Phase 2 (Chronic Phase), HOME CARE MANAGEMENT OF DM


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Bronchial Asthma in Acute Exarcebation, Diabetes Milletus Type 2, and Hypercholesterolemia

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Phase 2 (Chronic Phase), HOME CARE MANAGEMENT OF DM

  1. 1. Name: Dave Jay S. Manriquez RN 2. Heredofamilial disease includes asthma on Subject: Adult Health Nursing phase 2 her paternal side and diabetes on her (Chronic Disease) maternal side. Patient is allergic to chicken Time: 6-9pm and seafoods which include shrimp, crab and squid. She is also allergic to Biographic data: Fluticasone+Salmeterol (Seretide). Patient Name: S.G. 3. Year 1994 – Patient sought consult at Age: 51 years old Compostela Clinic for complaints of difficulty Gender: Female in breathing. It was triggered by exposure to Address: Compostela, Cebu dust and smoke and by emotional stress. 4. Year 1999 – Patient was admitted at Visayas Admitting Hospital: Cebu Velez General Hospital Community Medical Center for complaints of Admitting Date: September 5, 2009 difficulty in breathing. She was diagnosed with Admitting time: 9:47pm asthma. 5. Year 2000 – Patient was admitted at Cebu Chief Complaints: Difficulty of breathing 8 hours prior Velez General Hospital for complaints of to admission and vomiting amounting to 1 glass of difficulty in breathing under the service of Dr. previously eaten food noted 9 hours prior to admission. Giselita Maambong. She was diagnosed with bronchial asthma. Diagnosis: Bronchial Asthma in Acute Exarcebation, 6. May 2005 – Patient was admitted for asthma Diabetes Milletus Type 2, and Hypercholesterolemia attack 7. July 2005 – Patient was admitted for difficulty SUMMARY OF SIGNIFICANT FINDINGS in breathing secondary to bronchial asthma 8. September 2005 – Patient was admitted for PRESENT HEALTH HISTORY difficulty in breathing and productive cough at Cebu Velez General Hospital under the service 1. Two days prior to admission, patient had of Dr. Manuel Emerson Donaldo. She was productive cough with mucopurulent sputum. No diagnosed with Bronchial asthma, CAP medications were taken. ( Community Acquired Pneumonia) and 2. Nine hours prior to admission, patient had the onset Urinary Tract Infection. of vomiting amounting to 1 glass of previously 9. November 2005 – Patient was admitted again eaten food. Minutes after the first episode of at Cebu Velez General Hospital for complaints vomiting, patient had another episode which of difficulty in breathing secondary to consists of saliva. She didn’t take medication for bronchial asthma relief of symptoms. 10. . She was diagnosed with Bronchial asthma 3. 8 hours prior to admission, patient had the onset of and Contact Dermatitis difficulty in breathing. It was precipitated since she 11. August 2006 – Patient was again admitted at wasn’t able to sleep well because she was awoken Cebu Velez General Hospital under the service up by her mother. No consult was done. Difficulty of Dr. Manuel Emerson Donaldo of Dept. of of breathing is associated with nasal flaring. Internal Medicine for complaints of difficulty Patient took Salbutamol + ipratropium nebulization in breathing secondary to bronchial asthma. with slight relief of symptoms. She was also diagnosed with Diabetes Mellitus 4. Hours prior to admission, patient had difficulty in Type 2. breathing that cannot be tolerated. She took 12. September 5, 2009 – Patient was admitted Salbutamol + ipratropium nebulization but no again for complaints of difficulty in breathning relief was noted. secondary to Bronchial Asthma. PAST MEDICAL HISTORY GORDON’S FUNCTIONAL HEALTH PATTERN 1. Patient is a known diabetic for 3 years with 1. Patient doesn’t have regular check-up. highest CBG of 333mg/dl and lowest CBG of 2. She doesn’t use efficascent oil and omega since she 108 mg/dl. She was diagnosed with DM is allergic from those. Patient doesn’t practice Type 2 last 2006 by Dr. Manuel Emerson Breast Self Examination Donaldo at Cebu Velez General Hospital. 3. she rates her health 7/10 as 10 as the highest and Patient is also known asthmatic for 15 years. 1 as the lowest. She was diagnosed with asthma by Dr. 4. Patient was also diagnosed with DM Type2 last Danggoy at Compostela Clinic. August 2006 5. Her highest CBG is 333mg/dL and lowest CBG is 108mg/dL.
