A Case Presentation On

DIABETES MELLITUS
In partial fulfilment for the Requirements in Related Learning Experience III

Presented to: Mrs. Rubilyn Bulquerin - Sumaylo, R.N. Mrs. Nadia Bisnar, R.N. Ms. Maureen N. Patricio, R.N. Presented by: Celestial, Charmie Lou D. Contreras, Patricia Janelle A. Deocampo, Melode Jean A. Fonte, Ann Marie Zol H. Horneja, Mary Georgette Gay M. Langurayan, Deo Ray C. Lauron, Jasmin Joyce A. Sarbues, Arvin C. Toledo, Maria Evette M. Trinidad, Gladys Mae D. Verjes, Kathleen Jade S BSN B 2013

TABLE OF CONTENTS
Page

I. II. III. IV. V. VI.

VII.

VIII.

IX. X. XI. XII. XIII. XIV. XV. XVI.

Acknowledgment-------------------------------------------3 Introduction-------------------------------------------------4 Objectives---------------------------------------------------- 5 Textbook Discussion---------------------------------------6-7 Anatomy and Physiology---------------------------------8-9 Vital Information-------------------------------------------10 a. Clinical Assessment----------------------------------------11 b. Present Health Status-------------------------------------11 c. Past Health Problem/ Status----------------------------11 d. Family Genogram---------------------------------------- 12 e. Patterns of Functioning-----------------------------------13 Brief Social, Cultural, and Religious Background --14 a. Educational Background--------------------------------- 14 b. Occupational Background------------------------------- 14 c. Religious Practice------------------------------------------ 14 d. Economic Status--------------------------------------------14 Clinical Inspection------------------------------------------14 a. Vital Signs---------------------------------------------------- 14 b. BMI-------------------------------------------------------------14 c. Physical Assessment---------------------------------------15-16 d. General Appraisal------------------------------------------16 Laboratory and Diagnostic Reports-------------------17-20 Pathophysiology-------------------------------------------21 Medical Management------------------------------------22-43 Concept Map ---------------------------------------------- 44-45 Nursing Management -----------------------------------46-55 Discharge Planning--------------------------------------- 56-57 Our Journey-------------------------------------------------58 References-------------------------------------------------- 59

Acknowledgment
People may come and go, but there are people who left footprints in our hearts. They are the people who are nevertheless worth our heartfelt gratitude. First and foremost, we would like to thank our dear God, the Father, for our lives most especially and to every day he had given us. We would also to thank Him also for giving us these people who had been there for our group throughout this exposure. Next in line, are our beloved parents. They are to support us in our every decision in life, in guiding us towards life and they are also there to support us in our financial needs. They strive hard to give us a good life, good education and a brighter future. To our smart, jolly and charming Clinical Instructor, Miss Rubilyn Bulquerin- Sumaylo, R.N. with the support and guidance of our former Clinical Instructors Mrs. Nadia Bisnar, and Ms. Maureen Patricio We are thankful that we have you. Thank you for being our second mother in the clinical area and for providing us the knowledge that we all need. You are always there to guide us in the different procedures we did and you are always there to shower us with knowledge in every case that we handled. We really did enjoy and learned at the same time in our exposure under your care. To both our advisers, Mrs. Shiela Ritas- Soluta and Miss Jemmillee Ellen Olilang, thank you for your unending support and inspiring advices. We are lucky to have you both as our adviser. Thank You for the patience. The group would also like to express our sincerest gratitude to all the staff nurses of Saint Joseph Ward who unselfishly shared their knowledge and skills while we are on duty as student nurses. We learned so much from you. Thank you very much!

I. Introduction
Have you heard about the sweetest temptation? Yes. The sweetest temptation you never resisted. The one you would trade yourlife for to twist your fate. This disease is sweetly killing us, sweetly consuming every part of you. Inch by inch its sweetly eating you. Have you ever heard of this sweet cry? The cry of being sweetly diagnosed by diabetes. How about the mourn of an amputed leg to its master? Then the master is crippled forever. Have you seen the tears of an eye to its last sight? Or a man struggling for his sweet life? Is it worth one more cup? Is it worth one more slice? Life is sweet but diabetes is the price! Do you know that in the year 2010 Under 20 years of age 186,300 or 0.22% of all people in this age group have diabetes About 1 in every 400 to 600 children and adolescents has type 1 diabetes About 2 million adolescents aged 12 to 19 have pre-diabetes

Age 20 years or older Men 12.0 million, or 11.2% of all men aged 20 years or older have diabetes 23.5 million or 10.7% of all people in this age group have diabetes Age 60 years or older 12.2 million, or 23.1% of all people in this age group have diabetes

Women 11.5 million, or 10.2% of all women aged 20 years or older have diabetes.

I would like to ask all of you, would you rather live your life in every piece of it, enjoying those sweetest food that you could ever tasted? Or suffer by the sweet revenge of diabetes?

II. OBJECTIVES
A. General Objective After the discussion of this case, the students will be able to deal and care for patients with Diabetes Mellitus integrally by applying their knowledge, skills, and positive attitudes based on what they have learned out of the discussion. B. Specific Objectives At the end of the case discussion, it is expected that the students will be able to: Skills 1. Deal patient with Diabetes Mellitus. 2. Provide proper care according to the problem manifested by the patient. 3. Conduct physical assessment and organize data efficiently. 4. Formulate and apply nursing care plans utilizing the nursing process. 5. Learn new clinical skills as well as sharpen our current clinical skills required in the management of the patient with Diabetes Mellitus. Knowledge 1. Define Diabetes Mellitus. 2. Trace the pathophysiology of the disease. 3. Have an overview about the disease, including its causes and complications. 4. Determine the signs and symptoms and the possible symptomatic treatment of each. 5. Review the anatomy and physiology of the organ affected. 6. Identify and enumerate the management needed for Diabetes Mellitus and its related complications. 7. Formulate nursing care plans that will aid in the improvement of patients condition.

Attitudes 1. Develop a positive attitude in caring the patient with Diabetes Mellitus throughout the nursing Process. 2. Establish rapport with the patient and folks. 3. Develop respect and trust. 4. Develop our sense of unselfish love and empathy in rendering nursing care to our patient so that we may be able to serve future clients with higher level of holistic understanding as well as individualized care.

