Nursing Care In Patient With Diabetes Mellitus

NURSING CARE IN Mrs. “S” WITH DIABETES MELLITUS AT DR. SOETOMO GENERAL HOSPITAL ON 11TH – 13TH NOVEMBER 2009

BY: GROUP I MIRA UTAMI NINGSIH

(139015216)

NINIK ENDANG S

(139015146)

AGUS

(139015151)

DIONISIA R.W. DJAWA

(139015164)

IRNA SUSIATI

(139015219)

KASHMIR

(139015226)

WIWIN NURMALANTIKA

(139015234)

HUSNUL MUBAROK

(139015235)

FACULTY OF NURSING AIRLANGGA UNIVERSITY SURABAYA 2009 PREFACE

We really grateful to the Most Glorious and the Most Merciful Allah SWT, we can finished this case report about “Nursing care in Mrs. ‘S’ with chronic diabetes mellitus at RS. DR. Soetomo on 11th – 13th November 2009” ontime. This paper is written as a part of process in studying English in nursing science and technology. Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer who has generously provided us with constructive criticism and suggestions to completed this paper. Special thanks to all of our colleagues in class B 12 who have participated in our seminar discussion about the case in this paper. We aware that still there are many lack in this paper so we could use some direction and we always open to your suggestion to make it better. At last, we hope this paper may brings much advantages to all of us.

Surabaya, 21st November 2009

Author

2

CONTENTS

Cover...........................................................................................................................i Preface.......................................................................................................................ii Contents....................................................................................................................iii Nursing Care in Mrs. “S” with Diabetes Mellitus at DR. Soetomo General Hospital, On 11th – 13th November 2009 A. Assesment......................................................................................................1 B. Data Analysis and Nursing Diagnosis............................................................6 C. Planning..........................................................................................................9 D. Implementation.............................................................................................13 E. Evaluation / Discharge Planning..................................................................18

3

NURSING CARE IN Mrs.“S” WITH DIABETES MELLITUS AT DR. SOETOMO HOSPITAL, ON 11th – 13th NOVEMBER 2009

A. ASSESMENT NURSING HISTORY : 11th Nov 2009

Admission Date No. Reg

: 10177388

Time Medical Dx

: 08.56 a.m : Diabetes mellitus + diabetic foot

Date of Assesment : 11th Nov 2009 I. Patient identity 1. Name

: Mrs. “S”

2. Age

: 60

3. Sex

: female

4. Race

: Java, Indonesia

5. Religion

: Islam

6. Education

:-

7. Occupation

: Housewife

8. Address

: Lamongan, Karang Anyar

I. History of present illness 1. Chief complain

: shortness of breath

2. Present illness history : patient has a sudden shortness of breath since

an hour before hospitalized but it’s getting better. She had cough, nausea and vomiting a day ago. She has pain, swollen and redness at right pedis since three days ago. Feverish a day before hospitalized. She feel faint and weakness. Patient has diabetic mellitus type II since twelve years ago. I.

Past nursing history 1. History of contagious disease : None 2. Hereditary disease

: None

3. Allergic history

: None 4

I.

Family health history : Patient said that her family has no contagious disease one of her family member, her aunt also has diabetes mellitus Genogram +

+

Explanation: : +male : female : client : stay together with client + II.

: pass away

Observation and physical examination Vital Sign: T:37,50C

P: 75x/mnt

RR: 20x/mnt

BP: 100/60 mmHg

1. B1: Breathing Complain

: Cough (-), SOB (-), pain (-)

RR pattern

: Frequency 20 x/mnt, Rhythm : Regular

Breathing

: wheezing (-), ronchi (-), secret (-)

O2 adm

: (-)

Problem

: None

2. B2: Blood Complain

: chest pain (-), P = 72 times/minute

Heart sound : Normal Rhythm

: regular

CRT

: 2 second

JVP

: Normal

Edema Problem

: (-) : None 5

3. B3: Brain Orientation

: Person, Time and Place normal

Awareness

: Composmentis

GCS

: E4 V5 M 6

Eye

: Pupil Isochors, Light reflex (+), eye lens: snoring (+/+).

