case press1
TRANSCRIPT
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I. DEMOGRAPHIC DATA
NAME: L.F.L
AGE: 45
ADDRESS: 031 Payatas B, Quezon City
GENDER: Female
DATE OF BIRTH: Nov. 27,1964
PLACE OF BIRTH: Butuan City
CIVIL STATUS: Married
OCCUPATION: Housewife
RELIGION: Roman Catholic
EDUCATIONAL ATTAINMENT: High School Graduate
II. NURSING HISTORY
PAST HEALTH HISTORY
The client verbalized that she has a complete vaccine, Sabi kasi ng mga
magulang ko kumpleto ako ng vaccine. She doesnt have any diseaseswhen she was a child. Fever,cough and colds are the illnesses that she
encountered. And to threat this illnesses she always taking self prescribed
medicines like solmux, neozep and biogesic. She doesnt have any allergies,
accidents and injuries. She also told us that it is her first time to be
hospitalized.
FAMILY HISTORY OF ILLNESS
She verbalized that her father was died because of kulam. yun kasi yung
sabi nila kung bakit namatay, dahil daw sa kulam. Three years old ako nungnamatay sya kaya wala ako masyadong alam sa kanya she added. Her
mother was died because of myoma at the age of 39. Her grandmother and
her grandmother (mother side) was died because of hypertension. Yung lolo
at lola ko sa father side namatay sa katandaan, she added. She also said
that they doesnt have a history of diabetes.
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III.PATTERNS OF FUNCTIONING
HEALTH PERCEPTION AND HEALTH MANAGEMENT
For the client, being health means that you are taking good care of
yourself by means of taking a bath per day and by brushing her teeth 2x a
day, one in the morning and one in the evening. But she is not trimming her
nails since she was confined to the hospital. She rated her health as 9, 1 as
the lowest and 10 as the highest because she said that inaalagaan ko ang
sarili ko, umiiwas ako sa bisyo, malinis ako sa katawan at lagi ako
nagpapachek-up lalo na kung kinakailngan. She visits her physician
whenever she feels strange on her body especially when she was sick and
has fever.
She also stated that her husband is a chain smoker. Naninigarilyo yung
asawa ko pero sa labas ng bahay kasi meron akong maliliit na mga apo, she
added. She verbalized that there is a junk shop near their house. Minsan
mabaho sa amin kasi nagsusunog sila ng copper tska alambre, she stated.
She added that their ventilation is ok, Ok naman kasi medyo maluwang
naman yung bahay tska may mga puno naman sa harap bakuran. She
added May mga alaga din akong baboy. 10 years na akong nagaalaga, yung
kulungan nasa likod naman ng bahay. Hindi naman nangangamoy.
She takes metoprolol once a day for her health maintenance in
hypertension. The client usually cooks for herself before, but now that she
was hospitalized, she cannot prepare his own food because of her condition.
She said that it is alright because she knows that it is for the good of her
condition.
NUTRITIONAL AND METABOLIC PATTERN
Our client stated that proper nutrition is eating nutritious food. Sa palagay
ko naman ay kumakain ako ng masustansyang pagkain kasi ospital ang
nagbibigay ng pagkain, she also stated. She also told us that she hates
eating spicy foods, Mas gusto kong kumain ng mga gulay katulad ng pechay
basta mg adahon dahon wag lang maanghang. She usually eats at their
house together with his family. She also stated that she have sudden weigth
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loss. Hindi naman ako ganito kapayat dati, pero gawa ng akoy maospital eh
medyo pumayat ako. She sometimes experiencing eating difficulty of eating
foods because of her illness.,Minsan nawawalan akong ganang kumain,
marami kasing bawal
3 DAY DIET RECALL
TUESDAY (AUGUST
10, 2010)
BREAKFAST LUNCH MERIENDA DINNER
1 medium bowl of
lugaw
slice of orange
I pc. Of banana
(lakatan)
1 serving of adobo
(1 pc. Chicken)
1 medium bowl of
lugaw
2 pcs. Of tasty
bread
1 glass of
pineapple juice
(240 ml)
1 medium bowl of
lugaw
1 serving of paksiw
nab angus(1/4 na
bangus)
serving of pansit
1 pc of banana
(1L/day of water)
WEDNESDAY
(AUGUST 11, 2010)
BREAKFAST LUNCH MERIENDA DINNER
2 pcs. Medium
sized of pandesal
