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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.
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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.
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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.
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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
Ischaemic heart disease 5.27 13.7%
Stroke and other cerebrovascular disease 4.91 12.8%
Chronic obstructive pulmonary disease 2.79 7.2%
Lower respiratory infections 2.07 5.4%
Diarrhoeal diseases 1.68 4.4%
HIV/AIDS 1.03 2.7%
Road traffic accidents 0.94 2.4%
Tuberculosis 0.93 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
Ischaemic heart disease 1.42 15.6%
Stroke and other cerebrovascular disease 0.79 8.7%
Trachea, bronchus, lung cancers 0.54 5.9%
Alzheimer and other dementias 0.37 4.1%
Lower respiratory infections 0.35 3.8%
Chronic obstructive pulmonary disease 0.32 3.5%
Colon and rectum cancers 0.30 3.3%
Diabetes mellitus 0.24 2.6%
Hypertensive heart disease 0.21 2.3%
Breast cancer 0.17 1.9%
World Deaths in millions % of deaths
Ischaemic heart disease 7.25 12.8%
Stroke and other cerebrovascular disease 6.15 10.8%
Lower respiratory infections 3.46 6.1%
Chronic obstructive pulmonary disease 3.28 5.8%
Diarrhoeal diseases 2.46 4.3%
HIV/AIDS 1.78 3.1%
Trachea, bronchus, lung cancers 1.39 2.4%
Tuberculosis 1.34 2.4%
Diabetes mellitus 1.26 2.2%
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.
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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
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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
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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.
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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.
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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
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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
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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
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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
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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 (-)
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PATHOPHYSIOLOGY
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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
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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.
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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
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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-blood7/30/2019 Diabetes Mellitus Rizza (Repaired) (1)
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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
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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 - -
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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).
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TT 0.5 SQ
Started: January 18, 2013 (8:50 pm) at ER
Generic Name Mechanism ofAction
Indication Side effects NursingResponsibilities
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
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ATS 6,000 TIM (-) ANST
Started: January 18, 2013 (9:00 pm) at ER
DRUG STUDY 47 | P a g e
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=3617/30/2019 Diabetes Mellitus Rizza (Repaired) (1)
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Drugs given at the Ward
Ketorolac 50 mg Q8
Started: January 18, 2013
Ended: January 22, 2013 (13 doses)
Generic Name Mechanism ofAction
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
Started: January 18, 2013
Ended: January 22, 2013 (8 doses)
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.
Started: January 19, 2013
Ended: January 28, 2013 (4 doses)
Generic Name Mechanism of
Action
Indication Side effects Nursing
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.
Started: January 19, 2013
Ended: January 29, 2013 (11 doses)
Generic Name Mechanism of
Action
Indication Side effects Nursing
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.
Started: January 20, 2013
Ended: January 29, 2013 (7 doses)
Generic Name Mechanism of
Action
Indication Side effects Nursing
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
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Metronidazole 500 mg TIV Q6
Started: January 22, 2013
Ended: January 27, 2013 (14 doses)
Generic Name Mechanism of
Action
Indication Side effects Nursing
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.
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Humulin r 10 units
Started: January 22, 2013
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
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acid Advise patient toavoid vigorousexercise immediatelyafter insulin injection,especially of the areawhere injection wasgiven, because itincrease absorptionand risk of highglucose episodes
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Fusidate sodium 5 grams, topical ointment
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Generic Name mechanism ofaction
Indication Side effects NursingResponsibilities
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=19927/30/2019 Diabetes Mellitus Rizza (Repaired) (1)
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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
DRUG STUDY 57 | P a g e
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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.
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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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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/Health7/30/2019 Diabetes Mellitus Rizza (Repaired) (1)
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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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ALGORHITM OF CAIR76 | P a g e
(+) 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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