66524559 individual-case-study

Clinical SummaryName: Manuel Galang Delos SantosSex: MaleAge: 68 years oldAddress: A-A 6-20 PArola Tondo Manila Date of Birth: May 9, 1943Birth Place: MindanaoCivil Status: MarriedReligion: Roman CatholicNationality: FilipinoDate of Admission: September 5, 2011Ward and Room: Medicine Ward and Rm. 621Admitting Diagnosis: Diabetes Mellitus Type II

A.    Personal Data Patient is Mr. Manuel Galang Delos Santos, a 48 years old male from A-A 6-20 Parola Tondo Manila. He is married, they have three children’s, and they are all Roman Catholic.  

B.     Chief Complain The patient was admitted at Gat Andres Bonifacio Memorial Medical Center last September 5, 2011 due to the complaint of difficulty of breathing (DOB). He was attended at the Emergency Department and had taken a clinical history and physical assessment. He was transferred at the Medicine ward particularly in the isolation room of the hospital for further evaluation of the complaint. He was attended by Dr. Ancheta resident physician of the said hospital. 

C.   Past Medical HistoryThe patient is known hypertensive, diabetic and asthmatic since he was a child it is triggered by dust, scented products and Strong odors from paints. Last attack of asthma he did not take any maintenance and medication. He has a history of asthma in her family. Whenever asthma attacks he uses inhaler if available. He does not have allergies to whatever kind of foods and medication as far as she kno

D.     History of Present illnessThe patient condition started about 2 months ago prior to consultation, as onset of cough, fatigue and difficulty of breathing.One week prior to admission the patient experienced worsening of the condition, he had a Positive for Bipedal Edema with orthopnea gradually progressive. He also

stabbing pain on his chest according to the assessment it is 8/10 and it radiates to his back. He just used inhaler and used of oxygen inhalation at home. On the day of September 05, 11 he was rushed into the hospital because of difficulty of breathing. Previously when he started experiencing these conditions, he immediately consults a doctor. 

E.     Family History  Mother side = (+) Asthma                           (+) Hypertension  Father side =   (+) Hypertension                           (+) Diabetes Mellitus

F.      Social HistoryThe Patient is a jeepney driver, he works hard for his children.

Nursing Care Plan

Assessment

Diagnosis Planning Intervention

Rationale Evaluation

Subjective:“hindi ko na magawa yung mga nagagawa ko dati” as reported by the patient.Objective:Generalized weaknessPolyphagia PolyuriaPolydypsiaRestlessnessDrowsyLethargyVital Signs:Bp;130/90mmHgRR:25bpmPr:95bpmTemp.:37.20C

Activity Intolerance related to poor glucose control as evidence by experiencing shortness of breath when ambulating.

Short TermAfter 8 hours of nursing intervention, will be able to participate in physical activity with appropriate changes in heart rate, blood pressure, and respirations.

Long Term:After 3 days of nursing intervention, will be able to demonstrate increased tolerance to activity by discharge.

1.Evaluate medications the client is taking to see if they could be causing activity intolerance

2.Assess nutritional needs associated with activity intolerance.

3.Provide emotional support

1.Medications such as beta-blockers, lipid- lowering agents, which can damage muscle, and some antihypertensives such as Clonedine and lowering the blood pressure to normal in the elderly can result in decreased functioning.

2.The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.

3.Fear of breathlessness, pain, or falling may decrease willingness to increase activity.” 

Short Term:

After 8 hours of nursing intervention, goal met, as evidence by participating in physical activity with appropriate vitals changes.

Long Term:After 3 days of nursing intervention goal met, as evidence by demonstrating increased tolerance to activity.

and encouragement to the client to gradually increase activity.

4.Monitor vital signs before and after any activity, noting any abnormal changes.

5.Assess for pain before activity.

4.This can be caused by a temporary insufficiency of blood supply.