w/ meat loaf
glass of
powdered milk
1 medium bowl of
lugaw
1 serving ofsinabawang baka
skipped 1 serving of
chopsuey
1 medium bowl oflugaw
1 serving of
adobong manok
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(1L/day of water)
THURSDAY
(AUGUST 12, 2010)
BREAKFAST MERIENDA DINNER
2 pcs. Medium
sized of pandesal
w/ sausage
glass of
powdered milk
1 medium slice of
papaya
1 serving of
sinabawang baka
1 medium bowl of
lugaw
skipped 1 medium bowl of
lugaw
1 plate of pansit
1 serving of
adobong baboy
(1 matchbox sized)
(1L/day of water)
SLEEP AND REST PATTERN
The client usually sleeps 5-6 hours at night and she feels unrefreshed
every time she wakes up. Putol-putol tulog ko kasi ihi ako ng ihi. Tapos para
akong pagod pagkagising ko, she verbalized. She usually sleeps at 11pm
and wakes up at 5am. Watching TV and drinking milk helps her to easily fall
asleep. She is not engaged in self relation and any other activities. The client
sleeps in a room that have proper ventilation. She usually takes nap during
siesta on about 1-2 hours a day. She verbalized, Natutulog na lang ako sa
hapon para makabawi ng tulog.she is not using any drugs to fall her sleep.
She wants to sleep in lights off.
ELIMINATION PATTERN
The client usually defecates at least 1-2 times a day. She verbalized,
dumudumi ako tuwing umaga pagkagising ko. She usually goes to comfort
room when ahe feel the urge to defecate. She describes their comfort room
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clean and have adequate space. She desribe her stool smooth, brown in
color and have foul odor. She was not experiencing any problems regarding
her bowel movement.
With regards in her urination, she said, ihi ako ng ihi kaya pati pagtulog ko
naiistorbo. The client describe her urine having yellowish color. She alsosaid that she has not experiencing any pain when she urinates. Pakiramdam ko
tuloy lagi akong nanghihina saka nauuhaw she also added.
Self-Perception Pattern
The client perceived herself before hospitalization as a healthy and
happy person because Inaalagaan ko naman ng mabuti yung sarili ko as
verbalized by the client. She also added that she usually interacts with other
people to make herself happy. She verbalized maayos naman akong tao,
para sakin malusog ako, kundi lang talaga ako nahospital. She thinks of
herself as a healthy wife who takes good care of his husband and family. She
also verbalized sana nga hindi na lang ako nagkasakit, hindi ko tuloy
masubaybayan yung pamilya ko ng mabuti. She verbalized para mas
maging maayos ako, inaalagaan ko naman ng mabuti sarili ko kahit may
sakit pa ako, minsan, irritable lang kasi medyo mainit tapos madami pa
nagtatanung na estudyante
ROLE RELATIONSHIP PATTERN
The client said that she is currently living with her family. The client
stated that hindi naman mawawala ang problema sa isang pamilya, pero
syempre inaayos naming ito kaagad .She said that voicing out her opinions
relieved her. According to her she is satisfied with her role in the family,
being the mother, and the wife. Right now the client is not going through big
changes in her life.
COGNITIVE PATTERN
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The client is not having difficulty in hearing, understanding following
instructions, except for she is having some difficulty in reading, the client
stated Malabo na mata ko, may salamin ako sa bahay, the client uses
reading glasses with the grade of 100 both eyes.
VALUES AND BELIEF PATTERN
With regards to the Values and Belief of the client she stated that
para maging healthy kaylangan mong magtrabaho sa bahay para di ma
stroke. For her health is important she said that it is 100% important. She
has no religious practices relevance to her health. And she stated that
religion is very important for her because it helps a lot when she is dealing
with her problems in life.
SEXUALITY PATTERN
With regards to the sexuality of the client she said that she has no
difficulty with her opposite sex. She express herself by dressing and
grooming herself. until now she is engage in sex. But not often as before.
