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    Nursing Care in Patients With A Medical Diagnosis of Diabetes Mellitus 1. Identity Patien Identity

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    Rai Sriyanti
    1. The patient, a 58-year-old Indonesian woman, was hospitalized for pain in her toe and diarrhea related to her diagnosis of diabetes mellitus. She reported a pain level of 7. 2. Her treatment plan included insulin, medications, and wound care for gangrene on her feet. Nursing care focused on pain management through monitoring, relaxation techniques, and analgesics. 3. A second problem was inadequate nutrition related to decreased appetite. Interventions included supervised feeding and encouraging small, frequent meals to meet nutritional needs and stabilize blood sugar levels.

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    Nursing Care in Patients With A Medical Diagnosis of Diabetes Mellitus 1. Identity Patien Identity

    Uploaded by

    Rai Sriyanti
    55 views10 pages
    1. The patient, a 58-year-old Indonesian woman, was hospitalized for pain in her toe and diarrhea related to her diagnosis of diabetes mellitus. She reported a pain level of 7. 2. Her treatment plan included insulin, medications, and wound care for gangrene on her feet. Nursing care focused on pain management through monitoring, relaxation techniques, and analgesics. 3. A second problem was inadequate nutrition related to decreased appetite. Interventions included supervised feeding and encouraging small, frequent meals to meet nutritional needs and stabilize blood sugar levels.

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    1. The patient, a 58-year-old Indonesian woman, was hospitalized for pain in her toe and diarrhea related to her diagnosis of diabetes mellitus. She reported a pain level of 7. 2. Her treatment plan included insulin, medications, and wound care for gangrene on her feet. Nursing care focused on pain management through monitoring, relaxation techniques, and analgesics. 3. A second problem was inadequate nutrition related to decreased appetite. Interventions included supervised feeding and encouraging small, frequent meals to meet nutritional needs and stabilize blood sugar levels.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    55 views10 pages

    Nursing Care in Patients With A Medical Diagnosis of Diabetes Mellitus 1. Identity Patien Identity

    Uploaded by

    Rai Sriyanti
    1. The patient, a 58-year-old Indonesian woman, was hospitalized for pain in her toe and diarrhea related to her diagnosis of diabetes mellitus. She reported a pain level of 7. 2. Her treatment plan included insulin, medications, and wound care for gangrene on her feet. Nursing care focused on pain management through monitoring, relaxation techniques, and analgesics. 3. A second problem was inadequate nutrition related to decreased appetite. Interventions included supervised feeding and encouraging small, frequent meals to meet nutritional needs and stabilize blood sugar levels.

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    Nursing Care in Patients with a Medical Diagnosis of Diabetes Mellitus

    1. Identity
    Patien Identity
    Patient name

    : Ms. S

    Age

    :58 years

    Sex

    :Female

    Tribe/Nation :Indonesia
    Religion

    :Hindu

    Education

    :Senior High school

    Job

    :Office staf

    Address

    : Bali

    Hospitalized date:4 December 2015


    Assessment date:7 December 2015
    Register number:12345678
    Medical diagnose: Diabetes mellitus
    Person in charge
    Name

    :Mr.S

    Age

    :60 years

    Patient realionship: Husband


    Tribe/nation

    :Indonesia

    Religion

    :Hindu

    Education

    :Senior High school

    Job

    :Office staf

    Address
    1. History of illness

    :Bali

    Main Complaint

    :Patien feeling paint on the toe

    The current assessment : Pain scale 7

    Reason for hospitealized and course of the disease at this time


    Patient complaint of pain in the toe and diarrhea since 2 days ago, because it does not go
    away ,patient was taken to hospital by her family,Patient examined in emergency room.Patient
    referred to hospitalized in the nakula room at 12:00 am .
    Efforts made to overcome
    Before hospitalized patient went to health center and taken medicine mefenamic acid and
    newdeatab
    Past health history
    Disease ever experienced
    Patient said had experienced hypertension and DM
    Treated history
    Patient said have a history of diabetes mellitus since 5 years ago and had been hospitalized 4 x
    Allergy
    Patient said not have history of allergy
    Family illness history
    Patient said not have a history of family illness
    Medical diagnose and therapy
    Medical diagnose :Diabetes mellitus
    Therapy : Infusion DX 5 % 20 drops/minute
    Digoxin 2 x 5 mg
    Captopril : 3 x 12.5 mg
    Mefinal : 3 x 500 mg