5.Pain restricts the client from a achieving a maximal activity level and if often exacerbated by movement.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Nutritional Long 1.Obtain 1. Long Term:

“palagi ako nagugutom kya palagi din ako kumakaen” as verbalized by the patient. Objective:Generalized weaknessPolyphagia PolyuriaPolydypsiaRestlessnessDrowsyLethargyVital Signs:Bp;130/90mmHgRR:25bpmPr:95bpmTemp.:37.20C

Imbalance more than body requirement related to intake in excess of activity expenditures as evidence by

Term:After 3 days of nursing intervention, will be able to have nutritional balance between needs and intake.

accurate history of weight changes.2.Record accurate food hstory, including daily intake.

3. Encourage use of internal reward systems when goals are accomplished.4. Set a realistic plan with Mr. galang to include reduced food intakeAnd increased energy expenditure.5. Encourage attendance at support groups for weight loss and/orRefer to a community weight control program.

Increases awareness of activities and foods that contribute to excessiveintake2. Increases awareness of activities and foods that contribute to excessiveintake.3. Goal setting provides motivation, which is essential for a successfulweight-loss program4.. A combined plan of calorie reduction and exercise can enhanceweight loss since exercise increases caloric utilization

After 3 days of nursing intervention, goal met as manifested by understanding of nutritional balance between needs and intake.

5. Overweight people are often nutritionally deprived. Intake mustbe reduced by 500 calories per day to obtain a one-pound-per weekWeight loss.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:“nanghihina ako at walang gana kumaen” as verbalized

Risk for Injury (hypoglycemia) related to effects of insulin as evidence by

Long Term:After 3 days of nursing intervention, will be

1.Assess client’s level of disorientation to determine

1.Knowledge of client’s level of functioning is necessary to formulate

Long Term:After 3 days of nursing intervention, goal, met as

by the patient.Objective:Generalized weaknessPolyphagia PolyuriaPolydypsiaRestlessnessDrowsyLethargyVital Signs:Bp;130/90mmHgRR:25bpmPr:95bpmTemp.:37.20C

restlessness. able to understand whats the cause of his restlessness.

specific requirements for safety.2. Obtain a urine sample for laboratory analysis of substance con-tent.

3. Place client in quiet room.

4. Institute necessary safety precautions as follows:

Observe client behaviors frequently; assign staff on one-to-one basis if condition is warranted; accompany and assist client when ambulating; use wheelchair for transporting client long distances.

Be sure that

appropriate plan of care.2. Subjective history is often not accurate. Knowledge of substance ingestion is important for accurate assessment of client condition.3. Excessive stimuli increase client agitation4. Client safety is a nursing priority.

evidence by understanding the cause of his restlessness.

side rails are up when client is in bed.

5. Ensure that smoking materials and other potentially harmful objects are stored away from client’s access.6. Monitor client’s vital signs every 15 minutes initially and less frequently as acute symptoms subside.

5. Client may harm self or others in disoriented, confused state.

6. Vital signs provide the most reliable information about client condition and need for medication during acute detoxification period.

GordonsBefore Hospitalization

During Hospitalization

Analysis and Interpretation

Health Perception/Management

He always consult a doctor whenever he feels sick

He realized the good effect of always consulting a doctor.

Normal concern regarding on his body

strength and capabilities.

Nutritional-Metabolic Pattern

He usually eats 4-5 times a day. He loves to eat food with high cholesterol .And usually drinks 6-7 glass of water a day.

He only eats 3-4 times a day; eating food with high cholesterol was minimized. And water demand was increased due to his present condition, usually 8-10 glass a day.

Decreased due to patient’s condition.

Elimination Pattern He usually urinates 4-5 times a day and defecates at least once a day.

He urinates 5-6 times a day and defecates once a day.

Patient number of void decreases due to lessen amount of oral intake

Activity-Exercise pattern Since his a jeepney driver he just seat for a longer period of time and not practicing any form of exercise.

He just spends his time talking to his wife during hospitalization.

Patient activity is altered because of being bedridden

Sleep-Rest Pattern He usually sleeps 2-4 hours a day.