And her menstrual cycle is regular. And the client said that she is satisfied
with her sexuality. And she doesnt have any diseases regarding her
reproductive system.
COPING STRESS TOLERANCE PATTERN
With regards to the coping stress tolerance of the client she stated that
pag nagkakasakit ako ganun ang nakaka stress sakin dahil di ako makapag
trabaho sa aming bahay at para mawala ito umiinom ako ng gamot at ako
ay nagdadasal. Nakakatulong naman ang mga paraan kong ito para ang
aking stress. The client has no big changes in her life in the past two years.
And whenever she is encountering problems in her life she prays a lot. And
by that she will feel relieved.
IV. ACTIVITIES OF DAILY LIVING
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PATTERN BEFORE
HOSPITALIZATION
AFTER
HOSPITALIZATION
INTERPRETATION
and ANALYSISNutrition The client eats
three times a daythe client prefer
foods with soup
such as sinigang
and can
consumed 1
cup of rice, the
client has no
allergies to any
kind of food and
drinks 2 liters of
water a day.
The client still
eats three timesa day but she
only consumed 1
cup of rice during
her stay in the
hospital and
drinks 1 litter of
water a day
Decreased
metabolic activityand decrease
physical activity
mean a decrease
in caloric need.
(Kozier 8th
edition,
Fundamentals of
Nursing page
1243)
Elimination According to the
client she
urinates six times
a day and
defecate twice
during the
morning and
afternoon, shedescribed that
her feces is
brown,
During her stay in
the hospital the
client doesnt
know how many
times she
urinates because
she has a
catheter and sheonly defecate
once a day.
Although peoples
pattern of
elimination ate
highly individual
most people void
about 5 to 6
times a day.
(Kozier 8th
edition,
Fundamentals of
Nursing page
1290)Activity and
Exercise
The client states
that when she is
at home she
always clean the
house and wash
their clothes and
this is her
exercise
according to her.
The client always
stays at bed, sit
and walk in the
hallway.
Exercise and
Activity are
essential
components for
maintaining and
regaining health
and wellness.
(Kozier 8th
edition,
Fundamentals of
Nursing page
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1160)HYGEINE The client told
that she takes a
bath once
everyday,
brushes her teeth
everyday twice,
one in the
morning and one
in the evening.
She said that
over all, she
observes proper
hygiene.
Since
hospitalization,
she cannot take a
bath everyday
because of her
sickness. Her
sister wipes her
body for her
using a wet
towel. In terms of
brushing her
teeth, she still
brushes her teeth
twice a day.
Personal hygiene
is the self-care by
which people
attend to such
functions as
bathing, toileting,
general body
hygiene, and
grooming.
Hygiene is a
highly personal
matter
determined by
individual valuesand practices. It
involves care of
the skin, hair,
nails, teeth, oral
and nasal
cavities, eyes,
ears, and
perineal-genital
areas. (Kozier 8th
edition,
Fundamentals of
Nursing page
742)SUBSTANCE
ABUSE
The client does
not smoke or
drink alcoholic
beverages. The
client does not
use any illicitdrugs. Ayoko
uminom o
manigarilyo,
masama yan
The client does
not smoke, drink,
nor uses illicit
drugs.
Lifestyle refers to
a persons
general way of
living, including
living conditions
and individualpatterns of
behaviour that
are influenced by
sociocultural
factors and
personal
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characteristics.
(Kozier 8th
edition,
Fundamentals of
Nursing page
301)SLEEP AND REST According to the
client, she usually
sleeps 10 in the
evening and
wakes 7 in the
morning. The
client does not
have any
problem whensleeping. Before
she sleeps, she
washes her face
as her ritual.
There are days of
difficulty of
sleeping. She
sleeps
intermittently
because of the
temperature. She
verbalize that it is
hot and probablybecause of her
sickness
Most healthy
adults need 7 to
9 hours of sleep a
night, (National
Sleep Foundation,
n.d.b.). However
there is individual
variation as some
adults may beable to function
well (e.g., without
sleepiness or
drowsiness) with
6 hours of sleep
and others may
need 10 hours to
function
optimally. (Kozier
8th edition,
Fundamentals of
Nursing page
1168)SEXUAL ACTIVITY The client
verbalized Oo,
nag gaganun pa
kami ni mister
bago ako
nahospital, activepa. The client
also verbalized
that comparing
before, they are
not that active.
