` `

A Case Analysis on:

Non-Hodgkin’s Lymphoma

Presented to:
Asst. Prof. Osel Sherwin Melad, RN

Prepared by:
Angel Clyla Amit
TABLE OF CONTENTS
Letter for Application
Mission and Vision
Objectives
Acknowledgement
Introduction
I. Psychosocial Profile
A. Demographic Data Genogram
B. Growth and Development
II. Anatomy and Physiology
Pathophysiology
 III. Medical Management
A. Drugs and Treatment
B. Laboratory and Diagnostic Exams
C. Procedures
IV. Nursing Care Management
A. FHP
B. NCP
C. Summary of Nursing Diagnoses
Including High Risks
V. Annotated Readings
VI. Bibliography
August 7 , 2017

Asst. Prof. Osel Sherwin Melad, RN

Clinical Instructor, Medicine Rotation –A2
College of Nursing, Silliman University
Dumaguete City

Dear Asst. Prof. Melad,

I, Angel Clyla Amit, level IV section A2 students of Silliman University College of Nursing in the Medicine rotation, would like to apply on a case study of our
patient, Mrs. K.A.G., 34 years old from Mangnao Dumaguete City, admitted to SUMC Medicine Department last June 17, 2017 with a diagnosis of Non-hodgkin
lymphoma. This case study would provide comprehensive information regarding our patient and will surely enhance our knowledge, skills and capabilities as
future nurses.

We will assure to you that patient’s confidentiality will be kept, and the data gathered will be used for educational purposes only. In this way, we could further
share our knowledge to our fellow classmates throughout the case presentation.
We are hoping for your kind consideration. Thank you very much!

Sincerely yours,

Angel Clyla Amit

Approved by:

Dr. Theresa A. Guino-o, RN, MSN, PhD

Clinical Intructor
 VISION

A leading Christian institution committed to total human development for the well-being of
society
and environment.

MISSION

• Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ.
• Provide an environment where Christian fellowship and relationship can be nurtured and
promoted.
•Provide opportunities for growth ad excellence in every dimension of the University life in
order to strengthen character, competence and faith.
•Instill in all members of the University community an enlightened social consciousness and a
deep sense of justice and compassion.
•Promote unity among peoples and contribute to national development.
OBJECTIVES OF CASE STUDY
Topic Description

This case study deals on the care given to the female patient during her stay in the Silliman University Medical Center – Medicine department. The
anatomy and physiology of the involved organs of the Lymphatic system, Integumentary System, and Endocrine System, and well as the physical assessment of
the patient will be discussed and explored in this study. This study also includes the pathophysiology, functional health pattern using Gordon’s FHP Tool as well as
the holistic care given to the patient. This case study aims to further enhance our knowledge on Acute Gastroenteritis with Moderate Dehydration, Hypertension
Stage 2, and Diabetes Mellitus Type 2 and how to properly deal with these conditions as a nursing student.

Case Study Objectives: Our objectives for our case study are the following:

1. To further broaden our knowledge on the said disease conditions of the patient.
2. To explain the process of how the diseases develops.
3. To incorporate our knowledge learned during our lectures, ward classes, and conferences into the actual hospital setting.
4. Research more on the disease conditions to supplement the knowledge we gained from lecture discussions.
5. To discuss the applied learned medical procedures done in the actual hospital setting.
6. Identify the developmental stage of the client and check if she has accomplished her developmental tasks.
7. Discuss the anatomy and physiology of the cardiovascular system, integumentary system, and endocrine
system that are very much affected with regards to the diseases.
8. Analyze the physical and psychological changes of the patient.
9. Develop appropriate nursing interventions for each stage to promote patient’s comfort.
10. Gain knowledge about acute gastroenteritis with moderate dehydration, hypertension type 2 and diabetes
mellitus type 2.
11. Learn about the pathophysiology of diseases.
12. Discuss the complications and causes of the said disease conditions.
13. Discuss the preventive and curative aspects of the disease conditions.
Case Presentation Objectives: Within our 1-hour case presentation, the learners will:

1. Review related concepts on previous lectures covered in Nursing Care Management

2. Discuss the process of how the disease conditions develops

3. Explain the pharmacodynamics of the medications given to the patient.

4. Identify the physiological and psychological changes associated with the diseases.

5. Analyze critically the nursing care plans.

6. Participate in the open forum.

INTRODUCTION
“The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of those
depths.” This is according to Elisabeth Kubler-Ross. Truly, life has its own version of each of our ups and downs. In line with these, our patient is battling
courageously with her Non-hodgken’s lymphoma but never losing her hope that she will survive amidst the crisis she is currently facing right now.