He now has 6-7 hours of sleep a day and can sleep very well.

Interrupted sleep during hospitalization because of environmental factors and hospital procedure

Cognitive-Perceptual Pattern

He was very active, alert and responsive. Can understand and speaks well.

He was not that active, alert and responsive and slightly understands what others telling him.

Normal cognitive patterns

Self Perception/Concept He takes a bath every day, always well-groomed.He has a high self-esteem

He just takes sponge bath, slightly well-groomed. Still has high self-esteem.

Patient family was dependent on him.

Role-Relationship Pattern He was the father and living with family happily.

He can’t do the thing he used to do at home, his wife was very loving and caring, his sons and daughters visited him often due to his work.

Patient family was dependent on him.

Sexuality-Reproductive Pattern

Not Applicable Not Applicable Not Applicable

Coping-Stress Tolerance Whenever he feels stressed or has a problem, he just wrote all his feeling in a piece of paper then crampled and throws it, to relieve stress.

Whenever he feels stressed or has a problem, he just wrote all his feeling in a piece of paper then crampled and throws it, to relieve stress.

Patients display normal psychosocial, psychosexual and cognitive development. Emotional stability

Value-Belief Pattern

The client goes to church every Sunday with his family & always prays.

He can’t go to church but he still prays & has strong faith in God.

Patient has strong religious belief.

ANATOMY AND PHYSIOLOGY:Every cell in the human body needs energy in order to function. The body’s

primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or

when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

PATHOPHYSIOLOGY

PHYSICAL ASSESMENT

Normal Findings Actual Findings ANALYSIS

Level of consciousness

Conscious and coherent

Responsive

The client is conscious and coherent; responsive

Normal

Head (Skull, Scalp, Hair)

Skull

· Generally round, with prominences in the frontal and occipital area. (Normocephalic).

· No tenderness noted upon palpation.

Scalp

· Can be moist or oily.

· No scars noted.

· Free from lice, nits and dandruff.

· No lesions should be noted.

· No tenderness nor masses on palpation.

Hair

· Evenly distributed covers the whole scalp (No evidences of Alopecia)

· Maybe thick or thin, coarse or smooth.

· Neither brittle nor dry.

The client’s head has a round skull contour. The hair is thick, brown (on dye), and fine which is evenly distributed. The scalp is smooth and firm. No lesions noted.

Normal

Eyes Eyebrows

·Symmetrical and in line with each other.

·Maybe black, brown or blond depending on race.

· Evenly distributed. Eyes ·Evenly placed and inline with each other.

· Non-protruding.

Her eyes are symmetrical, black in color, almond shape. Pupils constrict when diverted to light and dilates when she gazes afar. Conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink.

Normal

·Equal palpebral fissure.

Eyelashes

· Evenly distributed.

Ears

· The ear lobes are bean shaped, parallel, and symmetrical.

· The upper connection of the ear lobe is parallel with the outer canthus of the eye.

· Skin is same in color as in the complexion.

· No lesions noted on inspection.

· The auricles are has a firm cartilage on palpation.

· The pinna recoils when folded.

· There is no pain or tenderness on the palpation of the auricles and mastoid process.

· The ear canal has normally some cerumen of inspection.

· No discharges or lesions noted at the ear canal.

· On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in

color

Ears are symmetrical with no discharge. The client’s auricles have the same color as the facial skin. It is mobile, firm, and not tender. The pinna recoils often as it is folded. Moderate loud voice is needed when talking with the client.

Most of the geriatric client has problem with their hearing. Thus, moderate loud voice is needed when talking with her.

Nose Nose

- Symmetric and straight

- No discharge or flaring

- Uniform color

- Not tender and no lesions

External nose is symmetric and straight. Cilia present upon inspection. Nasal septum is not deviated. Both nostrils are patent as each nostril is being occluded. No discharge, tenderness and lesions

Normal

- Patent nares

- Mucosa is pink

- Clear, watery discharge- Nasal septum intact and in midline

Facial Sinuses

- Not tender

noted. The sinuses are well outlined after trans illumination.