The client
verbalized that
syempre hindi
na
During middle
adulthood both
men and women
experience
decreased
hormoneproduction,
causing the
climacteric,
usually called
menopause in
women. (Kozier
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8th edition,
Fundamentals of
Nursing page
1021)
V. Physical Assessment
Physical AssessmentArea of
AssessmentNormal findings Actual findings
Evaluation
Body build,
height, weight
Proportionate,
varies with
lifestyle
endomorph
Wt: not taken
Normal
Posture and
gait, standing
sitting walking
Relaxed, erect
posture;coordinated
movement
Relaxed
normal
Overall hygiene
and groomingClean, neat Clean, neat
normal
Body and
breath odor
No body odor or
minor body odor
relative to work or
exercise; no
breath odor
Has no notable
body odor and
breath odor
normal
Signs of
distress in
posture and
No distress noted There is distress
noted
Deviated
from
Normal
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facial
expression
Obvious signs
of health and
illness
Healthy
appearance
The client has
slightly weak looking
appearance
Deviated
from
Normal
Attitude
Cooperative, able
to follow
instructions
Cooperative, able to
follow instructions
Normal
Affect/moodAppropriate to
situation
Appropriate to
situation
Normal
Quantity and
quality of
speech
Understandable,
moderate pace;
clear tone and
inflection; exhibits
thought
association
Speech not clear,
soft spoken
Deviated
from
Normal
Relevance and
organization of
thoughts
Logical sequence;
makes sense, has
sense of reality
Logical sequence;
makes sense, has
sense of reality
Normal
HEAD
Skull
Rounded
(normocepha
lic and
symmetric
with frontal,
occipital and
parietal
prominence)
; smooth
skull
contour;
Absence of
nodules and
Rounded
(normocephali
c)
n/a
Normal
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masses
Scalp
Lighter than
facial skin,
moist, no
scar;
No lesions
and
tenderness
upon
palpation
Lighter than
facial skin, no
scar
n/a
Normal
Hair
Evenly
distributed;
thick; silkyand
resilient;
no infection
or
infestation
Evenlydistributed
thick
n/a
Normal
Normal
Face
Symmetric
facial
features
Symmetric
facial
movements
Symmetric
facial features
n/a
Normal
EYES
No lesions
and
inflammatio
ns
No lesions
and
inflammations
Normal
Eyebrows Hair evenly
distributed;
skin intact
Symmetricall
y aligned;
equal
Hair evenly
distributed
Symmetrically
aligned;
n/a
Normal
Normal
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movement
Eyelashes
Equally
distributed;
Curled
slightly
outward
Equally
distributed
n/a
Normal
Eyelids
Skin intact;
no
discharge,
no
discoloration
Lids close
symmetrically
Approx. 15
20
involuntary
blinks per
minute;
bilateral
blinking;
When lids
are open, no
visible sclera
above
corneas, and
upper and
lower border
of cornea
are slightly
covered
no discharge,
no
discoloration
Lids close
symmetrically
bilateral
blinking;
n/a
Normal
Normal
Normal
Conjuctiva:
Bulbar
Conjuctiva
Transparent;
capillaries
sometimes
n/a
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Palpebral
Conjuctiva
evident
Shiny,
smooth, and
pink or red
n/a
Sclera sclera
appears
white
sclera
appears white
Normal
Cornea
Transparent,
shiny and
smooth
Client blinks
when the
cornea istouched
Transparent,
shiny and
smooth
n/a
Normal
Iris
Proportional
to the size of
the eye, with
transparent
anterior
chamber
Proportional
to the size of
the eye
Normal
Pupils
Black; equal
in size;
normally 3-7
inches in
diameter;
round,
smooth
border, iris
flat and
round
Black; equal
in size; round
Normal
Visual acuity Able to read
newsprint 14
inches away
20/20 vision
on Snellen-
100/100
Deviation
from
normal
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type chart
Pupils reaction
and
Accommodation
Pupils
constrict
when
looking atnear object;
pupils dilate
when
looking at
far objects;
Pupils
converge
when near
