DIABETES MELLITUS TYPE 2HYPERTENSION

PRESENTED BY: BSN 3-1GROUP 2

PATIENT PROFILE

NAME: J.S ADDRESS: Dasma. Cavite AGE: 49 GENDER: Female EDUCATIONAL ATTAINMENT: Vocational

Technology (Food Service Technology) RELIGION: Roman Catholic CIVIL STATUS: Widow OCCUPATION: Secretary

II. RELIABLE SOURCE OF INFORMATION/ INFORMAT: Patient and Patient’s Chart

III. REASON FOR SEEKING CARE: - “namamanhid at nanghihina ang

buong katawan ko” as verbalized by the patient

IV. PATIENT MEDICAL HISTORY (PAST AND PRESENT) (+) Hypertension and Diabetes

Type II for more than 10 years Maintenance: amlodipine and

catapress Undergone Tubal Ligation (1988)

B. Immunizations

not knownC. Hospitalizations::4

D. Injuries : none

E. Transfusions: Feb.2,2011

F. Allergies : none

G. Obstetrics- Gravida:2 Para:2

(TPAL)Term: 2 Premature: 0 Abortion:0 Living: 2

v. SOCIAL AND PERSONAL HISTORY

Health Perception/ Health Management:Patient is aware and understands

medical diagnosis but acts little confuse and distracted

Answer questions regards to her health status.

Describes progress of previous illness in detail.

Nutritional and Metabolic Pattern:

Patient usual weight is 144 pounds. Usual diet is low sodium, low fat, and low cholesterol. Usual eating pattern is 3 times a day, most often fish

and vegetables , with 1 cup of rice every meal supplied by the hospital.

No food allergies Patient is taking food supplement such as Centrum. Patient is taking herbal such as Taheebo. Patient is taking insulin for Diabetes. Poor dental care w/ incomplete number of teeth

(upper part are all dentures) and most of the molar are dentures.

Elimination Pattern

Last bowel movement was March 3,2011. (around 8am)

No history of bleedingFrequent urination 6-8 times daily at

home

Activity – Exercise PatternWork as dietary.No assistance needed. (very

independent).No musculoskeletal impairment.Patient has hypertension. Hobbies watching T.V., cleaning the

house, and she loves cooking.

Sleep- Rest Pattern

Usual sleeping pattern is 8 hours of daily bedtime rituals watching T.V. before sleeping with one pillow in the heal.

In the hospital she hardly get’s some sleep 3-4 hours only due to her condition.

Self Perception/ Self conceptNo assistance needed to carry out

activities of daily living.Very Independent.

Cognitive- Perceptual Pattern:

Oriented to time, place and person.Response appropriately to verbal and

physical stimuli.Reports body weakness.Cooperative to attain good health.

Role- Relationship Pattern:

Lives with her 2 children, in good term5 years in relationship w/ her husband

before she became widowed. Does not need any kind of assistance.

Values BeliefCatholicAttending mass weekly.She has superstious beliefs.

Sexuality- Reproductive Pattern:

Ligated since 1988.Last menstruation was Jan. 20, 2011.Length of cycle is 1 month and the

duration is 3-4 days. COPING/STRESSPatient copes stress by relaxation.Expressing feeling of stress when she

has fight/ arguments w/ her children.

:

Sexuality- Reproductive Pattern:

Coping- Stress Tolerance Pattern:

Value- Belief Pattern:

VI. Physical Examination

General information:

Weight: 145lbs. Height: 5’4 Night sweat: none none abnormalities

seen

Mental Acuity Oriented : Coherent : Disoriented : Incoherent: Conscious : Unconscious : Semi- conscious:

SKIN HEAD

Itch: none Rash: none Bruising: none Bleeding: none Scar: (R) lower

hypogastric area Color change: fair

complexion

Skull –size: Presence of

masses/ nodules: none

Shape: round

HAIR EYES

Alopecia: no Color: black with white Length: shoulder level Type: normal With no lice. Scalp: normal not dry

Pain: none Diplopia: Sclera: white Glasses/Contact Lenses:

wearing while reading. Itchiness: when irritated

with dust or small particles.

Blurring: during reading Vision Loss: no Excessive Tearing: no

EARS NOSE

Earaches: none Discharge: none Tinnitus: none Hearing Loss: none

Obstruction: none Epistaxis: none Discharge: none Nasal flaring: none

THROAT and MOUTH NECK

Sore throat: normal, not inflammed.

Bleeding gums: Toothaches: Decay: with all

dentures at the upper part. No molars on the lower part.