Mouth

Teeth and Gums

- 32 adult teeth

- Smooth, white, shiny tooth enamel

- Pink gums (bluish or dark patches in dark-skinned clients)

- Moist, firm texture to gums

- Smooth, intact dentures

Tongue/Floor of the Mouth

- Central position

- Pink color (some brown on borders for dark-skinned clients); moist; slightly rough; thin whitish coating

- Moves freely; no tenderness

- No prominent veins and palpable nodules

Uvula

- Midline

Oropharynx and Tonsils

- Pink and smooth posterior wall

- No discharge

Has dentition. Oral mucosa and gingival are pink in color, moist, and there were no lesions or inflammation noted. Tongue is pinkish with thin whitish coating and free of swelling and lesions.

Normal

Neck 1.The neck is straight. The client’s head is coordinated with smooth

Normal

2.No visible mass or lumps.

3. Symmetrical

4.No jugular venous distension (suggestive of cardiac congestion)

5. The trachea is palpable. It is positioned in the line and straight.

Lymph nodes1.May not be palpable. Maybe normally palpable in thin clients.

2. Non tender if palpable.

3. Firm with smooth rounded surface.

4. Slightly movable.

5. The thyroid is initially observed by standing in front of the client and asking the client to swallow.

Thyroid

1. Normally the thyroid is non palpable.

2. Isthmus maybe visible in a thin neck.

movements and no discomfort. The neck supports the head properly. No presence of abnormal swelling or masses. Lymph nodes are palpable. No nodules are palpable.

Thorax and Lungs

Posterior Thorax

- Chest symmetric

- Spine vertically aligned

- Skin intact; uniform temperature

- Chest wall intact; no tenderness; no masses

- Full and symmetric chest expansion (3-5cm gap)

- Bilateral symmetry of vocal fremitus

She has a slight deviation of respiratory rate of 22 breaths per minute. Breath sounds are clear on both lungs upon auscultation. Excursion shows a 3-cm gap during inspiration. No signs of swelling or masses noted.

Normal; slight deviation in respiratory rate (22bpm) may be possibly caused by her present condition.

Anterior Thorax

- Quiet, rhythmic, and effortless respirations

- Full symmetric excursion

- Bronchial and tubular breath sounds upon auscultation on trachea

Heart

- Neck veins – JVD at 45

- Carotid arteries:

- Palpation (Amplitude and contour) – upstroke and amplitude are bilateral

- Auscultaion – no bruits

- Precordium

- Inspection – no lifts or heaves

- PMI not visible

- Palpation – no parasternal impulses and no thrills

-PMI – palpable in 5th ICS, MCL, equal size

- Auscultation:

- S1 – heard best at apex, nl intensity

- S2 – heart best at base, nl splitting, A2 > P2

- Extra sounds – no S3, S4

- No murmurs

Pulsation in apical pulse is visible. No lifts and heaves noted. Cardiac rate is 76 bpm. Blood pressure is 130/80 mmHg. Reported chest pain frequently.

Common sign of HCVD CASHD is chest pain. Slight increased blood pressure of 130/80 mmHg is still manageable. Normal cardiac rate.

Breast - Rounded shape, slightly unequal in size

- Same skin color as

The client’s breast is rounded in shape, slightly unequal in size, and generally symmetric.

Normal

abdomen

- Skin smooth and intact

Areola

- Round/oval or bilaterally the same

- Color varies (pink to dark brown)

Nipples

- Round, everted, and equal in size

- Discharge for lactating mother

Axilla

- No tenderness, masses, or nodules

The skin color of the breast was the same color as of the abdomen. The breast nipples are erect and not inverted. No tenderness noted.