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the
body. Non-Hodgkin lymphoma (also known as non-Hodgkin’s lymphoma, NHL, or sometimes just lymphoma) is a cancer that starts in white blood cells
called lymphocytes, which are part of the body’s immune system.

Therefore, this case study is conducted to hone, broaden and expand our knowledge and skills to armor us in
providing holistic and quality care to patients in the future that may have the same case. In this light, we are hoping
that this study gives us the needed and appropriate information and in due course, this will help in expanding and
even in elevating the standard of the our practice.
 I. DEMOGRAPHIC DATA

Name: K.A.V Civil Status: Married Sex: Female Educational Attainment: HRM Graduate

Address: Mangnao, Dumaguete City, Negros Oriental_ Religion: Roman Catholic Age: 34 Occupation: OFW (DH)

Room and Bed No.: Rm377 Doctor(s) in Charge: GBMLabaco, KLGubantes & MDUy Nationality: Filipino

Date and Time of Admission: July 17, 2017 at 7:00 am

Chief Complaints: R mandibular Mass

Diagnos(es): _Non-Hodkin’s Lymphoma

General Impression of client (appearance upon first contact):

Lying on bedside, asleep and weal. W/ signs of respiratory distress, R mandibular mass, R side of face is edematous and R eye
is exophthalmic.
GENOGRAM
  34 y/o
 64 y/o  65 y/o
 OFW (Taiwan)
 DM 2
 Non-Hodkin’s lymphoma

 40 y/o  35 y/o
 39 y/o  36 y/o
 Freelance worker  Call center 
 Jeep driver  Teacher OFW
 married agent
 married  married (Saudi Arabia)
 1 son  single
 1 daughter  2 sons

 8 y/o  6 y/o
 Asthma
C. GROWTH AND DEVELOPMENT
THEORY
Erik Erikson’s Psychosocial Development
 Intimacy vs Isolation
 (19 y/o to 40 y/o)
o Forming intimate, loving
relationships with other
people characterized by
closeness, honesty and love
o Able to develop deep and
meaningful relationships
o Forge strong relationship
with family and friends
Robert Havighurst’s Developmental Task
Theory
 Early Adulthood – 18 – 35 years
o Choosing a partner
o Establishing a family
o Managing a home
o Establishing a career
Daniel Levinson’s Seasons of Man
 Daniel Levinson’s Theory : Seasons of a
Man’s Life
 Early adulthood (17-45 y/o )
ACHIEVED or NOT REASONS
 ACHIEVED My client is able to form strong lasting relationships
as evidenced by the support system she is receiving
from her husband. There is no sign of neglect.
Closeness and love is evident between the two.
Strong bond between my px and her family is
evident. Her sister is willing to sacrifice her work to
be able to care for my px. The same thing goes with
her husband. Friends and high school batch mates
also showed support by raising funds for her
treatment. This is an evidence of a strong
relationship formed.
 ACHIEVED My client has chosen her lifetime partner and
established a family of her own. She is also the one
responsible of providing for her family. She shares
this responsibility with her husband. She works as a
domestic helper in Taiwan and she verbalized that
she likes her job and her bosses are very nice to
her.
 ACHIEVED My client has established her life with a job and a
family of her own. She has assumed the role of a
mother and a wife. With this she works hard to be
The second stage would be a stable period because able to provide for her family as a mother and a
it marks the time where the adult must pick a role, wife. Before hospitalization the px is looking
establish goals and build a life structure. This forward to going to Hong Kong for a new job.
stage provides the young adult with any roles and
choices for their future. Levinson believes that it is
during this time that the young person dreams of
his future success in a career, family life and
status. Levinson also believes that the presence of
a mentor or older teacher is a great influence in
guiding the person through the obstacles in their
career paths.
ANATOMY AND
PHYSIOLOGY
 Lymphatic System
The lymphatic system returns fluids that have leaked from the blood (vascular system) back to the blood. Without it, our cardiovascular and immune systems
would begin to shut down. The lymphatic system contains three parts, a network of lymphatic
vessels, a fluid inside of the vessels called lymph, and lymph nodes that cleanse the lymph
while it passes through.