  2. 2. 6. Patient has the height of 5’2”, weight of 60kg nutrients (imbalance between intake and and IBW of 51.73 kg. utilization of glucose) to meet metabolic needs 7. She likes to eat sweets like chocolate. as evidenced by change in weight, muscle 8. She takes in Multivitamins only when she feels weakness, increased thirst and urination, and fatigued and when they have supply. She doesn’t hyperglycemia have any regular check-up.  Risk for impaired adjustment due to change in 9. She drinks 10 or more glasses of water. lifestyle, self concept requiring lifelong 10. She has no difficulty in voiding but she had UTI adherence to therapeutic regimen last September 2005.  Risk for infection due to decreased leukocyte 11. Patient claims that she is under stress which function, circulatory changes and delayed suspected her condition. healing. 12. She claims that there are times that she has  Risk for disturbed sensory perception due to difficulty in sleeping. endogenous chemical alteration (glucose, 13. During Onset of illness (September 5, 2009), insulin and electrolyte imbalances) patient claims that she doesn’t able to sleep well.  Compromised family coping related to 14. During hospitalization, patient has difficulty or has inadequate understanding by primary persons, sleeping disturbances due to taking of medicines in developmental crises, lifelong condition between and shortness of breath in between periods requiring behavioral changes impacting family of sleep. as evidenced by verbalizations that they are 15. She uses reading glasses to aid her in reading. having difficulty coping with situation, family Patient had no regular check-up with an eye does not meet physical/emotional needs of its doctor. members 16. She claims that there are times she has impaired sense of smell when she has difficulty in breathing. PHYSICAL EXAMINATION General Appearance  Head to Toe Assessment • dirty fingernails and toenails • presence of dental caries, decayed teeth  Neurologic Assessment • Cognitive, Cerebellar, Sensory • Cranial Nerves • Muscle Strength • Deep Tendon Reflex DIAGNOSTIC TESTS  Capillary Blood Glucose  Glycosylated Hemoglobin: 6.8% ( normal value: 4.5-6.3%)  Urinalysis  Lipid Panel: Glucose: 163 mg/dL normal 75-116 NURSING DIAGNOSES  Deficient knowledge regarding disease process/treatment and individual care related to unfamiliarity of the disease, lack of information, misinterpretation as evidenced by request for information, statements of concern, inadequate follow through of instructions and development of complications  Imbalanced Nutrition: less than body requirements related to inability to utilize
  3. 3. EXERCISE Regular exercise is an important part of diabetes control. Diabetes Mellitus Type 2 Home Care Management Exercise lowers blood glucose by: 1. increasing carbohydrate metabolism DIET 2. fosters weight reduction and maintenance 3. increase insulin sensitivity/enhance action The general goal of dietary management is to help of insulin diabetic clients improve metabolic control by 4. increase high-density lipoprotein (HDL) making changes in nutrition habits. levels 5. decreases triglyceride levels Specific goals include: 6. lowers blood pressure  Improving blood glucose lipid levels 7. reduce stress and tension  Facilitating weight management (in type 2 8. improve cardiovascular fitness diabetes)  Providing adequate nutrition for all stages Exercise at least 3 times a week for at least 30 of life and with coexisting medical minutes each session. Always carry quick sugar conditions sources like candy or soft drink to avoid hypoglycemia (low blood sugar) during and after * Avoid simple sugars like cakes and chocolates. exercise. Instead have complex carbohydrates like rice, pasta, cereals and fresh fruits. Example of exercises: * Do not skip or delay meals. It causes fluctuations 1. walking – is usually well tolerated in blood sugar levels. 2. stationary bicycle/swimming – possible for * Eat more fiber-rich foods like vegetables. client with foot problems * Cut down on salt. * Avoid alcohol. Dietary guidelines recommend no Interventions: more than two drinks for men and no more than 1. Clients with diabetes mellitus must consult one drink per day for women. the physician before starting an exercise program. Pre exercise screening may Interventions: include a: 1. It is also individualized based on the  History client’s current or desired weight and the  Physical examination presence of other existing health problems.  Glycosylated hemoglobin 2. Dietary intake should include 3 meals per  Exercise stress test day, eaten at consistent intervals, plus a  Foot evaluation mid afternoon carbohydrates snack and a  Laboratory determination of blood bedtime snack high in protein (e.g. peanut, glucose level butter sandwich); consistent intake of carbohydrates at each meal and snack is 2. Check the blood glucose levels before and needed. after strenuous exercise. 3. Instruct client to plan exercises on a Example of food items to treat Hypoglycemia for regular basis each day. Have the client Type 2 DM: plan an alternative activity in case  Commercially prepared glucose tablets environmental or other factors make th  6 to 10 life savers or hard candy usual exercise difficult. Unplanned  4 tsp of sugar exercises can be dangerous for clients  4 sugar cubes taking insulin or oral hypoglycemics  1 tbsp of honey or syrup agents.  ½ cup of fruit juice or regular (nondiet) 4. Clients with diabetes mellitus must start soft drink any new activity at a well-tolerated  8 oz low-fat milk intensity level and duration with gradual  3 graham crackers (over a period of weeks or months)
