessforsignsofdehydration.Encourageoralfluids

Minimizesinterruption ofblood

flow,reducesvenouspooling

Glycosuria mayresult indehydrationwithconsequentreduction of

circulatingvolumeandfurtherimpairment ofperipheralcirculation

Short-term

After 8 hours ofnursingintervention, the

client was ableto:

1. Verbalizedunderstanding ofrelationship betweendiabetesmellitusandcirculatorychanges

2. Demonstrated

awarenessof safetyfactors andproper footcare

Long-term

After 1 week ofnursingintervention, the

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NURSING MANAGEMENT

edis- 1

Palenessof L foot

Dry skin Cool to

touch (Lfoot)

Capillary

refill of 5seconds

Brittletoenails

Edema+2 (bothfeet)

Obesity:ht-52in.

wt- 80 kg

After 1 week ofnursingintervention, theclient will:

1. Demonstratebehaviors

and lifestylechanges toimprovecirculationsuch asregularexercise,balanceddiet, weightloss, andcessation ofsmoking

- Maintainadequatelevel of

hydration tomaximizeperfusion asevidencedby balancedintake andoutput,moist andwarm skin,capillaryrefill of lessthan 3

-Comparetheskintemperatureandcolorwithotherfootwhenassessingextre

mitycirculation

- Assesspresence,location anddegree ofswellin

Todifferentiate thetype ofproblem

Usefulinidentifying andquantifyingedemaininvolvedextremit

y To

determineadequacy ofsystemiccirculation

Weight

client was ableto:

1. Demonstratedbehaviorsandlifestylechanges to

improvecirculationsuch asregularexercise,balanceddiet,weightloss, andcessationof smokingMaintainedadequatelevel ofhydrationtomaximizeperfusionasevidencedbybalancedintake andoutput,moist andwarm skin,capillary

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NURSING MANAGEMENT

seconds,absence ofedema andpresence ofstrongperipheralpulses

g

- Measure thecapillaryrefill

- Notetheclientsnutritionalandfluidstatus

- Palpat

lossmakesischemic tissuesmoreprone tobreakdown.Dehydra

tionreducesbloodvolumeandcompromisesperipheralcirculation

Todetermine levelofcirculatorydamage

Toevaluatedistribut

refill of lessthan 3seconds,absence ofedema andpresenceof strongperipheralpulses

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NURSING MANAGEMENT

earterialpulsesequality aswell asintensity and

comparewithunaffectedextremity

- Determinethepulsesequality aswell asintensity andcomparewithunaffectedextremities

- Instruct theclientto

ion andqualityof bloodflow

compromisedcirculation anddecreased painsensation mayprecipitate oraggravate tissuebreakdown

vascular

constrictionassociated withsmokinganddiabetesimpairsperipheralcirculati

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NURSING MANAGEMENT

avoidwearing tightclothes

on Althoug

h propercontrolofdiabetesmellitusmay notprevent

complications,severityof effectmay beminimized.Diabeticfoot areleadingcause ofnontraumaticlowerextremityamputations

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ALGORITHM OF CARE

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Assessed level of consciousness Conscious,

coherent

Continuously monitor level of consciousness

To monitor changes in consciousness.

Assessed Respiration RR: 26 cpm

- crackles

(-) cough

(-) dyspnea

Monitored respirations andbreathe sounds, noting the

rate and sounds

Elevated head of bed

Encouraged position changesdeep breating/coughing exercise

Demonstratedeffectiveairway

clearanceR

c

Assessed CirculationBP: 110/80 mmHg

Pale lips

PR: 80 cpm

Capillary time: 3secsPale conjunctiva

Monitord patients vitalsigns and heart rhythms

every 4 hours

Educate patient about importance ofexercise, need for low cholesterol. Low

calorie diet, need to avoid vasoconstrictors

Such as cold, stress, drinking alcohol andsmoking.

Normal BloodPressure

Encouraged ambulation and passive ROM

exercises to the level of tolerance toencourage circulation to extremities

Educated patient relaxation tachniques tohelp improve vasodilation and helpprevent

vasoconstriction caused by anxiety


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ALGORHITM OF CAIR75 | P a g e

Assessed For Tissue

Perfusion

Pale skin

Body weakness

Pale conjunctiva

Capillary Refill:Blood returns 3 sec.

Cold clammy skin

Demonstratedincrease in

Tissue Perfusion

Perform Range of Motionexercises

Encouraged restful and quiteatmosphere. Conserves energy

Keep the areaclean and dry

Carefully cleanthe wound

Redness around theaffected area

Disruption of skin surfaceat the left foot

Assessed SkinOffered daicleansing owound unt

theres anevidence o

wound heali

Still withimpaired skin

integrity


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(+) Foul odor

(+) edema Grade +2

(+) pain 5/10

(+) Pus

(+) itchingMaintained appropriate

moisture environment forparticular wound

Displayed timelywound healing

Carefully dress thewound in aseptic

technique

Wound hav

dried up:(-) itching(-) pain

Instructed patient to avoidwound to be exposed

from dust and pollutantsto prevent progress of

infection


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Legend

Assessment Procedures Outcome of Care

Findings ( s/sx ) if symtoms are relieved

Nursing Interventions is symptoms are not relieved

Happened not happened



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Glossary contains unfamiliar words that we encountered in these studies.

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diabetes mellitus rizza (repaired) (1)

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