    2. Fungsional Pattern
    Paterns of health management
    While the patient illness,The patient was going to healt centers to cure her disease
    Nutritional and metabolic patterns
    Before ill patients usually eat 3 times a day, the portion of 1 full plate with side dishes
    and drinking 4 cups/day frequency 2000cc /day. The patient weight 70 kg
    When ill complain of decreased appetite. Patient to eat portion of plates 3 times a day
    and drinking 4 cups/day frequency 2000 cc/day . Weight 65 kg
    Patterns of elimination
    Before ill patients defecation 1 x/day and urination 4 x/day without the help of others, while ill
    patienst complaint frequently defecation 4 x/day with a consistent liquid there are blood in faeces
    and urination 4 x/day.
    Patterns of activity and exercise
    Before ill patient can perform a normal activities, working and cooking. While ill patient can not
    perform normal activities because of pain
    Motor and cognitive patterns
    Patient said she knows an explanation of the illness
    Patterns of sleep and rest
    Before ill patiens do not have a complains with their sleep habits that 5-8 hours/day. When pain
    patients complaint of difficulty sleeping because feel want defecation dan Pain on the her feet.
    The pattern of self-perception and self-concept
    Patient confused with the current situation but that she knew about her illness he felt that he
    would be cured after undergoing treatment in hospital
    Patterns of socal relationship

    Patient can not perform the role normally because of illness, but do with family very good.
    Patterns of sexuality and reproduction
    Patient was female, she have 1 husband and 2 son's.
    Patterns overcome the problems of life
    Patien always deliberate on the family when there are problems, including disease exerenced
    today.
    Patterns of values and beliefs/religion
    Patient religious hindu , when ill patient can only pray in bed.
    3. Assessment of physical
    General state
    : Patient seen weak
    Level of consciousness : Komposmetis Verbal : 5 Psychomotor:4 Eye:6
    Vital signs
    : Pulse : 80 x/minute temperature:36C Blood pressure :140/90 mmHg
    RR: 20 x/minute
    Physical state
    :
    a. Head and neck
    Head :Mesosephal head shape, clean, no smell, no lesions, straight black hair
    Eye

    :Pupillary reflexes symmetrical, not anemic conjunctiva, sclera not ikteric,


    coordination symmetrical eye movement and is able to follow the movement of
    objects on a limited basis.

    Nose :Symmetrical, clean, no nasal polyps, nasal flaring does not exist.
    Mouth:Oral mucosa moist, tremor is not found, the tonsils are not enlarged, no dental
    stomatitis, and still even
    Neck

    : There is no enlargement of the thyroid gland, found no jugular venous


    distention. Tense neck muscles

    b. Chest
    Lungs
    I
    : The shape is symmetrical, symmetrical chest movement during breathing,
    increased respiratory frequency.
    P
    : Fremitus tactil normal
    P
    :The sound sonor
    A
    :Vesicular breath sounds
    Heart
    I
    :IC invisible
    P
    :IC palpable in IC VI

    P
    A

    :Limit of normal heart


    :Heart sounds I dan II normal

    Stomach
    Stomach symmetrical shape , there were no mass, abdominal distention was not found
    and no enlargement of the liver and bowel sounds normal
    Integumen
    Turgoe alstic, fairer skin, no hyperpigmentation and clean
    Extremitas
    Upper
    I
    : There is no lesions , clubbing fingers and nicotine staning
    P
    :CRT less than 3 seconds , there is no tenderness
    Under
    I
    :No edema in the sacrum, no varicose veins,there is ganggrene on feet
    P
    :There is tenderness on feet
    Neurologist
    Mental and emotional status
    Emotionally unstable patients
    Examination of reflex
    The ability of the movement joins no problem.
    5 Diagnostic tests
    The 4h December 2015
    Fasting blood sugar : 84,0 mg/dl
    Urea
    :20 mg/dl
    Choleseror
    :216 mg/dl
    HDL cholesterol
    : 33 mg/dl
    LDL cholesterol
    :155 mg/dl
    Albumine
    :1,9 mg /dl
    Hemoglobin
    :11gr/%
    Erytrosi
    :4, 55 million/mmk
    Leucocytes
    :5,42 thousand/mmk
    MCV
    :77,20 fl
    MCHC
    :34.00 g/dl

    Analysis
    No
    Dx
    1

    symptom

    Etiologi

    Problem

    DS : Pasien complained of An increase in blood sugar


    pain in the feet
    gangrene on feet
    Do : There is wound on feet
    There is tenderness on Inflammatory processes
    feet
    Paint scale 7
    Acute pain

