Escolar Documentos
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COLEGE OF NURSING
S.Y. 2008-2009
SUBMITTED BY:
RACHAEL ANN B. ESPINOSA
BSN III-A
GROUP A2
SUBMITTED TO:
MS. MARIA TERESA MENDOZA
CLINICAL INSTRUCTOR
PATIENT’S PROFILE
NAME: Mr. M
AGE: 54 YEARS OLD
SEX: Male
CIVIL STATUS: Married
OCCUPATION: Jeepney Driver
RELIGION: Roman Catholic
POSITION IN THE FAMILY: Father
ADDRESS: Gerona, Tarlac
DATE OF BIRTH: July 16, 1953
NATIONALITY: Filipino
HEIGHT: 5’4
WEIGHT: 76 kg
DATE OF ADMISSION: July 10, 2008
CHIEF COMPLAIN: Non-healing wound on the ® foot
DIAGNOSIS: Type II Diabetes Mellitus uncontrolled
Diabetic foot ®
INTRODUCTION
The cause of the common form of type II diabetes mellitus is
unknown. The genetic of type II are complex and not clearly defined.
Autoimmune mechanisms are not involved. Individuals with maturity
onset diabetes of youth (MODY), a subset o type II, are normal weight
to underweight. MODY is thought to be auto somal dominant because it
affects 50 % of first-degree relatives.
13 AREAS OF ASSESSMENT
1. SOCIAL STATUS
Mr. M is a 54 year old male born on July 16, 1953. He is presently
residing at Gerona, Tarlac. He is third eldest son to a family of 11
members. He worked as a company driver of a Chinese businessman in
Angeles City, Pampanga for more than 10 years. But he is now
currently driving his own passenger jeepney. He is a high school under
graduate. He lives with his wife and 3 children including his 2 sons-in-
law and 2 grandsons. He declares that his salary is just enough to
sustain their daily needs. He interacts respectfully to others and is
friendly. His family is a devout Catholic and they go to church together
every Sunday.
2. MENTAL STATUS
LEVEL OF CONSCIOUSNESS:
As I talked to him, he is increased in level of alertness, conscious
and coherent. He responded to some questions appropriately.
ORIENTATION:
Mr. M is aware of his present condition. He knows some of the
reasons why he was admitted in the hospital. The patient is well
oriented about the time, place, person, and date. And he is able to
answer all questions asked.
SPEECH:
Mr. M’s spoken words can be clearly understood. He can
understand and able to speak Tagalog, Ilocano and a bit of Pampango.
3. EMOTIONAL STATUS
AUDITORY ACUITY TEST: Patient can hear the words I was talking to him
a to a distance of 2 meters and he was able to hear me.
NORMS: Normal visual acuity of the person is 20/20. Visual acuity can
be impaired by pathology affecting the optic nerve or
neovascularization of the optic nerve with resultant bleeding and
related to diabetes mellitus. The patient should be able to perceive
light touch, superficial pain, and temperature accurately. Should be
able to distinguish and identify the odor with each nostril. Normal
sensation would be accurate perceptions of sweet, sour, salty, and
bitter tastes. (Health and Assessment and Physical Examination, 3rd
Edition by Estes)
5. MOTOR STABILITY