TEXTBOOK DISCUSSION
Every time we eat sugary or starchy food, the amount of glucose available to the body rockets. Yet the levels of glucose in the bloodstream are maintained within narrow limits by two key hormones insulin and glucagon working to prevent hyperglycemia or hypoglycemia. What is Diabetes? Diabetes mellitus arises when insufficient insulin is produced, or when the available insulin does not function correctly. Without insulin, the amount of glucose in the bloodstream is abnormally high, causing unquenchable thirst and frequent urination. The body's inability to store or use glucose causes hunger and weight loss. There are two main types of diabetes. Insulin-dependent diabetes type 1 diabetes occurs when there is a severe lack of insulin due to the destruction of most or all of the beta cells in the islets of Langerhans. This type of diabetes develops rapidly, usually appearing before the age of 35, and most often between the ages of 10 and 16. Regular insulin injections are required to survive. Non-insulin-dependent diabetes type 2 diabetes occurs when the body does not produce enough insulin, and the insulin that is produced becomes less effective. This type of diabetes usually appears in people over the age of 40, and tends to have a more gradual onset. In most cases, glucose levels in the blood can be controlled by diet, or diet and tablets, although sometimes insulin injections may be needed. About 90 per cent of diabetics are non-insulin dependent.

What causes diabetes? In type 1 diabetes, the insulin-producing beta cells are destroyed by an autoimmune process, whereby the body's immune system its defence mechanism against disease for some reason recognises the cells as being 'foreign' rather than 'self', and therefore attacks them. In susceptible individuals, this autoimmune process is thought to be influenced by environmental factors which are as yet unknown. Such susceptibility is genetically determined two genes have been identified that appear to put an individual at risk, but there are certain to be more genes involved. Type 2 diabetes is thought to be due both to defects in the islet beta cells, so that less glucose is produced, and to an impairment of insulin's ability to stimulate the uptake of glucose in muscles and other tissues. The cause of this insulin resistance has not yet been fully established, but may involve defects in the action of insulin after it has bound to the insulin receptor on the surface of cells. There is a genetic influence, as type 2 diabetes tends to run in families even more strongly than type 1 diabetes, and several genes are likely to be involved. But increasing age, obesity and a sedentary lifestyle also increase the risk of type 2 diabetes.

Type 2 diabetes is a progressive disease. This progression is characterized by continuing decline in beta-cell mass and function added to worsening insulin resistance. This means that most patients require intensified therapy over time to maintain glycemic control. In type 2 diabetes, either the pancreas does not make enough insulin and/or the body does not use it properly. No one knows the exact cause of type 2 diabetes, but it's more likely to occur in people who:

are over 40 years of age are overweight have a family history of diabetes developed gestational diabetes during a pregnancy
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have given birth to a baby that is more than 4 kg (9 lbs) have high blood pressure have high cholesterol have IGT or impaired fasting glucose are of Aboriginal, Hispanic, Asian, South Asian, or South African descent

Signs and Symptoms Type 2 diabetes symptoms may develop very slowly. In fact, you can have type 2 diabetes for years and not even know it. Look for:

Increased thirst and frequent urination. As excess sugar builds up in your bloodstream, fluid is pulled from the tissues. This may leave you thirsty. As a result, you may drink and urinate more than usual. Increased hunger. Without enough insulin to move sugar into your cells, your muscles and organs become depleted of energy. This triggers intense hunger. Weight loss. Despite eating more than usual to relieve hunger, you may lose weight. Without the ability to metabolize glucose, the body uses alternative fuels stored in muscle and fat. Calories are lost as excess glucose is released in the urine. Fatigue. If your cells are deprived of sugar, you may become tired and irritable. Blurred vision. If your blood sugar is too high, fluid may be pulled from the lenses of your eyes. This may affect your ability to focus clearly. Slow-healing sores or frequent infections. Type 2 diabetes affects your ability to heal and resist infections. Areas of darkened skin. Some people with type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies usually in the armpits. This condition, called acanthosis nigricans, may be a sign of insulin resistance. Decreased sensation or numbness in the hands and feet Dry, itchy skin Frequent bladder and vaginal infections Frequent need to urinate Increased thirst and hunger Male impotence (erectile dysfunction) Tiredness According to the Book Manifested by the patient

Polyuria Polydipsia Polyphagia Weight loss Dry skin Sores that are slow to heal Frequent infections Tingling or numbness of extremities Dehydration Sudden vision change Dry, itchy skin/ itchiness in the genitalia Tiredness/ fatigue Areas of darkened skin Male impotence (erectile dysfunction)

III. ANATOMY AND PHYSIOLOGY

Pancreas- A fish-shaped spongy pinkish white glandular organ about 6 inches (15 cm) long that stretches across the back of the abdomen, behind the stomach. It is the second largest gland that is connected to the digestive tract, after the liver. The pancreas lies in the epigastrium and lefthypochondrium areas of the abdomen It is composed of the following parts:

The head lies within the concavity of the duodenum. The uncinate process emerges from the lower part of head, and lies deep to superior mesenteric vessels. The neck is the constricted part between the head and the body. The body lies behind the stomach. The tail is the left end of the pancreas. It lies in contact with the spleen and runs in the lienorenal ligament.

The pancreas is one of the few organs that has both an exocrine and an endocrine function. Exocrine glands are glands that secrete their products into ducts (duct glands). Endocrine glands are glands that secrete their product directly into the blood rather than through a duct.

The pancreas is an important organ for digestion and the control of circulating levels of glucose. The functions of the pancreas are the following: -Completes the job of breaking down protein, carbohydrates, and fats using digestive juices of pancreas combined with juices from the intestines.

-Secretes hormones that affects the level of sugar in the

blood.

-Produces chemicals that neutralize stomach acids that pass from the stomach into the small intestines by using substances in pancreatic juice. -Contains Islets of Langerhans, which are tiny groups of specialized cells that are scattered throughout the organ. These cells secrete: Glucagon- raises the level of glucose (sugar) in the blood Insulin-stimlates cells to use glucose Somatostatin- may regulate the secretion of glucagons and insulin.

IV. Vital Information

Name Age Sex Address Civil Status Religion Occupation Diet Date and Time Admitted Ward/ Room Chief Complaint Admitting Diagnosis A.M. 61years old Female Capricho 1 , Roxas City, Capiz Single Roman Catholic Government Employee (Commission on Audit ) Low salt, Low Fat, Diabetic Diet August 7,2011 @ 1:30pm Saint Joseph Ward/ Room 315 Abscess at left subcostal margin Draining Abscess at left Subcostal Margin; Hypertension; DiabetesMellitus Type 2 Abscess at Left subcostal area S/P: I & D, Hypertension Stage 1, Diabetes Mellitus Type 2 Insulin requiring, Mixed Dyslipidemia

Final Diagnosis

Attending Physicians

Dr.R.H, Dr.C N, Dr. A.B., Dr. N.C.