object is
moved
towards
nose
Pupils
constrict
when lookingat near
object; pupils
dilate when
looking at far
objects;
Pupils
converge
when near
object is
moved
towards nose
Normal
Normal
Lacrimal gland,
lacrimal sac
and
nasolacrimalgland
No edema,
no
tenderness
or tearing
noted
n/a
Extraocular
muscles
Both eyes
coordinated,
move in
unison, with
parallel
alignment
Both eyes
coordinated,
move in
unison, with
parallel
alignment
Normal
Visual fields Whenlooking
straight
ahead, the
client can
see objects
n/a
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in periphery
EARS
Auricles
Color same
as facial
skin;
symmetrical;
Aligned with
outer cantus
of eye,
about 10
degrees
from
vertical;
Mobile, firm
and not
tender;
pinna recoils
after it is
folded
Color same as
facial skin;
symmetrical;
Aligned with
outer cantus
of eye, about
10 degrees
from vertical;
n/a
Normal
Normal
External Ear
Canal
Distal third
contains hair
follicles andglands, dry
cerumen,
grayish-tan
color, or
sticky, wet
cerumen on
various
shades ofbrown
n/a
Hearing acuity Normal voice
tones
audible;
Able to hear
Normal voice
tones audible
n/aNormal
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ticking in
both ears
when
performing
the watch
thick test
Sound is
heard in
both ears or
is localized
at the center
of the head
(Weber
Negative)
when
performing
the tuning
fork test
AC hearing
is greater
than BC
hearing
(positive
rinne)
n/a
n/a
NOSE
External
Internal
Sinuses
Symmetric
and straight;
No discharge
or flaring;
Uniform
color
Not tender;
no lesion
Air moves
freely as the
Symmetric
and straight;
No discharge
or flaring;
Uniform color
no lesion
n/a
n/a
n/a
Normal
Normal
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client
breathes
through the
snares
Mucosa pink;
Clear watery
discharge;
no lesions;
nasal
septum is
intact and in
midline
Maxillary
and frontal
sinuses are
not tender
MOUTH
Lips
Outer lips:
Uniform pink
color; soft,
moist,
smooth
texture;
symmetry of
contour;
ability to
purse lips
Inner lips:
Uniform pink
color
Outer lips:
Uniform dark
pink color,
dry,
symmetry of
contour;
ability to
purse lips
Inner lips:
Uniform dark
pink color
Deviation
from
normal
Normal
Buccal mucosa moist,
smooth,
soft,
glistening,
and elastic
moist Normal
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texture
Teeth
32 adult
teeth;
smooth,
white, shiny
tooth
enamel
Total of 4
teeth
Deviation
from
normal
gums
pink gums;
moist and
firm texture
to gums; no
retraction of
gums
pink gums;
moist
normal
Tongue or floor
of the mouth
central
position;
pink color;
moist;
slightly
rough; thin
whitish
coating;
smooth
lateral
margins; no
lesions;
raised
papillae
moves
freely; no
tenderness
smooth
tongue base
with
prominent
central
position; pink
color; moist;
slightly rough;
thin whitish
coating; no
lesions;
moves freely
n/a
n/a
Normal
Normal
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veins
smooth with
no palpable
nodules
salivary duct
openings
have same
color of
buccal
mucosa and
floor of the
mouth
Palates
Uvula
light pink,
smooth soft
palate;
lighter pink
hard palate
with
irregular
texture
uvula is
positioned in
the midline
of soft
palate
n/a
n/a
Body partsNormal
Findings
Actual
FindingsInterpretation
Integumentar
y
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Skin
Skin color,
uniformity of
color
Varies from
light to deep
brown; from
rudy pink tolight pink;
from yellow
overtones to
olive
Generally
uniform
except onareas exposed
to the sun.
Fair complexion.
Skin color is
deep brown.
Normal
Presence of
edema
No edema No Edema noted
in joints.Normal
Presence of
lesions
according to
location,
distribution,
size, shape,
type or
structure.
Freckles, some
birthmarks,
some flat and
raised nevi; no
abrasions or
other lesions.
Nevi and freckles
noted on part of
the face. someskin areas are
wrinkled.
