DIABETES MELLITUS TYPE

2
HYPERTENSION
PRESENTED BY:
BSN 3-1
GROUP 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
C. Hospitalizations::4
not known
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 bleeding
 Frequent urination 6-8 times daily at home
Activity – Exercise Pattern

 Work 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 concept
 No 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 term

 5 years in relationship w/ her husband before she
became widowed.
 Does not need any kind of assistance.

 Values Belief
 Catholic
 Attending 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/STRESS
 Patient 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:
Mental Acuity
 Weight: 145lbs.  Oriented :
 Height: 5’4  Coherent :
 Night sweat: none  Disoriented :
 none abnormalities seen  Incoherent:
 Conscious :
 Unconscious :
 Semi- conscious:
 SKIN HEAD

 Itch: none  Skull –size:

 Rash: none  Presence of masses/
 Bruising: none nodules: none
 Bleeding: none  Shape: round
 Scar: (R) lower
hypogastric area
 Color change: fair
complexion
 HAIR EYES

 Alopecia: no  Pain: none

 Color: black with white  Diplopia:
 Sclera: white
 Length: shoulder level
 Glasses/Contact Lenses:
 Type: normal wearing while reading.
 With no lice.  Itchiness: when irritated with
 Scalp: normal not dry dust or small particles.
 Blurring: during reading
 Vision Loss: no
 Excessive Tearing: no
 EARS NOSE

 Earaches: none  Obstruction: none

 Discharge: none  Epistaxis: none
 Tinnitus: none  Discharge: none
 Hearing Loss: none  Nasal flaring: none
THROAT and MOUTH NECK

 Sore throat: normal, not  Swelling: none

inflammed.  Dysphagia: none
 Bleeding gums:  No mass palpated
 Toothaches:
 Decay: with all dentures at
the upper part. No molars
on the lower part.
 CHEST BREAST

 Cough: none  Lumps: none

 Rales : none  Bleeding : none
 Wheeze : none
 Pain : none
 Dyspnea ( rest/ exertion): none
 Discharge: none
 Sputum: amount/ character:
none
 Heart rate of 84bpm.
 Quality: normal
 Rhythm: normal
 GIT GUT
 Heartburn: none  Polyuria: 3x during night
 Vomiting : none  Retention: controllable
 Constipation: none  Urinate 6-8 x a day.
 Pain: none
 Change in BM: none
 Nausea: none
 Bloating: none
 Melena: none
 Jaundice: none
 EXTREMITIES NEURO

 Varicose vein: with  Headache: none

varicosities at the back of  Numbness: none
the (R) knee.  Memory Loss: none
 Injuries/ Lesion: 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 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.
Endocrine tissue
The 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, not
only 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 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.
 PATHOPHYSIOLOGY
Predisposing 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 Activity After 2-3 hours of Assess the  The stated After 2-3 hours of
lagi ako nghihina intolerance r/t nursing patients’ response parameters are nursing
at naliliyo“ generalized interventions the to activity noting helpful in interventions the
as verbalized by weakness AEB patient will be able pulse rate, assessing patient
the patient. abnormal heart to demonstrate a increased BP physiological demonstrated that
  rate or BP decrease in during or after the response to the she can now do
  response to physiological signs activity and stress of the some of her daily
Objective: activity. of activity excessive fatigue activity. activities like
Dry skin intolerance. and weakness. walking in the
Poor skin turgor   morning.
Sudden weight Encourage the Energy saving  
loss (160 lbs to 144 patient in energy techniques can Goal partially met.
lbs) conserving reduce energy
  techniques like expenditure there
Vital signs taken sitting to brush by assisting in
as follows: teeth or comb hair equalization of
T:36.8 and carrying out of oxygen supply and
PR: activities at a slow demand.
RR: pace
BP:160/90
 NCP(DM II)
Assessment Nursing Planning   Rationale Evaluation
Diagnosis Nursing
Interventions