  4. 4. increases in intensity and duration until 3. Assess the client’s knowledge of diabetes preset exercise goals are reached. mellitus and the use of oral hypoglycemic. 5. Clients should make sure they are 4. Teach the action, use and side effects of adequately hydrated before starting oral antidiabetics agents. exercise. 5. Remind that aspirin, alcohol, 6. Advise client that prolonged strenuous sulfonamides, oral contraceptives, and exercise may require increase food at monoamine oxidase inhibitors increase the bedtime at bedtime to avoid nocturnal hypoglycemic effect, causing a decrease in hypoglycemia. blood glucose levels. 7. Exercise should include warm-up and cool 6. On the other hand, glucortocoids, thiazide down periods before and after the activity. diuretics, and estrogen increase blood 8. Counsel patients to inject insulin into the glucose levels. abdominal site on days when legs are 7. Teach client to recognize symptoms of exercise. hypoglycemia and hyperglycemia. 9. The primary effect of acute exercise is 8. Teach the client to avoid over-the-counter hypoglycemia (low glucose level), which medications unless prescribed by the is a significant risk for clients who physician. exercise while taking insulin or oral 9. Inform the client with type 2 DM that hypoglycemics. Adjustments are insulin may be needed during stress, sometimes needed to prevent surgery, or infection. hypoglycemia in the client taking insulin, 10. Teach the client about importance of because hepatic glucose production is compliance with the prescribed blocked or partially inhibited by medications. exogenous insulin. 10. During periods of exercise, the muscles are INSULIN stimulated to take up glucose therefore, blood glucose levels should be checked Is used to treat type 1 DM and type 2 DM when because it can fall abruptly. diet and weight control therapy have failed t maintain satisfactory blood glucose levels. WEIGHT CONTROL 1. Assist patient to reduce fear of injection by If you are overweight or obese, start weight encouraging verbalization of fears reduction by diet and exercise. This improves your regarding insulin injections conveying a cardiovascular risk profile. sense of empathy, and identifying supportive coping techniques. * It lowers your blood sugar 2. Demonstrate and explain thoroughly the * It improves your lipid profile procedure for insulin self-injection. * It improves your blood pressure control 3. Help client to master technique by taking a step-by-step approach. MEDICATIONS  Allow patient time to handle insulin and syringe to be familiar Oral hypoglycemics medications are prescribed for with the equipment. clients with DM type 2. Maintain a normal blood  Teach self-injection first to pressure level. Since having hypertension puts a alleviate fear of pain from person at high risk of cardiovascular disease, injection. especially if it is associated with diabetes, reliable  Instruct patient in filling syringe BP monitoring and control is recommended. when she express confidence in self-injection procedure. 1. Identify any barriers to learning, such as  Review dosage and time of visual or hearing impairment, low literacy, injections in relation to meals, and distractive environment. activity and bedtime based on 2. Encourage active participation of the client client’s individualized insulin and family in the educational process. regimen.
  5. 5. 4. Teach the client regarding the importance 7. Early laser photocoagulation therapy can of knowing the peak action time of insulin reduce risk of vision loss. to prevent any possibility of hypoglycemic reactions occurring during therapy. PATIENT EDUCATION FOR FOOT CARE: Signs and symptoms of hypoglycemic: 1. Provide meticulous skin care and proper  Headache foot care.  Irritability/restlessness/shakiness 2. Inspect feet daily and monitor feet for  Disorientation redness, swelling, or break in skin  Nausea and vomiting integrity.  Diaphoresis/ sweating/ cool skin 3. Notify the physician if redness on a break  Pallor in the skin care.  Weakness 4. Avoid thermal injuries from hot water,  Convulsion/ seizure heating pads, and baths. 5. Wash feet with warm (not hot) water and Signs and symptoms of hyperglycemia: dry thoroughly (avoid foot soaks).  Headache 6. Do not soak feet.  Nausea and vomiting 7. Do not threat corns, blisters, or ingrown  Coma toenails.  Flushed, dry skin 8. Do not cross legs or wear tight garments  Glucose in urine that may constrict blood flow.  Kaussmaul’s respiration 9. Apply moisturizing lotion to the feet but  Rapid thread pulse not between toes. 10. Prevent moisture from accumulating PATIENT EDUCATION FOR EYE CARE between the toes. 11. Wear lose socks and well-fitting (not tight) Teach the visual complication of DM. shoes, and instruct the client not to go barefoot. 1. DM can cause diabetic retinopathy, which 12. Change into clean cotton socks daily. can lead to vision loss. 13. When socks to keep feet warm. 2. There is a relationship between 14. Do not wear open-toed shoes or shoes with hyperglycemic and diabetic retinopathy. It a strap that goes between the toes. is extremely important to normalize blood 15. Check shoes for cracks or tears in the glucose level. lining and for foreign objects. 3. Hypertension can worsen diabetic 16. Cut toenails straight across. retinopathy. Its diagnosis and aggressive 17. Do not smoke. treatment are important. 4. If the client’s vision is blurred while Remember reading, he may have hyperglycemia or molecular edema. Floaters may indicate If you have the classic symptoms of diabetes: hemorrhage, and flashing lights may indicate retinal detachment. If the client * See your doctor for blood sugar testing experiences any of these occurrences, it * Start dieting should be reported. * Eat plenty of vegetables 5. If the client has diabetic retinopathy, he * Avoid sweets such as chocolates and cakes should know that isometric exercises raise * Cut down on fatty foods intraocular pressure and can aggravate * Exercise regularly proliferative retinopathy. * If you are obese, try to lose some weight 6. An ophthalmologist will be brought in to * Avoid alcohol drinking and stop smoking be part of the client’s diabetes * If you are hypertensive, consult your doctor for management team. If you have any visual advice and management impairment, he can be referred to appropriate organization for assistance