    Acute
    pain
    related
    to
    inflammatory
    processes
    indicated by gangrene on feet

    Ds : When ill complain of Acute Pain


    decreased appetite. Patient to
    eat portion of plates 3 stress
    times a day and drinking 4
    cups/day frequency 2000 Diarhea
    cc/day . Weight 65 kg.
    No appetite
    Do :
    A : age 58 years , weight 65 Imbalanced nutrition less than
    kg
    body requirements
    B : Fasting blood sugar
    : 84,0 mg/dl, Urea:20
    mg/dl, Choleseror
    :216 mg/dl HDL
    cholesterol
    :33
    mg/dl
    LDL cholesterol
    :155
    mg/dl
    C: Pulse : 80 x /m
    RR :20 x/m
    BP:140/90
    Tem:36C

    Imbalanced nutrition less than


    body requirements related to
    acute pain indicated by
    patient complain decrease
    appetite.

    Nursing Care Plan


    Date

    No
    Dx

    Goal and expected


    outcomes

    Interventions

    Rationale

    7
    December
    2015

    After the given nursing


    care 3 x 24 hours expected
    the patient pain is reduce
    with expected outcomes :
    a. Patient verbally
    said the pain was
    reduce

    1. Observation the
    frequency and level
    of pain.
    2. Create quit
    environment

    3. Teach distraction
    and relaxation
    techniques
    4. Do massage and
    compress the
    gangrene while
    wound care
    5. Collaboration with a
    doctor for analgesics
    7
    December
    2015

    After the given nursing


    care 3 x 24 hours expected
    nutrients patient are met
    with expected outcomes :
    a. Blood sugar levels
    in the normal
    limits
    b. Weight and height
    idel

    1. Observation the
    nutritional status and
    eating habits
    2. Supervised input
    /output and weight
    periodically
    3. Cooperation with
    other helth team to
    given insulin and the
    best diet

    1. To determine the
    pain scale
    2. Excessive
    stimulation of
    the environment
    will aggravate
    the pain
    3. Can reduce the
    pain
    4. Can provide
    comfort
    5. Helping to
    reduce the
    patient's pain
    1. To determine the
    patien's
    nutritional state
    2. To meaure the
    effectiveness of
    nutrition
    3. To prevent
    complications

    Implementation
    Date

    Time

    7
    december
    2015

    13 :00

    No
    Dx
    1

    14:00

    16:00

    20:00

    8
    Decembe
    r 2015

    Implementation
    Observation vital signs

    Ds : Pasien
    complaint pain on
    her feet
    Do: BP:140/90 RR:
    20 x/m, Pulse : 80
    Teach relaxation dan distraction x/m
    techniques
    Ds : Pasien said
    more comfortable
    Do : Pasien seen
    more comprotable
    Provide oral medication
    Mefinal 500 mg
    Ds: Pasien said
    more comportable
    Do: Pasien seen
    more comprotable,
    Observation the leverl of pain

    07:30

    Observation nutritional status

    08:00

    Encourage patient to little ead


    but often

    13:00

    evaluation

    Advise patient to rest

    Ds: Patient said


    reduce the pain
    Do : Pain scale 2
    Ds : Paient
    complain of
    decreased appetite
    Do:Patien seen limp
    Ds: Patients said
    could eat a little
    Do: Patients eat 1
    serving plate
    Ds :Patient said her
    condition improved

    Signature

    9
    Decembe
    r 2015

    13 :00

    Encourage patient to little ead


    but often

    15:00

    Observation nutritional status

    20 :00

    1,2

    Observation vital signs

    Ds: Patients said


    could eat a little
    Do: Patients eat 1
    serving plate
    Ds: Patien said
    increased appetite
    Do:Patien seen
    better weght 70 kg
    Do : Paien said feel
    better
    Do: BP 130/60
    RR: 24 x/m
    Pulse:80 x/menit
    Tem:36

    EVALUATION
    Date
    10
    December
    2015

    10
    December
    2015

    No
    Dx
    1

    Evaluation

    S: Patient said her appetite increases


    O:Patien can eat 1 serving plate weight 70 kg
    A:The problem is resolved
    P: Overseeing the patient's condition

    S :Patien said the pain was reduce


    O :Pain scale 2
    A:The problem is resolved
    P:Overseeing the patient's condition

    Signature

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