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V. CLINICAL ASSESSMENT
A. PRESENT MEDICAL HISTORY
One week prior to admission, she noticed swelling with erythema on the left subcostal area accompanied with foul smelling and yellowish to greenish with blood streaks discharges. It was also accompanied with pain but no consultation was done. She did not take any medication. Two days prior to admission, she had fever and chills. She took Biogesic once and ciprofloxacin two times a day. Fever and chills were relief. She also applied hot compress on the area but no relief of signs and symptoms so she decided to seek medical attention and was advised for an admission.

B. PAST HEALTH HISTORY

In 1992 she was diagnosed with Diabetes Mellitus Type 2. In July 2009, she was admitted in St. Anthony College Hospital because of Urinary Tract Infection under the service of Dr. C.N. She started her insulin injections Humulin N 25 U pre-breakfast and 20 U pre-supper. She was also given with Metformin 500mg two times a day before lunch and before supper and Janumet 50/120 once a day before lunch. In December 2010, she was again admitted with the same complaints under the same doctor. She did not undergo any surgical procedure in the past. She has no known allergies to both foods and medications.

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FAMILY GENOGRAM

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PATTERNS OF FUNCTIONING
Patterns of Functioning Breathing Patterns Home Hospital Respiratory rate ranges from 20-24 breaths per minute. Circulation Blood pressure ranges from 130/80 to 150/100mmHg. Cardiac rate of 84 to 88 beats per minute. Sleeping Patterns Usually sleeps at 11 oclock in the evening and wakes up at 4 to 5 oclock in the morning. Sleeps at 10 oclock in the evening and wakes up at 5 to 6 oclock in the morning. Sleeps at intervals during daytime.

Drinking

Drinks 8 to 10 glasses of water everyday. Seldom drinks sodas and juices. If ever, she only drinks coke zero.

Drinks 10 to 12 glasses of water.

Eating

Eats the three regular meals with snacks in between everyday.

Eats three regular meals but not allowed to eat between 1 to 5 oclock in the afternoon. Tepid sponge bath and mouth care were provided by her significant others. Urinates 10 to 12 times a day depending upon her fluid intake. Defecates every morning.

Hygiene

Takes a bath regularly and brushes her teeth two to three times a day.

Elimination

Urinates 5 to 10 times a day depending upon her fluid intake. Defecates 1 to 2 times a day, one in the morning and one before going to bed, depending upon her food intake.

Recreation and Exercise

Does not involve herself in any physical exercises. For her, her exercise is when she do the marketing every Saturdays and Sundays. Plays mah-jong during her leisure time.

Dos not exercise and watches television when she is awake.

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VI. BRIEF SOCIAL, CULTURAL, AND RELIGIOUS BACKGROUND

Educational Background She finished her Bachelor of Science in Commerce at Colegio De la Purisima Concepcion. Occupational Background She works as a government employee in Commission on Audit at the Capiz Provincial Capitol. Religious Practices She is a devoted Roman Catholic. She goes to church everyday to attend the holy mass. She occasionally receives the Holy Communion because she does not go to confession regularly. Prays the Holy Rosary every night. Economic Status The family belongs to the middle class. They all have college degrees and have their permanent jobs.

VII. CLINICAL INSPECTION

A. VITAL SIGNS
Upon Admission (August 7, 2011) 36.7 C 24 breaths per minute 88 beats per minute 85 beats per minute 150/ 90 mmHg During Care ( August 10,2011 @ 4pm) 36.2C 20 breaths per minute 84 beats per minute 82 beats per minute 140/100 mmHg Temp. RR CR PR BP

B. BMI- 36.42 (Obese ) HEIGHT- 63 inches WEIGHT- 205.03 lbs

Formula: Weight in pounds X 705 (Height in inches)

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C.

PHYSICAL ASSESSMENT

General Assessment Conscious, oriented, lying in a supine position to hospital bed with an IVF#2 PNSS IL x KVO at her left metacarpal vein. Skin Fair complexion, normal turgor, cool to touch, and rough. Abscess in the left subcostal margin noted about 2 inches in diameter. No signs of edema and lesions in other parts of the body. Hair Hair is black with some gray and white due to aging. Hair loss noted specifically at the posterior part of the head. No lice and flakes noted but with foul smell. Face The face is wrinkled due to old age. Head Symmetrical and can move from side to side; scalp is smooth and no lumps or lesions noted. Mouth Gums and buccal mucosa are pinkish, smooth and moist. No presence of lesions found. Tongue has white spots and can move from side to side when instructed. Tonsils are not inflamed. Lips are moist and pinkish. Missing premolars, first and second molars on both the maxillary and mandibular teeth noted. Cavities noted and her mouth has an offensive odor or halitosis.

Eyes Pupils are equally round reactive to light and accommodation; pupils constrict 2mm, and pinkish conjunctiva. No noted lesions and unusual discharges. Wears eyeglasses.

Ears Symmetrical. Has good hearing capacity. No presence of lesions and discharges. Nails Fingernails and toenails are pinkish and cool to touch. Not well trimmed and presence of dirt noted. Capillary refill is less than three seconds. Nose Nasal mucosa is pinkish, no noted polyps or discharges. No signs of flaring, lesions and swelling.

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Neck Symmetrical, proportional to head and shoulders. Carotid artery is palpable. The thyroid gland was not visible upon inspection. The gland ascends normally during swallowing. Upper Extremities Upper extremities were very flabby due to accumulated fat tissues. Dark skin pigmentation on her elbows. Chest Abscess in the left subcostal margin approximately 3 cm in diameter noted with soaked dressing with offensive odor . Axilla Axillae were dry and has slightly offensive odour. Presence of fatty tissues in the area. With palpable lymph nodes on her left axilla.

Respiratory System Respiration rate ranges from 20- 24 breaths per minute. Does not use accessory muscle in breathing. Cardiovascular System Heart rate ranges from 84- 88beats per minute. Blood pressure ranges from 130/80 to 150/100mmHg. Gastrointestinal System The bowel sounds were present during auscultation. Does not complain of pain during palpation.