Swelling: none Dysphagia: none No mass palpated

CHEST BREAST

Cough: none Rales : none Wheeze : none Dyspnea ( rest/

exertion): none Sputum: amount/

character: none Heart rate of 84bpm. Quality: normal Rhythm: normal

Lumps: none Bleeding : none Pain : none Discharge: none

GIT GUT

Heartburn: none Vomiting : none Constipation: none Pain: none Change in BM: none Nausea: none Bloating: none Melena: none Jaundice: none

Polyuria: 3x during night

Retention: controllable Urinate 6-8 x a day.

EXTREMITIES NEURO

Varicose vein: with varicosities at the back of the (R) knee.

Injuries/ Lesion: none

Headache: none Numbness: none Memory Loss: none

Memory Health Status

Oriented Alert Cooperative Communication/ speech: Clear Follows commands

Anatomy and Physiology

Anatomy 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:

Exocrine tissueThe exocrine tissue secretes digestive enzymes. These enzymes are secreted into anetwork of ducts that join the main pancreatic duct, which runs the length of thepancreas.

Endocrine tissueThe endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Anatomy of the Kidneys

The kidneys play key roles in body function, notonly by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells.

The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term "renal" is derived from the Latin name for kidney.)

The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine (Cr).

Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells.

Kidneys are also the source of erythropoietin in the body, a hormone thatstimulates the bone marrow to make red blood cells. Special cells in the kidney monitorthe oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and thebody starts to manufacture more red blood cells.

PATHOPHYSIOLOGYPredisposing Factors Precipitating Factors

-Age > 40yrs old -Stress

-Heredity -Obesity

-Elevated Cholesterol Level

-Hypertension

Destruction of Beta Cells

↓ insulin production

↑ insulin resistance

Hyperglycemia

Hyperosmolarity of serum Chronic Elevation of Blood Glucose

Insufficient intracellular

glucose supply

Renal threshold for Accelerated Glucose become

glucose reabsorption atherosclerosis glycoprotein

in the blood

vessel walls

Ability of the Decrease energy Sateity center

kidney to re- production responds by Blood flow ↓production

absorp glucose increasing is blocked of insulin

was surpassed weakness / fatigue appetite

↑ pressure against ↑insulin Polyphagia blood vessels resistance

Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective:“Pakiramdam ko lagi ako nghihina at naliliyo“as verbalized by the patient.  Objective:Dry skinPoor skin turgorSudden weight loss (160 lbs to 144 lbs) Vital signs taken as follows:T:36.8PR:RR:BP:160/90

Activity intolerance r/t generalized weakness AEBabnormal heart rate or BP response to activity.

After 2-3 hours of nursing interventions the patient will be able to demonstrate a decrease in physiological signs of activity intolerance.

Assess the patients’ response to activity noting pulse rate, increased BP during or after the activity and excessive fatigue and weakness. Encourage the patient in energy conserving techniques like sitting to brush teeth or comb hair and carrying out of activities at a slow pace

 The stated parameters are helpful in assessing physiological response to the stress of the activity.

Energy saving techniques can reduce energy expenditure there by assisting in equalization of oxygen supply and demand.

After 2-3 hours of nursing interventions the patient demonstrated that she can now do some of her daily activities like walking in the morning. Goal partially met.

NCP(DM II)Assessment Nursing

DiagnosisPlanning  

NursingInterventions

Rationale Evaluation

Subjective :“nangingimi ang mga braso ko” as verbalized by the patient.Objective: generalized weaknessbody weaknesswt. lossVital signs taken as follows: T: 36.8PR: 79RR: 24BP:160/90

Ineffective tissue perfusion r/tPeripheral vasoconstriction as manifested by high blood pressure high blood sugar.

After 3 hours of nursing intervention the patient will verbalize the understanding of the disease process and treatment regimen.

Assist patient about the current life style specially the diet.

Measure and record blood pressure as indicated. Observed skin color, temperature, moisture capillary refill time. 

To further assess the predisposing factors that causes the increase in sugar level. This will provide baseline data for monitoring. Presence of pallor: cool moist skin; and delays capillary refill time maybe due to peripheral vasoconstriction. 

After 3 hours of nursing interventions the patient understands her condition treatment and prevention

Provide calm, restful surroundings, minimize environmental activity or noise. Limit the number of visitors and length of stay. Assess patient understanding of direct relationship between hypertension and obesity. Encourage the patient to decrease or eliminate caffeine like coffee or tea, cola or chocolates. 

This will reduce physical stress and tension that affect blood pressure.   

Obesity is an added risk with high blood pressure because of the disproportion. 