Subjective :
“nangingimi ang Ineffective tissue After 3 hours of Assist patient To further After 3 hours of
mga braso ko” as perfusion r/t nursing about the current assess the nursing
verbalized by the Peripheral intervention the life style specially
predisposing interventions the
patient. vasoconstriction patient will the diet. factors that patient
Objective: as manifested by verbalize the causes the understands her
generalized high blood understanding of increase in sugar condition
weakness pressure high the disease level. treatment and
body weakness blood sugar. process and   prevention
wt. loss treatment Measure and This will
Vital signs taken regimen. record blood provide baseline
as follows: pressure as data for
  indicated. monitoring.
T: 36.8    
PR: 79 Observed skin Presence of
RR: 24 color, pallor: cool moist
BP:160/90 temperature, skin; and delays
moisture capillary capillary refill
refill time. time maybe due
  to peripheral
vasoconstriction.
 
Provide calm, This will reduce
restful physical stress
surroundings, and tension that
minimize affect blood
environmental pressure.
activity or noise.  
Limit the number  
of visitors and  
length of stay.
 
Assess patient Obesity is an
understanding of added risk with
direct high blood
relationship pressure because
between of the
hypertension and disproportion.
obesity.  
 
Encourage the Caffeine can
patient to aggravate
decrease or increase in sugar
eliminate level likewise to
caffeine like stimulate cardiac
coffee or tea, cola function.
or chocolates.  
 
Instruct the Alternating in
importance of rest and activity
accomplishing can increase
rest periods . tolerance to
activity
progression.
 XII. Laboratory/Diagnostic
Procedure
RESULT RESULT
ERYTHROCYTE: DIFFERENTIAL
MALE: 4.5-6.O x COUNT:
BANDS 0-0.05
10 / L 18.8 SEGMENTERS 0.50- 0.74
FEMALE: 4.5- 5.5 x 0.70
10/L LYMPHOCYTES 0.20- 0.22
0.40
= WBC 4.5 -10.0x EOSINOPHILS 0-0.05
10X10/L MONOCYTES 0-0.07
HEMATOCRIT:
MALE: 0.40-0.54
0.45 BASOPHILS 0-0.005
BLEEDING TIME 1-4
0.04
FEMALE: 0.37-0.47 min
HEMOGLOBIN: CLOTTING TIME 2-6
MALE: 120- 170G/L min
FEMALE: 110-150G/L

151
THROMBOCYTE COUNT: BSR
150-400 x G/L INCREASE
RETICULOCYTE:
5-15x 10
DRUG STUDY
BRAND GENERIC CLASSIFICATION CONTRAINDIC SIDE NURSING
NAME NAME ATION EFFECTS RESPONSIBIL
/ADVERSE
EFFECTS ITIES

Norvasc Amlodipine Pregnancy Hypersensitivit Palpitate  Monitor

Category C: y, Peripheral liver
Anti- Severe aortic edema function.
hypertensives stenosis, Tachycardia  Assess
Obstructive Headache cardio
coronary artery Dizziness respiratory
disease Nausea status:
Shortness of anginal
breathe pain, BP
Muscle cramps Respiratio
Pair or n.
inflammation.  Assess
hydration
and fluid
volume
status: Input
and output
ratio,
presence of
edema,
lung
crackles.
Therabloc Beta – blockers Sinus Bradycardia  Monitor vital
bradycardia Hypotensio signs and ECG
Heartblock n should be
other than 1st Dizziness monitored q 5-
degree Fatigue 15 min during
Cardiogenic Diarrhea and for several
shock hours
Unstable heart after parenteral
failure administration.

Lasix Furosemide Diuretics Anuria  Assess

Hypovolemia patient for
Lactation Headache tinnitus,
Fatigue hearing, loss
Weakness for pain.
Vertigo  Monitor for
Loss of renal,
hearing cardiac,
neurologic
and
hypokalemia.
Folic Acid Vitamin B9 Vitamin b- Deficiency Flushing  Monitor
complex electrolyte
group Anemia Bronchospas s
Supplement m potassiu
Pregnancy C m,
Category A sodium,
calcium,
magnesi
um.
 Assess b/p
before
and
during
therapy.
Ketoanalogues Ketosteril Hemostatic Hypercalcemi Hypercalcemia Instruct
a patients to have
proper hygiene
Monitor 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.