Genitourinary System Urine output is adequate every hour (between 100- 150 cc per hour). Discretely scratches her genital area during observation. Musculoskeletal System Moves slowly from side to side due to her weight and probably due to pain from her surgical incision. No presence of contractures or fractures. D. General Appraisal 1. Speech Speaks in a small, soft voice, and utters comprehensible words. No slurring of speech noted. 2. Language She speaks Hiligaynon, Filipino, and English. 3. Hearing Has a good sense of hearing and answers accordingly to questions when asked. Reacts to noises inside the room 4. Mental Status She is coherent and oriented with person, time and place.
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VIII. LABORATORY AND DIAGNOSTIC DATA

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Date/ Type / Purpose of Examination

Results
08/07/11

Normal Values

Significance

Hematology
To check the blood component for any abnormality To check the volume of RBCs in the blood. WBC Indicates the possible presence of severity of infection or inflammatory response. Platelet Used to assess the ability of the bone marrow to produce platelets and to identify the destruction or loss of platelets in the circulation. 12.2 x109/L (Increased) 4.5-11x109/L Infection

516 x109/L (Increased)

150-450x109/L

Infection

WBC Deferential Count:

Used to assess the ability of the body to respond to and eliminate infection. It also detects the severity of the infection, allergic reactions, and parasitic infection and identifies various stages of leukemia. 0.07 0.25 -0.40 Infection Lymphocytes (Decreased) 0.82 0.45-0.65 infection Segmenters (Increased) 9.2 % 4.5-6.8 % Poorly controlled 08/07/11 (Increased) Diabetes Mellitus Hemoglobin AC A Glycosylated Hemoglobin determination is used to measure a patients diabetic control over a period of weeks or months. The maximum period for evaluation of control is the life span of the red blod cells (120 days) -

Glucose
Used to Measure the Blood Glucose Level

7.72 mmol/L (Inreased) 08/07/11

4.1-5.9 mmol/L

Diabetes Mellitus

URINALYSIS
Is a physical, chemical & microscopic analysis of the urine Useful for diagnosing renal disease or Urinary Tract infections and for detecting metabolic disease not related to kidneys. Transparency WBC/hpf Bacteria Turbid Numerous to count moderate Clear to slightly hazy 0-5 None Presence of bacteria in the urine infection infection

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8/7/2011

RADIOGRAPHY CHEST AP
It helps to assess Pulmonary Status and detect Pneumonia, Atelectasis, Pneumothorax, Pulmonary Bullae, and Tumors. It helps to determine correct placement of Pulmonary artery catheter, Endotracheal tube, or Chest Tube. Impression: - Pulmonary congestion - Atheromatous and tortuous aorta - Cardiomegaly borderline 8/8/11 Wound discharge gram No growth Bacterial infection stain - Stained smear shows -

Determine whether a wound is infected, and to identify the bacteria causing the infection, method of differentiating bacteria of one species into two large groups (Grampositive and Gramnegative)

many gram(+)Cocci in singles in pairs and in chain; occasional gram (-) bacilli in singlesPus cells 18-30 / OIF

08/10/11

Bacteriology
Is the study of Bacteria. It comprises the identification, classification and characterization of bacterial species. Nature of specimen: wound discharge Organ identified: modified growth of Sphingomonas paucimobilis Sensitive to: Resistant to: Amo/ penicillin Cefuxitin Amox/clav Cefepime Piperacillin/tazobactam Tobramycin Ticarcillin Amikacin Ticar/clav Getamicin Cefuroxime Ceftazidine Meropenem Imipenem Cortrimoxazole Netilmicin Ciprofloxacin 08/11/11

Bacteriology
Is the study of Bacteria. It comprises the identification, classification and characterization of bacterial species. Specimen: Urine Organism identified: very light growth of Escherichia coli. Colony CT: <10,000 CFVs/ mL Sensitive to: Resistant to: - Amo/penicillin; tobramycin - Cotrimoxazole - Amox/clav;amikacin - Moxifloxacin - Piperacillin/tazobactam; gentamicin - ciprofloxacin - Ticarcillin; netilmicin

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Ticar/clav.; ampicillin-sulbactam Cefoxitin; ceftriaxone Cefepime;cefixime Cefuroxime Meropenem

Capillary Blood Glucose Monitoring

Carried out to assess and manage patients with Diabetes mellitus. Provides current data that are used to determine the next dose of insulin or to monitor the patients response to diabetic medications. 08/08/11 CBG results Normal Values 12:00 pm - 192mg/dl 5:30 am - 160mg/dl 11:30am - 170 mg/dl 60-110mg/dl 5:30 pm - 193 mg/dl 08/09/11 5:30 am - 188 mg/dl 5:20pm - 201mg/dl 11:30 pm - 166mg/dl 08/10/11 4:00 am - 122mg/dl 8:00 am - 141mg/dl

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IX. PATHOPHYSIOLOGY
Predisposing Factors: *Family history of DM *Race/ ethnicity *Age (30 and above ) *Obesity *Sex Precipitating Factors: *Sedentary lifestyle *Frequent infections Too much sweets intake

Beta cell exhaustion

Decreased insulin production

Increased glucagon production

Elevated blood glucose levels. Production of glucose from protein and fats

Increased osmolarity Wasting of lean body mass Polydipsia, polyphagia, polyuria, weight loss Chronic elevation in blood glucose Fatigue, weight loss

Glycoprotein cell wall deposits

Precipitating Factors: Impaired mobolity (hemiparesis) Weather (cold and rainy seasons) Chronic disease states Malnutrition History of cigarette smoking

Small vessel disease

Accelerated atherosclerosis

Impaired immune function

CAD, HPN, Diabetic neuropathy, diabetic retinopathy, diabetic nephropathy

LDL

Delayed wound healing,infectiion

End- stage renal failure

Numbness and tingling sensation, wasting of intrinsic muscle, foot ulceration, dry skin, impotence,

Other systemic complications which may eventually lead into DEATH

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X.

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Generic Name/Brand Name, Dose, Route, Frequency

Action

Mechanism of Action

Indications

Contraindications Side Effects

Adverse Effects

Nursing Responsibilities

MEDICAL MANAGEMENT
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Humulin N 28u SQ pre breakfast 26 u SQ pre supper

Antidiabetic, hormone

Insulin is a - Treatment of hormone type 2 secreted by diabetes beta cells of mellitus that the pancreas cannot be that, by controlled by receptordiet or oral mediated drugs. effects, promotes the storage of the body fuels, facilitating the transport of metabolites &ions (potassium) through cell membranes & stimulating the synthesis of glycogen from glucose, of fats from lipids, & proteins from amino acids.

Contraindicated to patient with hypoglycemia, IV administration, Hyperglycemic coma

Rash, redness, Decline in swelling, pulmonary function, itching. angioedema

1. Alternate injection sites regularly to prevent breakdown at injection sites 2. Ensure uniform dispersion of insulin suspensions by rolling the vial gently between; hands, avoid vigorous shaking. 3. Store drug in the refrigerator or in a cool place out of direct sunlight; do not freeze insulin. 4. Monitor urine or blood levels for glucose and ketones. 5. Report fever, sore throat, and vomiting, hypoglycemic or hyperglycemic reactions, rash. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During:

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 Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patient for possible untoward reaction.