Conjunctiva : hiperemi (-/-), sub conjunctiva bleeding (-/-) Sclera

: anemis

Nerves disturbance: sensory perceptual; visual Problem

: Disturbed sensory perception; visual. Risk for Injury

4. B4: Bladder Complain

: polyuri

Fluid intake : Oral + 2500cc/day, Parenteral Urine output

: + 3000 cc/day

Others Problem

: 1000 cc/day

color: light yellow

smell: normal

: cateter adm (-) : Altered urinary elimination pattern Risk for deficit fluid volume

5. B5: Bowel Mouth

: normal

Abdomen

: normal

Diit

: Diit B1 2100 kkal

Alvi elimination

: frequency once a day, consistency: soft

Peristaltic

: 15 x/mnt

Others

: none

Problem

: none

6. B6: Bone Joint Activity : Free Back Injury

: None

Integuments

: pale, acral warm

Turgor

: good

Others

: right pedis: wound, swollen, redness, pain. Post amputated falanx digit 1 pedis, osteomilitis.

Problem

: impaired skin integrity 6

7. Endocrine system Complain

: CBS: 288, polyuria, polydipsi

Prolem

: hyperglycemia

I. Psychosocial assessment 1. Client perception about his disease : God-struggle 2. Client expression toward his/her disease : Quite 3. Year reaction: cooperative 4. Self concept disturbance : none

I. Diagnosis test and medical treatment 1. Laboratory:

Hematology 11th Nov 2009 Hb : 10,3

Ca: 9

Leukosit: 17.800

Cl: 101

Plt: 221.000

K: 4,5

BG: 288

Na: 140

BUN: 19,5

Globulin: 4,98

Creatinin: 1,5

Albumin: 2,8

SGOT/SGPT: 10/8

Bilirubin direct: 0,26

2. Radiology: Thorax photo (PA): cardiomegali Pedis photo: osteomilitis amputated phalanx digit 1 pedis dextra. 3. Therapy IVFD Pz 14 drops/minute Humolin R 3x4 IU SC Humolin N 4 IU SC malam Ceftazidine 3 x 1gr IV Metronidazole 3 x 500 mg IV Metformin 3 x 500 per oral Wound care 4. Additional data:

Consult internist: unregulated DM and selulitis pedis (D), osteomilitis Consult ophthalmologist: OD cataract mature, OS cataract immature 7

WEB OF CAUTION DIABETES MELLITUS Decrease of insulin production (auto immune) Ineffective glucose movement to the Increase blood glucose

Low immune system

Body tries to get rid of the extra sugar in blood Risk for

Excreting sugar through urine

Decrease of capability for attacking foreign particles and blood

Prompt urinate

Lead to loss of weight Negative calorie effect

Glucose + amino protein Accumulation of AGE (advance glicosilasi end

Induce unwanted biological

Excess fluid excretion

Poor wounding healing Impaired skin integrity

Metabolize fat &protein to gain energy Uses more energy

Hyperglycem ia Resists the flourishing of WBC

Imbalanced nutrition; less than body

Insulin resistance by liver fat and muscle cell

Altered urine eliminatio n pattern

Risk for deficit fluid

Glucose metabolize

8

A. DATA ANALYSIS AND NURSING DIAGNOSIS No 1

Data

S:

Etiology

Problem

Decrease of insulin

hyperglikemi

production (auto – Patient said that she

immune)

has had Diabetes

Or

mellitus since 12

Insulin resistance by

years ago.

liver, fat and muscle

O:

Fatig ue

Activity intoleranc

cell – BG: 288 mg/dl Ineffective glucose movement to the cell Increase blood glucose level

Neuron, blood vessel, Kidney, eye lens

Causes damage of blood vessel within the

Hyperglycemia 2

Hyperglycemia Sorbitol + Impaired skin

S: –

patient said that her

Riskfoot for has swollen,

redness and pain since three days ago. O: –

fructose

Impaired sensory there is aperception; wound at

right pedis that seems swollen, redness – Leukocyte : 17.800 – Photo pedis: osteomilitis and

integrity

resists the flourishing Decrease fosfoinosida of white blood cells

metabolism and signal

Osmotic load

Lead blood and fluid into the surrounding tissue

low immune system Neuropathy, retinopathy decrease ofnephropathy, capability

Affects the ability of lenses to

for attacking foreign particles (microorganism etc.) and blood vessel repair

9

shows amputated

poor wound healing

phalanx digit 1 pedis dextra – BG: 288 mg/dl 3

S:

Hyperglycemia – Patient complains

volume

about urinate

Body tries to get rid of

frequently

the extra sugar in the

O:

Risk for deficit fluid

blood by excreting it –

Polyuria

through urine

– BG : 288 mg/dl –

Urine output: + 3000 cc/day

Prompt urinate frequently Excess fluid excretion (carries a large amount of water out of the body along with it)