While blood circulates through the body, wastes, gases, and nutrients are exchanged between
the blood and interstitial fluid. Different pressures (hydrostatic and colloid osmotic pressure)
operating at capillary beds (at the very tip of where arteries and veins meet) cause most of
the fluid to be reabsorbed at the vein end. The fluid that remains behind in the tissue spaces
between the capillary beds (as much as 3 liters a day) becomes part of the interstitial fluid.

This leaked fluid, along with plasma proteins that have escaped from the bloodstream, must
be returned, to make sure the cardiovascular system continues to operate properly. The
problem of circulatory dynamics is resolved by lymphatic vessels, also known as lymphatics.
Lymphatic vessels are drainage vessels that collect the excess interstitial fluid and return it to
the bloodstream. Once interstitial fluid enters the lymphatic vessels, it is called lymph.
Lymphatic vessels form a one-way system in which lymph only flows toward the heart.

Lymphatic Capillaries

Lymph transport begins at the very tip of microscopic lymphatic capillaries. These capillaries weave through tissue cells and blood capillaries in loose connective
tissues of the body. Lymphatic capillaries are widespread, but they are absent from bones, teeth, bone marrow, and the central nervous system (where excess
tissue fluid drains into cerebrospinal fluid).

Although they are similar to blood capillaries, lymphatic capillaries are so permeable that scientists used to think they were open at one end like a straw. Now,
scientists have discovered that they owe their unique permeability to two specific structural modifications.

 The endothelial cells that form the walls of lymphatic capillaries are not tightly joined. Instead, the cells edges overlap each other loosely, forming easy
opening flaplike minivalves.

 Collagen filaments anchor the endothelial cells to surrounding structures so that any increase in interstitial fluid
volume opens the minivalves, rather than causing the lymphatic capillaries to collapse.

Proteins in the interstitial space are unable to enter blood capillaries, (they’re too big) but they can enter lymphatic
capillaries easily. In addition, when tissues become inflamed, lymphatic capillaries develop openings that permit the
uptake of even larger particles such as cell debris, pathogens, and cancer cells. The pathogens can then use the
lymphatics to travel throughout the body. This threat is partly neutralized because lymph travels through lymph
nodes, where it’s cleansed and examined by cells of the immune system. A special set of lymphatic capillaries
called lacteals transports absorbed fat from the small intestine to the blood stream. Lacteals are so-called because
of the milky white lymph that drains through them. This fatty lymph, called chyle drains from the fingerlike villi of
the intestinal mucosa.

Larger Lymphatic Vessels

From the lymphatic capillaries lymph flows through larger and thicker-walled channels – first, collecting vessels,
then trunks, and finally the largest vessels, the ducts. The collecting lymphatic vessels have the same three tunics
as veins, but the collecting vessels have thinner walls and more internal valves. Generally lymphatic vessels in the
skin travel along with superficial veins, while the deep lymphatic vessels travel with deep arteries.

The largest collecting vessels unite to form lymphatic trunks, which drain fairly large areas of the body. The major
trunks, which are named after the regions of the body they drain lymph from, are the paired lumbar, bronchomediastinal,subclavian, and jugular trunks, and the
single intestinal trunk. Lymph is eventually delivered to one of the two large ducts in the thoracic region. The right lymphatic duct drains lymph from the right
upper limb and the right side of the head and thorax. The thoracic duct (which is much larger) receives lymph from the rest of the body. It arises as enlarged sac
called the cisterna chyli, that collects lymph from the two large lumbar trunks that drain the lower limbs and from the intestinal trunk that drains the digestive
organs. As the thoracic duct runs superiorly, it receives lymphatic drainage from the left side of the thorax, left upper limb, and the left side of the head. Each
terminal duct empties its lymph into the venous circulation at the junction of the internal jugular vein and subclavian vein in its own side of the body.