Janumet 50/ 120 OD pre lunch

Antidiabetic

Exact mechanism is not understood;

Adjunct to diet to lower blood glucose with type 2

Contraindicated with allergy to metformin.

Nausea, vomiting, diarrhea, allergic skin

Lactic acidosis

1. Give drug before lunch. 2. Monitor urine and serum

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possibly increases peripheral utilization of glucose, decreases hepatic glucose production, & alters intestinal absorption of glucose.

diabetes mellitus. As part of combination therapy with a sulfonylurea or insulin when either drug alone cannot control glucose levels in patients with type 2 diabetes mellitus.

reactions.

glucose level to determine effectiveness of drug. 3. Report fever, sore throat, unusual bleeding or bruising, rash, dark urine, light-colored stools, hypoglycemic or hyperglycemic reactions. 4. Encourage patient not to stop taking this drug without consulting healthcare provider. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO

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 Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patient for possible untoward reaction.

Metformin 500mg 1tab BID A.C. lunch, supper.

Antidiabetic

Exact mechanism is not understood; possibly increases

Adjunct to diet to lower blood glucose with type 2 diabetes mellitus in

Contraindicated with allergy to metformin; heart failure, diabetes complicated by fever, severe infections, severe 27

nausea, vomiting diarrhea, flatulence.

Hypoglycemia, Anorexia, lactic acidosis.

1. Instruct patient to swallow drug whole, do not cut, chew or crush. 2. Encourage the patient to do not

peripheral utilization of glucose, decreases hepatic glucose production, and alters intestinal absorption of glucose.

patients 10 yr and older, ER in patients 17 yr and older.

trauma, major surgery.

3.

4.

discontinue this medication without consulting health care provider. Monitor blood or urine for glucose and ketones. Report severe fever, sore throat, unusual bleeding or bruising, rash, dark urine. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patient for possible untoward reaction.

Piperacilin + tazobactam (Tazocin)

Antiibiotic

Bactericidal inhibits synthesis of cell wall of sensitive

Severe infections caused by sensitive organisms

Contraindicated with allergies to penicilins, cephalosporins or other allergens.

Sore mouth, nausea, vomiting, diarrhea, rash, fever.

Seizures thrombocytopenia, leucopenia, nephritis.

1. Monitor serum electrolytes and Cardiac status(B/P,CR and cardiac output).

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2.25gms. IVTT Q8h ANST

organisms, causing cell death.

(streptococci). Prophylaxis of rheumatic fever & chorea.

2. Inform patient that she may experience these side effects: Nausea, vomiting, diarrhea, mouth sores, pain at injection sites. 3. Report difficulty of breathing rashes, sever diarrhea, severe pain at injection site, mouth sores, unusual bleeding or bruising. 4. Check IV sites carfully for signs of thrombosis or local drug reaction. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After:
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 Record the drug after its administration (charting) Observe the patients for possible untoward reaction.

Coamoxiclav (Augmentin ) 1gm/tab. 1 tab.

Antibiotic

Inhibits transpeptidase , preventing cross-linking

skin at skin structure infections, & urinary tract infections

Hypersensitivity to drug or any penicillin. Phenylketonuria (some products)

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nausea, vomiting, diarrhea, abdominal pain,

seizures, intestinal nephritis.

1. Give w/ or without food. 2. Monitor patient carefully for sign & symptoms of

BID

of bacterial cell wall & leading to cell death. Addition of clavulanate (a beta-lactam) increases drugs resistance to betalactamase ( an enzyme produced by bacteria that may inactivate amoxicillin).

(UTIs) caused by susceptible strains of gram (-) & gram (+) organisms.

Histoy of cholestatic jaundice or hepatic dysfunction associated with this drug.

wheezing, rash.

hypersensitivity reaction. 3. Check patients temp. & watch for other signs & symptoms of super infection, especially oral or rectal candidiasis. 4. Instruct patient to immediately report signs & symptoms of hypersensitivity reaction, such as rash, fever or chills. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration

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(charting) Observe the patient for possible untoward reaction.

Clindamycin 300mg IVTT ANST Q6hrs

antibiotic

Inhibits protein synthesis in susceptible bacteria, causing cell

Treatment of septicemia caused by staphylococci, streptococci; acute

Contraindicated with Headache, allergy to dryness, clindamycin. urinary frequency, nausea, vomiting.
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Hypotension, cardiac arrest, severe colitis, thrombophle-bitis.

1. Store reconstituted product at room temperature. 2. Do not

death.

hematogenous osteomyelitis; adjunct to surgical treatment of chronic bone and joint infections due to susceptible organisms.

refrigerate reconstituted solution. Remember that reconstituted solution is stable for too weeks at room temperature. 3. Do not administer 1,200mg I a single 1hr infusion. 4. Do not mix with calcium gluconate,ampi cillin,phenytoin , barituates, amiphylline an magnesium sulphate.

Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO
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 Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patient for possible untoward reaction.

Algesia 1tab Q6h x 2 days

Analgesic

Binds to muopioid receptors & inhibits the reuptake of

Relief of moderate to moderately severe pain.

Contraindicated with allergy to tramadol or opioids or acute intoxication with alcohol, opioids, or
34

Dizziness, Hypotension, headache, seizures. confusion, sweating, rash, nausea,

1. Inform patient that she may experience these side effects:

norepinephrin e & serotonin; causes many effects similar to the opioidsdizziness, somnolence, nausea, constipationbut does not have the respiratory depressant effects.

psychoactive drugs.

vomiting, dry mouth.

Dizziness, sedation, drowsiness, impaired visual acuity. 2. Report severe nausea, dizziness, severe constipation. 3. Obtain history of hypersensitivity to tramadol before starting drug therapy. 4. Control environmental factors like temperature and lighting if sweating or CNS effects occur. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the

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patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patients for possible untoward reaction.

Cilostazol (Pletaal) 100mg./tab. 1

Antiplatelet

Reversibly inhibits platelet aggregation induced by a

Reduction of symptoms of intermittent claudication allowing

Contraindicated with allergy to cilostazol, heart failure of any severity (decreased survival rates have
36

Dizziness, Heart failure, headache, rhinitis. diarrhea, nausea, cough, back pain.