Normal
Skin moisture Moisture in
skin folds and
the axillae
Dry skinDeviation from
Normal
Skin
temperature
Uniform;
within normalrange
Uniform
temperature Normal
Skin turgor When pinched,
skin springs
back to
previous state
Skin springs
back to previous
state but not
immediately
Normal
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because of
wrinkled skin.
Nails
Fingernail plate
shape
Convex
curvature;
angle of nail
plate about
160
Convex
curvatureNormal
Fingernail and
toenail texture
Smooth
textureSmooth texture Normal
Fingernail and
toenail bed
color
Highly
vascular and
pink in light-skinned
clients; dark-
skinned clients
may have
brown or black
pigmentation
in longitudinal
streaks
Nail beds are
brown client has
long dirty nails
Deviation from
Normal
Tissuessurrounding
nails
Intactepidermis
Tissuessurrounding the
nails are not that
intact and
sloughing off.
Deviation from
Normal
Blanch test of
capillary refill
Prompt return
of pink or
usual color
(generally less
than 4seconds)
Return for 2
seconds.
Deviation from
Normal
Thorax
Posterior
Thorax
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Size, shape,
symmetry,
diameter of the
anteroposterior
thorax and
transverse
diameter.
Anteroposterio
r to transverse
diameter in
ratio of 1:2
Chest
symmetric
Chest symmetric Normal
Spinal
alignment
Spine
vertically
aligned
Client is kyphotic
but vertically
aligned
Temperature,
tenderness and
masses
uniform
temperature,
no tenderness,
no masses
During
symptoms, there
is tenderness
and difficulty of
breathing.
Normal
Auscultation of
posterior
thorax
Vesicular and
bronchovesicul
ar breath
sounds
Vesicular and
bronchovesicular
sounds noted.
Normal
Anterior
Thorax
Breathing
patterns
Quiet,
rhythmic,and
effortless
respirations
Quiet, irregular
breathingNormal
Temperature,
tenderness and
masses
uniform
temperature,
no tenderness,
no masses
Uniform
temperature, no
tenderness and
massess
Normal
Respiratory
excursion
Full and
symmetric
chest
expansion
Partial,
symmetric lung
expansion
Normal
Vocal fremitus Same as Vocal fremitus Normal
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posterior vocal
fremitus;
fremitus is
normally
decreased
over heart and
breast tissue
decreased over
heart and breast
Percussion of
anterior thorax
Percussion
notes resonate
down to the
sixth rib at the
level of the
diaphragm but
are flat over
areas of heavy
muscle and
bone, dull on
areas of the
heart and the
liver, and
tympanic over
the underlying
stomach
Resonate at the
level of
diaphragm but
flat over
mascular areas
and bone, dull
sounds are
heard on areas
of heart and
liver, tympanic
sounds on
stomach.
Normal
Auscultation of
the trachea
Bronchial and
tubular breath
sounds
Bronchial and
tubular sounds
present
Normal
Auscultation of
the anterior
thorax
Bronchovesicu
lar and
vesicular
breath sounds
Bronchovesicular
and vesicular
sounds
Cardiovascula
r
Aortic and
pulmonic areas
No pulsationsNo pulsations Normal
Tricuspid areas No pulsations,
lift or heave
No pulsations,
lift or heaveNormal
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Apical area Pulsations
visible in 50%
adults; no lift
or heave
no lift or heave Normal
Auscultation ofthe aortic,
pulmonic,
tricuspid and
apical valves
S1: usuallyheard at all
times and
usually louder
at apical area
S2: usually
heard at all
sites andusually louder
at the base of
the heart
S3 in children
and young
adults
S4 in many
older adults
S1 and s2sounds present
at the sites
where they are
usually heard
louder
Normal
Carotid
arteries
Palpation of
carotid artery
Symmetric
pulse volumes;full pulsations,
thrusting
quality
Carotid arteries
palpable withsymmetric pulse
volumes and
thrusing quality
Normal
Auscultation of
carotid artery
No sound
heard on
No sounds
auscultated
Normal
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Muscles size Equal size on
both sides of
the body
Equal size on
both sides of the
body
Normal
Inspection of
the muscle andtendons for
contractures
No
contractures
No contractures
Normal
Fasciculations
and tremors
No tremors Has tremors Deviation from
Normal
Muscle tonicity Normally firm Normally firm Normal
Bones
Inspection of
skeleton for
structure
No deformities Deformities
noted on joints
specifically on
joints.