Abdomen

Inspection

- Unblemished skin

- Uniform color

- Flat, rounded (convex), or scaphoid (concave)

- Symmetric contour

- Symmetric movements caused by respiration

- No visible vascular pattern

Auscultation

- Audible bowel sounds

Palpation

- No tenderness; relaxed abdomen with smooth, consistent tension

The abdomen is uniform in color. It’s rounded and has a symmetric contour. No tenderness was palpated

Normal

Upper Extremities

- No edema

- Skin texture resilient and moist

The client has a brownish complexion. A capillary refill of 3 seconds was noted. No lesions and scars noted. Able to extend arms in

Normal

- Capillary refill test: immediate return of color (2-3 sec)

- Limbs not tender

- Symmetric in size

front or push them out to the side.

Lower Extremities

- No edema

- Skin texture resilient and moist

- Capillary refill test: immediate return of color (2-3 sec)

- Limbs not tender

- Symmetric in size

With bipedal edema, dry skin and with some lesions and bruises on legs. With color deviation, darker brown complexion compared to upper extremities.

Edema on the lower extremities may indicate increased fluid retention on the body. Color deviation (darker) may indicate altered circulation of blood/oxygen throughout the body.

Neurologic Assessment

- Conscious and coherent

- Able to respond to reflex tests

- Able to distinguish different sensory functions.

The patient is conscious and responsive upon interaction. But sometimes, she cannot directly and clearly answer all questions rendered. Reflexes such as Blinking reflex and deep tendon reflex are present. She was able to distinguish touch, pain, hot, and cold.

Due to old age and present condition, her ability to answer clearly and directly is altered.

ISMN NitrateVasodilator

60mg ½ tab/ OD

Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption.

CNS: headache

CV: tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension, angina, rebound hypertension, atrial fibrillation

GI: nausea, vomiting, abdominal pain, incontinenceGU: dysuria, urinary frequency

Give sublingual preparations under the tongue or in the buccal pouch; discourage patient from swallowing.

Give oral preparation on empty stomach, 1 hour before or 2 hours after meals; take with meals if severe, uncontrolled headache occurs

Captopril

Angiotensinconvertingenzyme(ACE) inhibitor

25mg/ ½ tab/ OD

Blocks ACE fromconvertingangiotensin I toangiotensin IIleading todecreased bloodpressure,decreasedaldosteronesecretion, a smallincrease in serumpotassium levels,and sodium andfluid loss;increasedprostaglandinsynthesis also maybe involved in theantihypertensiveaction.

CV:TachycardiaAngina ,MI, CHFRaynaud'ssyndromeHypotension insalt- or volumedepletedpatientsGI:Gastric irritationAphthous ulcersPeptic ulcersCholestaticJaundiceHepatocellularinjury, AnorexiaConstipationGU:ProteinuriaRenal insufficiencyRenal failurePolyuria,oliguriaUrinary frequencyHematologic:NeutropeniaAgranulocytosisThrombocytopeniaHemolytic anemiaPancytopenia

Assess for history ofallergy to captopril andhistory of angioedema.

Use cautiously in patientswith CHF, impaired renalfunction, salt or fluidvolume depletion, or inpregnant or lactatingwomen.

Administer 1 hr before orOr 2 hrs. before meals.

Watch out forexcessive perspiration,or diarrhea; may causehypotension

Trim Vasodilator 35mg/ Improves CNS: headache, Assess

Laboratory Diagnostic/ laboratory procedure

Date ordered and date result/s in

Indication or purposes

Result Normal used values (units in the hospital)

Significance and Interpretation Reports

Electrolytes NaK

Date ordered: 9/6/11Date Received: 9/7/11

Tests that measure the concentration of electrolytes are needed for both the diagnosis and management of renal, endocrine, acid-base, water balance, and many other conditions.

134.63.25

135-1453.4-4.0

The result is within normal values.

Clinical ChemistryALP (Alkaline Phosphates)ALT/SGPTCholesterolCreatinineFBS (Glucose)Total Protein

Date ordered: 8/1/11

Date Received 8/2/11

It is the area of pathology that is generally concerned with analysis of bodily fluids.