1. Take drug on an empty stomach at least 30min. before or 2hrs. After

tab BID

variety of stimuli including ADP, thrombin, collagen, shear stress, epinephrine, & arachidonic acid by inhibiting cAMP phosphodieste rase III; produces vascular dilation in vascular beds with a specificity for femoral beds; seems to have no effect on renal arteries.

increased walking distance

occurred), active bleeding hemostatic disorders.

breakfast & dinner. 2. Encourage patient not to drink grapefruit juice while taking this drug 3. Report fever, chills, sore throat, palpitations, chest pain, edema or swelling, difficulty of breathing, and fatigue. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug

37

after its administration (charting) Observe the patient for possible untoward reaction.

Losartan K (lifezar) 100mg tab OD AC breakfast

Antihypertensive ARB

Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular

Treatment of hypertension, alone or in combination with other

Contraindicated with hypersensitivity to losartan, use cautiously with hepatic or renal impairment,
38

Headache, dizziness,inso mnia, abdominal pain.

Hypotension, urticaria, pruritus, alopecia.

1. Give this drug without regards to meals. 2. Encourge patient not to stop taking

smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the renin-angiotensin system as well as the release of aldosterone leading to decreased BP.

antihypertensives. Treatment of diabetic nephropathy with an elevated serum creatinine and protein-urea in patients with type 2 diabetes.

hypovolemia.

this drug without consulting her health care provider. 3. Monitor patient closely in any situation that may lead to a decrease in BP . 4. Report fever, chills, and dizziness.

Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe
39

the patient for possible untoward reaction.

Sodium Citrate (Ural) 1 sachet in glass of H2O TID

Urinary alkaliniser

Increases the excretion of free base in the urine.

Treatment of UTI, symptomatic relief of dysuria.

Contraindicated tobpatient with allergy to coponents of preparations; low serum chloride,

40

Weakness, nausea, irritability.

GI rupture, systemic alkalosis, tissue necrosis.

1. Give drug with or without food. 2. Dissolve 1 Sachet in Cold water

hypocalcemia Use cautiously with impaired renal function, Heart Failure, sodium retaining states.

3. Do not give within 1-2 hours of other oral drugs to reduce risks of drug interactions. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patient for possible untoward reaction. Abdominal discomfort, headache, dyspepsia, diz ziness, muscle Fatigue, rash, myopathy, asthenia,myalgia, pancreatitis 1. Give drug before bedtime. 2. Encourage patient not to drink grapefruit juices

Orovas 2omg 1tab HS

Antihyperlipidemic

Inhibits HMG-CoA reductase, the enzyme that catalyzes the

Adjunct to diet in the treatment of elevated cholesterol

Liver disease or unexplained persistent rise of serum transaminases.

41

first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs, and either an increase or no change in serum HDLs.

and LDL cholesterol with primary hypercholeste rolemia in those unresponsive to dietary restriction of saturated fat and cholesterol and other nonpharmacologi c measures.

Pregnancy & lactation.

cramps, vomiting.

while taking this drug. 3. Encourage patient to have a periodic blood tests. 4. Inform patient that she may experience these side effets: nausea,headache, muscle and joint aches and pain. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body.

After: Record the drug after its administration (charting) Observe

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the patient for possible untoward reaction.

Vigor ACE 1tab OD after lunch

Vitamins and Minerals

Vigor-ACE provides the synergistic actions of protective

Nutritional supplement to support active functioning in adults & to

No known contraindications

nausea, increased salivation, diarrhea, naus ea

Hepatitis, anorexia, pharyngitis, urinary tract infection.

1. Administer drug after meals to reduce GI disturbance.

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biologic antioxidants: Vitamins C and E, and selenium. Vitamin E protects the cell membranes against damage by preventing the formation of lipid hydroperoxides. Vitamin C and the seleniumcontaining enzyme, glutathione peroxidase, inactivate these oxidizing agents, thus maintaining the integrity and stability of the cell membrane structures.

help restore vitality in aging & convalescing patients.

2. Stress importance the Vitamin supplement 3. Teach patient about healthy dietary habits. Prior to: Wash hands thoroughly Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO Explain what is the general action of the drug to the body After: Record the drug after its administration (charting) Observe the patients for possible untoward reaction.

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XI. Concept Map

45

DIAGNOSIS Infection related to invasion of pathogens. OBJECTIVE Abscess at left subcostal margin approximately 3cm in diameter, with exudative drainage and foul odor. Erythema and warm skin around the abscess Laboratory results: Urinalysis (8-7-11) Transparency-turbid WBC/hpf- numerous to count Bacteria- moderate Hematology: WBC 12.2 x109/L Platelet - 516 x109/L Segmenters - 0.82 Lymphocytes-0.07 Bacteriology Specimen: Wound discharge moderate growth of Sphingomonas paucimobilis Urine - very light growth of Escherichia coli

1
DIAGNOSIS: Acute pain related to surgical incision SUBJECTIVE: Masakit akon kilid sa may samad dampit. OBJECTIVE: Grimacing face Guarding/protecting incision site BP 140/100mmHg Pain scale of 7 out of 10 S/P : Incision & Drainage

2 2

Chief Complaint Abscess at left subcostal margin Diagnosis Abscess at Left subcostal area S/P: I & D, Hypertension Stage 1, Diabetes Mellitus Type 2 Insulin requiring, Mixed Dyslipidemia

DIAGNOSIS: Risk for injury related to abnormal blood profile. SUBJECTIVE: kung masamadan ko dugay gid mag ayo. OBJECTIVE: Laboratory results: CBG results: 08/09/11: 5:30 am - 188 mg/dl 5:20pm - 201mg/dl 11:30 pm - 166mg/dl Hematology: WBC - 12.2 x109/L

DIAGNOSIS : Imbalanced nutrition; more than body requirements related to excessive food intake SUBJECTIVE: Namian gid ako magkinaon pirme kag damu guid ko pakan-on labi na guid kung mag kuyam-kuyam. OBJECTIVE Accumulated fatty tissues on triceps, abdomen, buttocks, back, and other parts of the body. Height:63 inches Weight:205.03 lbs BMI:36.42 (Obese ) Laboratory results: CBG results: 08/09/11: 5:30 am - 188 mg/dl 46 5:20pm - 201mg/dl 11:30 pm - 166mg/dl

DIAGNOSIS: Impaired skin integrity related to accumulation of drainage secondary to abscess. SUBJECTIVE: Makatol ang akon samad pati sa palibot sini. OBJECTIVE Abscess at left subcostal margin approximately 3cm in diameter, with exudative drainage. Erythema and warm skin around the abscess Soaked dressing with foul odor. Laboratory results: Hematology: WBC -12.2 x109/L CBG results: 08/09/11: 5:30 am - 188 mg/dl 5:20pm - 201mg/dl 11:30 pm - 166mg/dl

XII. Nursing Management

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

47

Objective: Abscess at left subcostal margin approximately 3cm in diameter, with exudative drainage and foul odor. Erythema and warm skin around the abscess

Infection related to invasion of pathogens.