Caffeine can aggravate increase in sugar level likewise to stimulate cardiac function. 

Instruct the importance of accomplishing rest periods .

Alternating in rest and activity can increase tolerance to activity progression.

XII. Laboratory/Diagnostic Procedure

ERYTHROCYTE:MALE: 4.5-6.O x 10 / L FEMALE: 4.5- 5.5 x 10/L= WBC 4.5 -10.0x 10X10/LHEMATOCRIT:MALE: 0.40-0.54FEMALE: 0.37-0.47HEMOGLOBIN:MALE: 120- 170G/LFEMALE: 110-150G/L

RESULT

18.8

0.45

151

DIFFERENTIAL COUNT:BANDS 0-0.05SEGMENTERS 0.50-0.70LYMPHOCYTES 0.20-0.40EOSINOPHILS 0-0.05MONOCYTES 0-0.07BASOPHILS 0-0.005BLEEDING TIME 1-4 minCLOTTING TIME 2-6 min

RESULT

0.74

0.22

0.04

THROMBOCYTE COUNT:150-400 x G/LRETICULOCYTE:5-15x 10

INCREASE

BSR

DRUG STUDY

BRAND NAME

GENERIC NAME

CLASSIFICATION CONTRAINDICATION

SIDE EFFECTS /ADVERSE EFFECTS

NURSING RESPONSIBIL

ITIES

Norvasc Amlodipine Pregnancy Category C:Anti-hypertensives

Hypersensitivity,

Severe aortic stenosis,

Obstructive coronary artery

disease

PalpitatePeripheral

edema TachycardiaHeadacheDizziness

NauseaShortness of

breatheMuscle cramps

Pair or inflammation.

Monitor liver function.

Assess cardio respiratory status:

anginal pain, BPRespiration.

Assess hydration and fluid volume status: Input and output ratio, presence of edema, lung crackles.

Therabloc Beta – blockers

Sinus bradycardiaHeartblock

other than 1st degree

Cardiogenic shock

Unstable heart failure

Bradycardia Hypotensio

nDizzinessFatigueDiarrhea

Monitor vital signs and ECG should be monitored q 5-15 min during and for several hours

after parenteral administration.

Lasix Furosemide Diuretics AnuriaHypovolemia

Lactation

Headache

FatigueWeakness

VertigoLoss of hearing

Assess patient for tinnitus, hearing, loss for pain.

Monitor for renal, cardiac, neurologic and hypokalemia.

Folic Acid Vitamin B9 Vitamin b-complex groupSupplementPregnancy CCategory A

Deficiency Anemia

Flushing Bronchospasm

Monitor electrolytes

potassium, sodium, calcium,magnesium.

Assess b/p before

and during therapy.

Ketoanalogues

Ketosteril Hemostatic Hypercalcemia

Hypercalcemia

Instruct patients to have proper hygieneMonitor serum Ca level.

DISCHARGE PLANNING

Instruct patient to have adequate rest. Encourage relaxation techniques to reduce anxiety. Encourage patient to have diet restrictions (e.g.

low sodium, low fat) Encourage patient to breathe in/out during

activities. Instruct patient to have more fluid intake to

minimize dehydration and dysrhythmias. Instruct patient to comply with his/her medications

on time. Instruct patient to go to his/her physician for a

follow-up check-up.

Health teaching

Advised patient to have adequate rest. Advised patient to have calm and restful environment and

away from stressor. instruct patient for relaxation technique. advised patient to minimize strenuous activities like prolonged

coughing and straining during defecation . advised patient to have his/her blood pressure to be monitor

frequently. instruct patient to decreased intake of foods containing salt,

fats, and sugar. instruct patient to have an adequate exercise and weight

reduction plans. instruct patient to avoid alcohol intake and smoking cigarettes. instruct patient to verbalize feeling of discomforts.

DM…. 1.advised patient to frequently monitor his/her blood sugar

level. 2.advised patient to meticulous foot care. 3.advised patient to have an adequate rest. 4.intructed patient to have a diet w/ approximately 60%

carbohydrates, 20% fats, and 20% protein. 5. instructed patient to promote proper hygiene by having a

conscientious skin care. 6.instructed patient to keep the skin dry keep lines dry and

wrinkle free. 7.advise patient to consume foods high and vit.c and other

minerals. 8. instructed patient to have a gradual change of position. 9.encourage patient to comply to the prescribed medication. 10. instruct patient to avoid consumption of foods 30 min.

before glucose testing. 11.instructed patient to keep hands or feet warm and to

avoid cool drafts and avoid use of hot water 12. Instruct patient to avoid high energy consuming

activities.