4

S:

Hyperglikemia – Patient said that she has blurry vision

Disturbed sensory perception; visual

Causes damage of blood vessel within

O:

the eye – Eye lens: snoring (+/ +) – Ophthalmologist examina-tion: OD

leak blood and fluid into the surrounding tissues

cataract mature, and OS cataract immature

affects the ability of lenses to focus

10

causes vision problems (blurry vision)

5

S:

Eye lens snoring

Risk for Injury

– Patient said that she has blurry vision

Affect the ability of lenses to focus

O: – Eye lens: snoring (+/

Causes vision

+) –

problem

Ophthalmologist examination: OD

Risk for injury

cataract mature, and OS cataract immature

Nursing Diagnostic 1. Hyperglycemia due to decrease of insulin production (auto immune) or insulin

resistance, signed by BG: 288 mg/dl. 2. Impaired skin integrity due to poor wound healing secondary to hyperglycemia,

signed by patient said that her foot has swollen, redness and pain since three days ago, there is a wound at right pedis that seems swollen, redness, photo pedis shows osteomyelitis and amputated phalanx digit 1 pedis dextra. 3. Risk for deficit fluid volume due to excess fluid excretion secondary to

hyperglycemia, signed by patient complains about urinate frequently, polyuri, BG: 288 mg/dl, urine output: + 3000 cc/day. 4. Disturbed sensory perception; visual due to the decline of lenses ability to focus,

signed by patient said that she has blurry vision, eye lens: snoring (+/+), OD cataract mature, and OS cataract immature.

11

5. Risk for injury due to vision problem, signed by patient said that she has blurry

vision, eye lens: snoring (+/+), OD cataract mature, and OS cataract immature

12

A. PLANNING Nursing Diagnosis

Hyperglycemia due

Goal and Objective

Goal:

1. Administer insulin therapy

to the decrease of

After 3 hours of nursing

insulin production

interventions, blood

(auto immune) or

glucose level will be

insulin resistance

decrease and controlled Outcome criteria: –

Nursing Orders

BG within normal

regularly as ordered 2. Consult nutritionist to

develop diet planning 3. Administer IVFD 4. Monitor laboratory results:

CBS, aseton, pH, HCO3 5. Teach client about the

limit: 120 – 160

importance of keeping diet

mg/dl

therapy as it programmed

– Patient follow the diet therapy

6. Promote comfortable

environment to minimize stressor that can induce increase blood glucose level

Impaired skin integrity due to poor wound healing secondary to hyperglycemia

1. Assess wound site for signs

Goal:

of infection such as

after 3 days of nursing

swelling, redness, pain.

intervention, shows

2. Review laboratory results

improvement of skin

(Hb/Hct, blood glucose

integrity

blood and /or wound

Outcome criteria; – Shows skin tissue regeneration – Wound healing

culture, albumin) to evaluate causative factors or ability to heal 3. Cleanse or irrigate wounds using physiological solution (e.g. isotonic saline) with 13

shows

syringe or gauze square,

progression

avoiding cotton balls or

– Blood glucose

other product that shed

within normal limit – Free of infection sign

fibers 4. Use appropriate barrier

dressing or wound covering to protect wound and surrounding tissue from excoriating secretion/ drainage and to promote wound healing 5. Carefully dress wounds and

stimulate circulation to surrounding areas to assist body’s natural process of repair. 6. Maintain a moist environment for wound 7. Practice and instruct client in scrupulous hand washing clean or sterile technique to reduce incidence of contamination or infection 8. Provide optimum nutrition

appropriate to diet planning (including adequate protein, lipids, calories, trace minerals and multivitamins [e.g., A, C, D, E]) to promote skin health/healing and to maintain general good health 9. Administer/monitor

medication regimen (e.g., 14

antimicrobials, drip infusion into osteomyelitis, subeschar clysis, topical antibiotics)

Risk for deficit fluid Goal:

1. Monitor input and output.

volume due to

After 3 days nursing

excess fluid

intervention, risk for

excretion

deficit fluid volume

secondary to

avoided and

3. Weigh daily

hyperglikemia

demonstrate adequate

4. Maintain fluid intake at least

Note urine specific gravity 2. Monitor orthostatic blood pressure changes

hydration

3000 ml / day within cardiac

Outcome criteria:

tolerance with oral intake is

–

Vital sign WNL

– CRT 2 second

resumed. 5. Promote comfortable

– Balance intake

environment. Cover patient

and output

with light sheets to reduce/

– Electrolyte WNL

replenish trans epidermal water loss. Collaborative: 6. Administer fluids as

indicated (e.g normal saline with or without dekstrose) 7. Monitor electrolyte results