At the end of the hospital stay, patient will be free from further infections as evidenced by timely wound healing and normal urinalysis results.

Independent: Informed the importance of proper hand washing Ensured sterile technique during dressing change.

To reduce risk of cross contamination.

Goal partially met. As evidenced by: Absence of necrotic cells and pus in the wound. With clean and dry dressing.

Laboratory results: Urinalysis (8-7-11) Transparency-turbid WBC/hpfnumerous to count Bacteria- moderate Hematology WBC 12.2 x109/L Platelet - 516 x109/L Segmenters - 0.82

Proper technique prevents cross contamination and the introduction of additional organism into the wound. Decreases susceptibility to infection. Increased urinary flow prevents stasis and aids in maintaining urine pH- acidity, reducing bacteria growth and flushing organisms out o the system.

Encouraged to increase oral fluid intake.

Repeat urinalysis revealed (8-10-11) Transparency hazy WBC 5-10/hpf Bacteria (-)

Lymphocytes-0.07 Bacteriology Specimen: Wound discharge moderate growth of Sphingomonas paucimobilis Urine - very light growth of Escherichia coli

Emphasized the importance of performing of good personal hygiene daily in the genital area.

Good personal hygiene reduces number of pathogens in the body.

Dependent: Administered: 48

Piperacilin + tazobactam (Tazocin) 2.25gms. Q8h ANST Clindamycin 300mg IVTT ANST Q6hrs.

Antibiotic treatment is the primary therapy and kills susceptible bacteria.

Vigor ACE 1 tab OD after lunch

Adequate nutrition enhances cellular healing.

Incision and drainage done by A.P. in the OR

To remove necrotic cells and pus which will facilitate in wound healing.

Independent:

Subjective : Masakit akon kilid sa may

Acute pain related to surgical incision

To alleviate pain from the pain scale of 7 down to 4 after 30 49

Provided comfort measures like

To promote

Goal met. As evidenced by reduction of pain form the pain scale of 7

samad dampit. Objective : Grimacing face Guarding/protecting incision site BP 140/100mmHg Pain scale of 7 out of 10 S/P : Incision & Drainage

minutes of nursing interventions.

repositioning and provided quiet environment. Encouraged use of relaxation techniques such as deep breathing exercises.

nonpharmacological pain management.

down to 4, absence of grimacing face.

To distract attention, relieves muscle and emotional tension; enhances sense of control and may improve coping abilities. To prevent fatigue.

Encouraged adequate rest periods. Reminded to splint area with pillow when moving or coughing.

Equalizes pressure on the wound minimizing pain.

Dependent: Administered: 50 Algesia 120mg/tab 1 To relieve pain.

tab Q6hrs. x 2 days PO

Piperacilin + tazobactam (Tazocin) 2.25gms. Q8h IVTT ANST

To kill susceptible bacteria thus help in minimizing pain.

Clindamycin 300mg IVTT ANST Q6hrs.

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Subjective : Makatol ang akon samad pati sa palibot sini. Objective: Abscess at left subcostal margin approximately 3cm in diameter, with exudative drainage. Erythema and warm skin around the abscess Soaked dressing with foul odor.

Impaired skin integrity related to accumulation of drainage secondary to abscess.

At the end of the shift, will verbalize decrease in discomfort.

Independent: Assisted in wound dressing. To protect the wound and for faster wound healing. Moisture potentiates skin breakdown Prevents contamination Promotes circulation and reduces risks associated with immobility. To enhance understanding and cooperation.

Goal met. As evidenced by verbalization of: Nag hagan hagan na ang katol kag daw ok na siya.

Removed soiled/wet linens promptly, and kept wound dressing clean and dry.

Instructed client not to touch the affected site. Encouraged early ambulation/ Mobilization.

Laboratory results: Hematology: WBC -12.2 x109/L CBG results: 08/09/11: 5:30 am - 188 mg/dl 5:20pm - 201mg/dl 11:30 pm - 166mg/dl

Repositioned client, involving her in the intervention.

52

Dependent: Administered: Vigor ACE 1 tab OD after lunch

To aid in skin/tissue healing and to maintain general good health

Piperacilin + tazobactam (Tazocin) 2.25gms. Q8h ANST

To kill susceptible bacteria that aids in skin breakdown..

Clindamycin 300mg IVTT ANST Q6hrs.

53

Subjective: Namian gid ako magkinaon pirme kag damu guid ko pakan-on labi na guid kung mag kuyam-kuyam.

Imbalanced nutrition; more than body requirements related to excessive food intake

At the end of the shift, will verbalize future plans to control food intake.

Independent: Stressed need for adequate fluid intake and taking fluids between meals rather than with meals. To meet fluid requirements and reduce possibility of early satiety resulting in feelings of hunger. To assist client in finding healthy options.

Goal met. As evidenced by verbalization of: ma dieta na ko, maski maka guwa na ko diri kay kabudlay gid kung daku-dako ako ah.

Objective: Accumulated fatty tissues on triceps, abdomen, buttocks, back, and other parts of the body. Height:63 inches Weight:205.03 lbs BMI:36.42 (Obese ) Encouraged to eat smart snacks like in season fruit slices instead of soft drinks, chocolates and cake. Emphasized the importance of avoid fad diets.

Laboratory results: CBG results: 08/09/11: 5:30 am - 188 mg/dl 5:20pm - 201mg/dl 11:30 pm - 166mg/dl
Discussed need to give self permission to include desired/craved food items in dietary plan.

Elimination of needed components can lead to metabolic imbalances. Denying self by excluding desired or favourite foods results in a sense of deprivation and feelings of guilt/ failure when individual succumbs to temptation. These feelings can sabotage weight loss.

54

Emphasized the importance of avoiding tension at meal times and not eating too quickly.

Reducing tension provides a more relax eating atmosphere and encourages more leisurely eating patterns. This is important because a period of time is required for the appestat mechanism to know the stomach is full.

Dependent: Administered: Vigor ACE 1 tab OD after lunch Obese individuals have large fuelreerves but are often deficient in vitamins and minerals.