Deviation from
Normal
Palpation of
bones to locate
any areas of
edema or
tenderness
No tenderness
or swellingNo swelling or
tendernessNormal
Joints
Swelling No swelling No Swelling
noted
Deviation from
Normal
Tenderness,
smoothness of
movement,
swelling,
crepitation, ad
presence ofnodule.
No
tenderness,
swelling,
crepitation, or
nodules
Joints move
smoothly
no swelling joints Normal
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Range of
motion
Varies to some
degree in
accordance
with persons
genetic
makeup and
degree of
physical
activity.
Limited range of
motionNormal
VI. LABORATORY AND DIADNOSTIC PROCEDURES
XI. ECOLOGIC MODEL
A. Hypothesis
Diabetes Mellitus is a condition in which the pancreas can no longer
produce enough insulin or cells stop responding to the insulin that isproduced, so that glucose in the blood cannot be absorbed in the cells of the
body.In the case of our patient, the form of diabetes she has is Type 2; it is
sometimes called age-onset or adult- onset diabetes. She is aged 43 years
old and lives a sedentary lifestyle by being a vendor on their little store,
sitting the whole day. Our client was also diagnosed with Coronary Artery
Disease and some other complications.
B. Predisposing Factors
Host-Female
-45 years old
-sedentary lifestyle
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-Coronary Artery Disease
Agent-Chemical- glucose (and any type of sugar)
Environment-living conditions (average)-economic level (average)
C. Ecologic Model
HOST
ENVIRONMENTAGENT
D. Analysis
The agent-host-environment model is primarily use in predicting illnessrather than promoting wellness, although identification of risk factors that
result from the interactions of agent, host, and environment are helpful inpromoting and maintaining health. Because each of the agent-host-
environment factors constantly interacts with others, health is an ever
changing state. Health is seen when all three elements are in balance while
illness is seen when one, two, or all three elements are not in balance.(Fundamentals of Nursing by Kozier)
Type 2 Diabetes Mellitus, previously called NIDDM or adult-onset
Diabetes Mellitus, is a disorder involving both genetic and environmental
factors. Type 2 Diabetes Mellitus is the most common type of Diabetes
Mellitus, affecting 90% of all people who have the disease. In addition, the
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prevalence of Coronary Artery Disease in people with DM is twice that in non-
diabetic population. (Medical-surgical nursing by Black)
E. Conclusion and Recommendations
We therefore conclude that our client is suffering from Type 2 DiabetesMellitus, probably due to her age, sedentary lifestyle, as well as herpredisposition to coronary artery disease. Other risk factors may also involvesuch as age and the way of living. There are complications that preceded herDiabetes mellitus such as chronic kidney disease, Type 2 Diabetes Mellitus,hypertensive diabetes mellitus, and PTB4.
Recommendations would include health promotion in assisting theclient and family to understand DM and the necessary lifestyle changes suchas regular and well-balanced diet.
VIII. PROBLEM IDENTIFICATION
CUES NURSING DIAGNOSIS
Subjective data:
The client always verbalized, Ang
pait naman ng mga gamot na yan,para san ba ang mga yan?
Ano ba ang dapat kong gawin sasakit ko?
Objective:
The client always asking about herdisease progression.
Ineffective Management of Therapeutic
Regimen related to knowledge deficit
related to Diabetes Mellitus
S-ihi ako ng ihi sa gabi.
M-glucose is 150mg/dL
O-the client is weak
Imbalanced Nutrition: less than body
requirements
Pakiramdam ko
lagi akong
Fluid volume deficient related to osmotic
diuresis from hyperglycemia
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nanghihina saka
nauuhaw
IX. PROBLEM PRIOTERIZATION
Nursing diagnosis Rank JustificationImbalanced nutrition
less than body
requirements related to
deficiency of insulin.
Ineffective management
of therapeutic regimen
High
Medium
This is because the need
for food requirement
specially glucose for
cells is depressed.