The lymphatic system lacks a pump. Under normal conditions, lymphatic vessels are low-pressure conduits and the same mechanism that promotes venous return
in blood vessels acts here as well (the milking action of skeletal muscles, pressure changes in the thorax during breathing, and valves to prevent backflow).
Lymphatic vessels are usually bundled together in connective tissue sheaths, along with blood vessels, and pulsations in nearby arteries also promote lymph flow.
In addition to these mechanisms, smooth muscles in the walls of lymphatic vessels contract rhythmically, helping to pump the lymph along.

Even with aid from the above, lymph transport is still slow and sporadic. Movement of adjacent tissues is very important in propelling lymph through the
lymphatic vessels. When physical activity and movement increase, lymph flows more rapidly. Because of this, it’s a good idea to immobilize a badly infected body
part to hinder flow of inflammatory material from that region.
CIRCULATORY SYSTEM
 LEGEND

Pathophysiology

Signs and Symptoms

Complications

Death

PATHOPHYSIOLOGY
 Acute Diabetes
RISK FACTORS:
Gastroenteritis Mellitus Type 2
RISK FACTORS:

- Improper Handwashing -Genetics

-Improper food handling -overweight/obesity
-People with weakened -inactivity
immune system -age

Intake of Food
Ingestion of food infected with the pathogen
(e.g. Virus [rotavirus, norovirus] or Bacteria)

Breakdown of starches
into glucose
Ingested food goes to the GIT with the pathogen

Glucose goes into the

Pathogen damages the bloodstream
epithelium

Beta cells of pancreas releases insulin

Inflammation Inability to digest and absorb

food and water Insulin Resistance

 Abdominal
 Nausea
Pain Glucose stays on the
 Vomiting
 Fever Moderate Dehydration bloodstream
 Diarrhea
 Hyperglycemia

Exerts an osmotic
diuresis effect Gluconeogenesis
Activation

Lipolysis Amino acids catabolizes

into energy
Polydipsia (excessive Polyuria (excessive
thirst) urination) Accumulation of by
product Decrease in protein
synthesis

Fatty acids

- Polyphagia
Atherosclerosis - Decreased
gamma
globulin conc.
- Impaired
Micropathy Macropathy wound
healing

Increase muscular
resistance
Neuropathy Retinopathy
(loss of (loss of Nephropathy
sensation) vision) Increase blood
pressure

HYPERTENSION
 MEDICAL
MANAGEMENT
 Drugs and Treatment
DRUGS AS ORDERED MECHANISM OF ACTION
Fenofibrate (Lipanthyl NT) 145 mg Fibric acid derivative with lipid-regulating properties. Lowers
1 cap a day plasma triglycerides apparently by inhibiting triglyceride
synthesis and, as a result, lowers VLDL production as well as
stimulates the catabolism of triglyceride-rich lipoprotein (e.g.,
VLDL). Produces a moderate increase in HDL cholesterol levels
in most patients.
Gliclazide (Diamicron MRC) 60 mg A second generation sulphonylurea which acts as a
1 tab OD hypoglycemic agent. It stimulates β cells of the islet of
Langerhans in the pancreas to release insulin. It also enhances
peripheral insulin sensitivity. Overall, it potentiates insulin
release and improves insulin dynamics.
Losartan 50 mg Angiotensin II receptor (type AT1) antagonist acts as a potent
1 tab OD vasoconstrictor and primary vasoactive hormone of the renin–
angiotensin–aldosterone system.
Semisynthetic second-generation cephalosporin antibiotic with
CORRELATION
Our patient was ordered with this drug to reduce the
level of serum triglycerides because her triglycerides is
249.14 mg/dL which is above the normal range (<150
m/dl).
Our patient was ordered with this drug to improve
tissue sensitivity to insulin, increase glucose transport into
skeletal muscles and fat, and suppress gluconeogenesis
and hepatic production of glucose, thus lowering blood
glucose levels. Because her Fasting Blood Sugar is 169.38
mg/dL which is above normal range (50-99 mg/dl).
Our patient was ordered with this drug to lower her
blood pressure. This drug also serves as her
maintenance medication ever since she was
diagnosed with hypertension.
Our patient was ordered with this drug to eliminate
Cefuroxime 500 mg structure similar to that of the penicillins. Resistance against microorganisms because her monocytes is 9 % (1-6 %)
1 tab 3x a day beta-lactamase-producing strains exceeds that of first and her WBC count is 11, 780 / cumm (4,500-11,000 /
generation cephalosporins. Antimicrobial spectrum of activity cumm) which indicates that there is a microorganism
resembles that of cefonicid. Preferentially binds to one or more invasion inside the body.
of the penicillin-binding proteins (PBP) located on cell walls of
susceptible organisms. This inhibits third and final stage of
bacterial cell wall synthesis, thus killing the bacterium. Partial
cross-allergenicity between other beta-lactam antibiotics and
cephalosporins has been reported.