Disturbed sensory

Goal

perception; visual

After 3 hours nursing

problem (e.g., loss of visual

due to the decline

intervention, patient can

field, change in depth

of lenses ability to

recognize/compensate

perception, double vision,

focus

for sensory impairments

blindness) that affects

Outcome criteria:

client’s ability to perceive

And

1. Note particular vision

15

Risk for injury due

–

to vision problem

Patient

environment and

demonstrate

learn/relearn motor skills

using resources

–

2. Speak to visually impaired

effectively and

client frequently, especially

appropriately

when entering room/client’s

Patient can

presence to provide

Identify/ modify

auditory stimulation and

external factors

prevent startle reflex.

that contribute to

3. Position objects to take

alterations in

advantage of intact visual

sensory/perceptu

field, and use eye patch,

al abilities

when needed, to decrease

– Be free of injury

sensory confusion when client has loss of vision or, field of vision in one eye. 4. Supply adequate lighting for reading and activities. 5. Place glasses/contacts

where they can be easily found and encourage client to wear corrective lenses during waking hours. 6. Arrange bed, personal articles, and food trays to take advantage of functional vision. 7. Maintain bed/chair in lowest position with wheels locked 8. properly placing alarms/fire extinguishers 9. Place assistive devices

(e.g., walker, cane, glasses, hearing aid) within reach, make sure call light is within 16

reach and client knows how to operate it.

17

A. IMPLEMENTATION Date Time

Number Dx

11-11-09

I

Implementation

– Maintain IVFD PZ 14

Evaluation

S: client said that they

drops/minute

understand and will keep

– Monitoring laboratory: blood

her diet as it programmed O:

glucose, electrolyte,

–

Hb, Hct, Albumin,

mg/dl Hb: 10,3 gr%

BUN, Creatinin

albumin: 2,8

– Teaching client about

– Client finish her meal

the importance of

appropriate to her diet

keeping diet as it

–

programmed

110/70 mmHg, P:

Injecting Humolin R 4 IU per SC t.d.s (0712-15)

– Helping and ensuring

Vital sign: T: 36,50C, RR: 20x/mnt, BP:

– Observing vital sign –

Blood glucose: 264

72x/mnt A: Goal met partially P: Continuing intervention

patient eat her meal appropriate to her II

diet (B1 2100 kal) –

Injecting Humolin N 4 IU per SC od (0-0-1)

–

Administering antibiotic : ceftazidine 1gr t.d.s and metronidazole 500

S:

mg IV t.d.s

– Client complain about

– Cleansing and

pain, redness and

irrigating wound

swelling in his right

using normal saline,

pedis 18

smearing Garamicyn

– Client said that they

cream then dressing

will keep sterile

it with gauze and

technique

Bactigras. Keeping aseptic and sterile

O:

technique –

III

–

Vital sign: T: 36,50C,

Teaching client about

RR: 20x/mnt, BP:

scrupulous hand

110/70 mmHg, P:

washing clean or

72x/mnt Leukocyte: 17.800

sterile technique to

–

reduce incidence of

– Wound clean and

contamination or

dressing well, there is

infection

no skin regeneration yet

– Observing vital sign – Monitoring laboratory result :leukocyte

A: goal not met yet

– Monitoring intake and P: continuing intervention output – Suggesting clients to drink at least 2500cc/ day – Monitoring electrolyte, S: client complain about urinate frequently

BUN, creatinin, blood IV,V

glucose

O: – Intake per oral: 2500 cc, parenteral: 1000 cc – Output urine: 3000 cc – Vital sign WNL – CRT 2 second –

Blood glucose: 264 mg/dl

– BUN: 19,5, creatinin: 1,5

19

–

Electrolyte WNL: Ca: 9

Cl: 101, K: 4.5, Na: 140 – Placing alarm near patient and teaching her how to operate it – Suggesting client to place glasses or any

A: Goal met partially P: continuing intervention S: client said that they understand how to compensate

assistive device within reach where she can easily found.

the impaired of vision O: – Patient demonstrate

– Ensuring the light is

using resources

adequate for clients

effectively and

sight –

appropriately

Maintaining client’s

– Patient free of injury

bed and chair in lowest position with wheels locked

11-12-09

I

A: goal met P: intervention stopped

– Injecting Humolin R 4 S: IU per SC t.d.s (0712-15)