Therefore, it needs
prompt attention. This is
a life threatening
situation if not
immediately treated it
may risk the life of the
patient since the
physiologic needs is
involved. This can be
modified since there is
sufficient foods. This can
lead to malnutrition and
exaggeration of other
complications brought
about by DM., if not
treated. The client
wants all regimens to bedone for hr wellness.
This is health
threatening because if
not immediately
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Fluid volume deficient
related to osmotic
diuresis from
hyperglycemia
Low
resolved it may risk the
health of the client
specially in managing
her situation. If
management still
ineffective other
complications may
arise. The clients want
to improve and have
knowledge about
managing her situation.
The problem is a health
deficit and requires less
immediate attention
because this is only
manifestation of
underlying disease. It is
modifiable since it
requires treating the
underlying disease. If
not prevented it will
result to dehydration
from polydipsia and
polyuria associated with
DM.
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XII. DISCHARGE PLAN
M edications to take at home
Medications of the patient should include Cefixime, Indur, Amlodipine,
Spirinolactone, Aspirin, Enalapril, Digoxin, Furosemide. These drugs should
act not only for the DM of the patient but as well as the other complications
brought about her illness. Advise patient to have strict compliance on the
medication regimen given by her physician.
E xercise
Client is advised to start any new activity at a well-tolerated intensity
level and duration(three to five times weekly or depending on the preference
of the client), with gradual (over a period of weeks or months) increases in
intensity and duration until preset exercise goals. Exercise should include
warm-up and cool-down periods before and after activity. It is best to
exercise once, at the same time of the day, if possible.
T reatments
Tell patient that treatments or medical management for Diabetes
Mellitus includes restoring and maintaining blood glucose levels to as near asnormal as possible by balancing diet, exercise, and the use of oral
hypoglycemic agents. Educate client that multiple medications are often
needed to achieve optimal glycemic control.
After adhering to the treatment regimen, the client should learn how to
monitor her blood glucose. You should demonstrate the techniques of blood
glucose self-monitoring, discuss the normal blood glucose range, goals for
good control (individualized for each client), when to test, how to record test
results, and what to do when abnormal results are obtained.
H ealth Teachings
Initial as well as ongoing client education is vital in helping the client
manage this chronic condition. As a nurse educator, you should explain to
the client and the family the basic pathophysiologic mechanism of Diabetes
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mellitus and how the disorder is managed. Health promotion actions and
health maintenance activities for Type 2 diabetes mellitus are as follows:
Follow eating habits based on the diet ordered by the dietician.
Avoiding foods high in refined sugars and saturated fats.
Maintaining ideal body weight
Exercising regularly
Using strategies shown to reduce complications of diabetes mellitus by
gradually removing coexisting factors such as smoking, hypertension,
and hyperlipidemia. (high-fat diet)
Teach meal planning and physical activity
Control of the complications by following the treatment regimen.
O ut patient follow-up
Clients require consistent follow-up, updating, and reinforcement.
Performing periodic assessments to determine the clients needs and to
assess glycemic control is necessary. Advise the client to have a follow-upcheck up when they see emerging symptoms or complications of diabetes
mellitus. This, in turn, could prevent possible recurrence of the disease
and to reinforce learning needs as well. The out patient visit is advised by
the physician.
D iet
Emphasize to the client and family members that they are not eating a
diabetic diet but, rather, are following a balanced meal plan. You should
also emphasize that nutritional changes can help to lower blood glucoselevels, decrease lipid levels, and lower blood pressure.
We should also consider the effect of alcohol and artificial sweeteners.
Clients may not need to give up alcohol beverages entirely; it should be in
moderation since the alcohol has calories which may, as well, affect the
glucose level of the patient. In regard with the artificial sweeteners, it
may help client achieve desired caloric restrictions.
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Recommended nutritional guidelines for clients with DM:
Calorie sufficient to achieve and maintain reasonable weight
Protein adequate to ensure maintenance of body protein stores. In
general, 10%-20% of total daily calories should be from protein. (equalto ~0.8 g/kg/day)
Fats less than 30% of calories should be from fat, less than 10% of
that from saturated fat sources; cholesterol intake should be limited to
300 mg/day or less.
Carbohydrates 50%-60% of total calories should be from
carbohydrates.
Fiber consume 20-35 g of fiber per day.