77.928.456.31.1980.1

35-12910-500-3844-10664-83

Some of the result is below or above normal range which indicated that there is something wrong in the release or secretion of body fluids.

AlbuminGlobulinA/g RatioUric Acid (BUA)

8.73.35.41.69.72

4.11- 5.93.4-4.83.0-3.51.1-1.80.14-0.41

Urinalysis Color

Transparency

ReactionSpecific Gravity AlbuminSugarRBcPus cellsSquamous cellsBacteria

Date ordered: 9/7/11Date Received 9/7/11

Urinalysis are performed for several reasons:

general evaluation of health

diagnosis of metabolic or systemic diseases that affect kidney function

Diagnosis of endocrine disorders.

Twenty-four-hour urine studies are often ordered for these tests

diagnosis of diseases or disorders of the kidneys or urinary tract

monitoring of patients with diabetes

testing for

Orange

Hazy

5.01.016

PositiveNegative0-11-3FewFewFew

Pale yellow Straw to amberClear to slightly hazyAcidic1.016- 1.022

NegativeNegative

NegativeNegativeNegative

NormalNormal

Glycosuria and Proteinuria due to increased glomerular permeability and presence of bacteria and pus cells for infection.

pregnancy

screening for drug abuse

HematologyHemoglobin

Hematocrit

Leukocyte

Platelet count

Date ordered: 9/7/11Date Received 9/8/11

It measures the total amount of hemoglobin in the blood , to determine the oxygen carrying capacity of the blood.

It measures the percentage of RBC’s in the total blood volume.It determines the number of circulating WBC’s of the whole blood.To evaluate platelet production. to assist in the diagnosis of bleeding disorders and to monitor patients who are being treated for any disease involving bone marrow

151g/ml

.467

8.2

271

120-180 gm/l

0.370-0.540

4.6-10.0

150-450

The result is within normal values.

The result is within normal values.

The result is within normal values.

The result is within normal values.

failure

DISCHARGE PLANNINGMedicine:

Ceftazidime 1g/IV/Q8 Aminoleban 1sachet/BID Kalium Duruyle 1tab/PO/TID Furosemide 40mg/IV/Q8 ISMN 60mg ½ tab/PO/OD Captopril 25mg ½ tab/ PO/OD Trimetazidine 35mg/tab/PO/BID Omeprazole 20mg/tab/PO/OD Metformin 500mg/tab/PO/OD Salbutamol neb Q6 Encouraged to take medications on time as prescribed by his physician. Report any adverse effect when taking the prescribed drug such as nausea

and vomiting or skin allergies. Instruct not to take other medications without consulting with the physician

to prevent any harmful drug-drug interactions.

Exercise: Encouraged patient to have adequate rest periods and sleep to promote

faster recovery. Encourage client to do deep breathing exercise to promote circulation of blood and

relaxations. Avoid lifting heavy objects. Advised client and family members to try to have or maintain safe, clean, comfortable and

calm environment.

Treatment: Advised client or significant others to take in time prescribed

medicines especially for high blood pressures.

Health Teaching: Encouraged to elevate the part where there is edema Teach the client to follow all the instructions including medications, diet

regimen and dos and don'ts that was instructed to him by the physician. Teach the patient to ensure rest for himself as much as possible. Encouraged the patient to comply with the medication as ordered by his

physician. Explain the importance of adhering to his treatment regimen.

Out- patient referral: Inform the patient to have follow-up check-ups to prevent further

complications and to update the medical team concerning the progress of the patient’s condition and to promote continuity of care.

Encourage him to comply with all the modifications and instructions given to her.

Advised significant others to immediately consult her physician if signs and symptoms of the diseases occurs or persist.

Diet: Emphasized limit fluid of intake. Keep on low fat, low sodium, full-diabetic diet. Encouraged to eat fruits and vegetables. Instructed to eat meals on time with proper diet.

SPIRITUAL Instruct client to attend mass every Sunday. Advised relatives or significant others to provide moral support and widen their

understanding. Also tell them to pray for the client to help with the recovery.