O: –

– Monitoring laboratory: blood

mg/dl – Client finish her meal

glucose, electrolyte, Hb, Hct, Albumin,

appropriate to her diet –

Vital sign: T: 36,50C,

BUN, Creatinin

RR: 20x/mnt, BP:

– Observing vital sign

110/60 mmHg, P:

– Helping and ensuring

76x/mnt

patient eat her meal appropriate to her diet (B1 2100 kal) II

Blood glucose: 252

A: Goal met partially P: Continuing intervention

– Injecting Humolin N 4 20

IU per SC od (0-0-1) –

Administering antibiotic : ceftazidine 1gr t.d.s and metronidazole 500 mg IV t.d.s

S: – Client complain about

– Cleansing and

pain, redness and

irrigating wound

swelling in his right

using normal saline,

pedis

smearing Garamicyn

– Client said that they

cream then dressing

will keep sterile

it with gauze and

technique

Bactigras. Keeping aseptic and sterile

O:

technique

–

– Observing vital sign

Vital sign: T: 36,50C, RR: 20x/mnt, BP:

III

110/60 mmHg, P: 76x/mnt – Wound clean and dressing well, there is no skin regeneration yet –

mg/dl

– Monitoring intake and output – Suggesting clients to drink at least 2500cc/

Blood glucose: 252

A: goal not met yet P: continuing intervention

day – Maintaining IVFD 14 drops /minute

S: O: – Intake per oral: 2500 cc, parenteral: 1000 cc 21

– Output urine: 3000 cc – Vital sign WNL – CRT 2 second –

Blood glucose: 252 mg/dl

A: Goal met partially P: continuing intervention 11-13-09

I

–

Injecting Humolin R 4 S: IU per SC t.d.s (07-

O:

12-17)

–

– Monitoring

mg/dl

laboratory: blood

– Client finish her meal

glucose, electrolyte,

appropriate to her diet

Hb, Hct, Albumin,

–

Vital sign: T: 36,50C,

BUN, Creatinin

RR: 20x/mnt, BP:

– Observing vital sign

100/60 mmHg, P:

– Helping and ensuring

72x/mnt

patient eat her meal appropriate to her diet (B1 2100 kal) II

Blood glucose: 330

– Injecting Humolin N 4 IU per SC od (0-0-1) –

Administering

A: Goal not met P: modify intervention. I: administer Humolin R 8 IU per SC t.d.s (07-12-17)

antibiotic : ceftazidine 1gr t.d.s and metronidazole 500 mg IV t.d.s –

Cleansing and irrigating wound using normal saline, smearing Garamicyn cream then dressing

S: – Client complain about pain, redness and swelling in his right pedis – Client said that they will keep sterile 22

it with gauze and

technique

Bactigras. Keeping III

–

Vital sign: T: 36,50C,

aseptic and sterile

RR: 20x/mnt, BP:

technique

100/60 mmHg, P:

– Observing vital sign

72x/mnt – Wound clean and dressing well, there is no skin regeneration

– Monitoring intake and output – Suggesting clients to drink at least 2500cc/

yet A: goal not met yet P: continuing intervention

day – Maintaining IVFD 14

S: client complain about urinate frequently

drops /minute O:

– Intake per oral: 2500 cc, parenteral: 1000 cc – Output urine: 3000 cc –

T: 36,50C, RR: 20x/mnt, BP: 100/60 mmHg, P: 72x/mnt

– CRT 2 second –

Blood glucose: 330 mg/dl

A: Goal met partially P: continuing intervention

23

A. EVALUATION / DISCHARGE PLANNING

Item Control

Messages – Control to Policlinic Ophthalmology, cataract division – Control to Policlinic DM and Rehabilitation

Medicine

Insulin 4 IU t.d.s before meals Metformin 500 mg t.d.s

Dressing

Cleansing and irrigating wound using normal saline, smearing Garamicyn cream then dressing it with gauze and Bactigras. Keeping aseptic and sterile technique. Done by nurse in homecare

Diet

B1 2100 kal

Nutrition

At 06.00 : 4 spoon rice + side dishes At 10.00 : 1 boiled potatoes At 12.00 : rice + fruit (apple, papaya) At 17.00 : 4 spoon rice + fruit At 20.00 : 2 slice of bread Water at least 3000 cc/day

Others

Wearing suitable pad Exercise appropriate to client’s ablity Keeping the diet therapy

24