55

Subjective: kung masamadan ko dugay gid mag ayo. Objective: Laboratory results:

Risk for injury related At the end of the shift will verbalize to abnormal blood understanding of profile.

individual factors that may contribute to the possibility of injury.

Independent: Informed to use well fitted shoes or slippers, and to cut nails regularly taking precautions not to injure/ cut the surrounding skin. Instructed to maintain a safe environment in their house by keeping sharp objects in a safe place. Informed to avoid very strenuous activities.

To avoid skin breakdown

Goal met. As evidence by verbalization of Mahalong nagid ko sa mga ginaubra ko para hindi ko masamaran dali- dali.

CBG results: 08/09/11: 5:30 am - 188 mg/dl 5:20pm - 201mg/dl 11:30 pm - 166mg/dl

To promote safe physical environment and individual safety. Strenuous exercise or activities may lead to bruising thus potentiates easy skin breakdown.

Hematology: WBC -12.2 x109/L

Dependent: Humulin N 28u

SQ pre breakfast 26 u SQ pre supper

To help in lowering blood glucose.

56

XIII. DISCHARGE PLANNING

Medication
Medications prescribed by the attending physician should be followed at the right time, right dosage and inform patient a on the importance of continuing the medications. Instruct patient to take the following drugs at home following the timing, and dosage. Humulin N 28 U before breakfast Humulin N 24 U before supper Celostazol (Pletaal)10 mg two times a day Losartan (Lifezar) 100 mg tab before breakfast Metformin 500 mg/tab 1 tab 2x a day after breakfast, after supper Janumet 50/500 mg 1 tab after lunch Simvastatin 20 mg/tab 1 tab at bedtime

Exercise and Activity

Encourage patient to engage herself in performing daily exercises like walking briskly early in the morning outside their house. Light stretching lexing and extending very slowly of upper and lower extremities. Rotating of the extremities at a very light and slow motion. Touch chin to the chest slowly Flex the head to the right and to the left shoulder at a very slow movement. Note: the exercise should be done with assistance of significant others at a very slow motion to avoid further complication.

Treatment
Instruct to maintain a clean home environment conducive to rest and relaxation. Instruct her to take medications as indicated. Notify physician for any adverse reaction. Instruct to seek medical assistance from a medical provider whenever she experiences any signs and symptoms.

57

Health Teaching
Emphasize the importance of clean environment for her fast recovery. Encourage to strictly adhere to medical regimen to ensure good recovery from her present condition. Instruct to avoid sharp objects or any activity that can cause cuts or any skin trauma. Remind the importance of correct proper hand washing and to give extra attention to her personal hygiene.

Out-patient Follow-up
Stress to follow the scheduled follow- up appointments by her attending physician in order to assess her improvement and to modify treatment if ever. Stress the importance and remind about follow-up check-ups on the 17th and on the 19th of August.

Diet
Encourage to have a regular meal and serve nutritious foods like green leafy vegetable, fruits, and fish. Encourage to avoid junk food and sweet delicacies. Encourage to follow the low salt, low fat, diabetic diet prescribed by her attending physicians. Encourage to eat high fiber foods. Teach patient to read labels of "health" foods because they contain sugar product such as honey, brown sugar and corn syrup.

Spirituality
Encourage to submit herself into a Confession and receive the Holy Communion when attending mass.

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XIV. Our Journey

Nursing encompasses an art, a humanistic orientation, a feeling for the value of the individual and intuitive sense of ethics and of the appropriateness of action taken. Nurses dispense comfort, compassion, and caring without even a prescription. There will always be learning in everyday of our life and in every step we take, and as a student nurse learning is an important factor in order to be competent and best health care provider. Being student nurses is never easy, we all need to balance everything; studies, duties, family, God and especially you need to give time to yourself. Sometimes, we almost want to give up and stop, but we always come to realize that we should always keep on moving forward. Not just because we need to but it is because we really want to. Weve been through a lot of tough times and our sacrifices are countless. But with our every downfall, we stand up and face every new challenge that is waiting for us. Our every experience in our duty days was priceless. The learning we have gained was the most precious thing we have earned in our every duty days. Weve experienced different consequences in our duties, weve been exposed to different people and different procedures. We also got a chance to handle different cases in the ward and in every case, there is learning. Weve been to different wards, weve been under different Clinical Instructors, weve been through different paths, but yet our group stands as one. We are different people who are stuck in these group but yet strangers became friends, friends became family. In our journey, the end is not the most important, it is the journey itself. And throughout our journey we are happy to have each other as our team mates. And we are proud to say that we played our game right and it is not winning we aim, but it is the learning. This is not the end of our journey; this is just the part of it. So we choose to make it meaningful, we choose to make it worth our sacrifices.

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XV.References
Nurses Manual of Laboratory Tests and Diagnostic Procedures. Louise Malarkey, Ellen McMorrow. 1st Edition. WB Saunders Company. 1996. Nursing Guide to Laboratory and Diagnostic Tests. Louise Malarkey. Elsevier, Inc. 2005 Laboratory and Diagnostic Tests Handbook. M. K. Gaedele. Addison- Wesley Publishing Company, Inc.1996. Pathophysiology Concepts of Altered Health States. Carol Watson-Porth. &th Edition. Lipincott- Williams and Wilkins. Straight As in Pathophysiology. Lippincott- Williams and Wilkins. 2006. Textbook on Medical- Surgical Nursing. Suzanne C.Smeltzer. 11th Edition. LipincottWilliams and Wilkins. 2008. Nursing: Understanding Diseases. Lippincott- Williams and Wilkins. 2008. Mosbys Pocket Dictionary of Medicine, Nursing, and Health Professions. 5th Edition.2006. www.mims.com MIMS Philippines. 125th Edition. 2010. 2010 Lippincotts Nursing Drug Guide. Lipincott- Williams and Wilkins. 2010. Essentials of Anatomy and Physiology. Stephens Seeley. McGraw- Hill Companies, Inc. 2007. Fluids and electrolytes made Incredibly Easy. Lipincott- Williams and Wilkins. 2005. Brunner and Suddarths Textbook of Medical- Surgical Nursing. Suzanne C. Smeltzer, et al.12th Edition. Lipincott- Williams and Wilkins. 2010.

www.wikipedia.com Mims. Com Philippines 119th Edtion. 2009 Nursing Care Plans ( Nursing Diagnosis and Intervention).6th Editiion. Meg Gulanick. Mosby Elsevier. 2007. Current Medical Diagnosis and Treatmant. Lawrence M. Tierney, Jr, MD, et al. 43rd Edition. The McGraw- Hill Coanies. 2004

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