Same with Cefuroxime, this drug is also an antibiotic,

Metronidazole 500 mg Synthetic compound with direct trichomonacidal and the doctor ordered 2 antibiotics to kill all gram-
1 tab 3x a day amebicidal activity as well as antibacterial activity against positive and gram-negative bacteria. It also has
anaerobic bacteria and some gram-negative bacteria. trichomonacidal and amebicidal activity.

Omeprazole 40 mg An antisecretory compound that is a gastric acid pump Our patient was ordered with this drug because it
1 cap OD inhibitor. Suppresses gastric acid secretion by inhibiting the H+, suppresses acid secretion which will relieve
K+-ATPase enzyme system [the acid (proton H+) pump] in the gastrointestinal distress.
parietal cells.
 LABORATORY AND DIAGNOSTIC EXAMS

DATE WITH RESULTS CORRELATION

COMPLETE BLOOD COUNT

12/11/16 CBC was ordered by because of the possible inflammation in the GI tract
detected by the doctor as manifested by the patient where she had
Hemoglobin 15.59 gm% (12-14 gm%) abdominal pain and diarrhea.
Hematocrit 47 % (37-44 %)
WBC 11, 780 / cumm (4,500-11,000 / cumm)
Segmenters 62 % (55-70 %)
Lymphocyte 27 % (20-35 %)
Eosinophil 2% (1-4 %)
Monocyte 9% (1-6 %)
Basophil 0% (0.00-1.00 %)
Platelet 317 T/cumm (150-400 T/cumm)

Red Blood Cell 5.4 M/cumm (4.2-5.4 M/cumm)

Mean Corpuscular Vol 86.4 Fl (80-96 fL)
Mean Corpuscular Hgb 28.7 pg (27-31 pg)
Mean Corpuscular Hgb Conc 33.2 % (33-36 %)

KIDNEY FUNCTION TEST Kidney function test was ordered because of the possible nephropathy as a
12/11/16 complication of her type 2 Diabetes.

Creatinine 1.0 mg/dl (0.5-1.2 mg/dl)

BUN 7 mg/dl (10-20 mg/dl)
Uric Acid 6.20 mg/dl (3.4-7.2 mg/dl)
LIVER FUNCTION TEST
12/11/16
Liver function test was ordered to check liver function. SGPT/ALT measures
SGPT/ALT 17.30 u/L (9-52 u/L) the enzymes that the liver releases in response to damage or disease

CHEMICAL CHEMISTRY Chemical chemistry was ordered to monitor her Fasting Blood Sugar,
12/12/16 Creatinine Serum, Blood Uric Acid, Potassium, SGPT/ALT HDL, Triglycerides,
Total Cholesterol, LDL and TC/HDL Ratio so that an appropriate immediate
Fasting Blood Sugar 169.38 mg/dl (50-99 mg/dl) management can be done to restore normal levels and functioning.
Creatinine Serum 1.0 mg/dl (0.5-1.2 mg/dl)
Blood Uric Acid 6.20 mg/dl (3.4-7.2 mg/dl)
Potassium 4.61 mEq/L (3.6-5.0 mEq/L)
SGPT/ALT 17.30 u/L (9-52 u/L)
HDL 21.27 mg/dl (>35 mg/dl)
Triglycerides 249.14 mg/dl (<150 m/dl)
Total Cholesterol 158.66 mg/dl (<200 mg/dl
LDL 87.56 mg/dl (<130 mg/dl)
TC/HDL Ratio 7.46 (<4.5)

URINALYSIS Urinalysis is ordered to detect and manage a wide range of disorders such as
urinary tract infection, glycosuria etc.
Physical Examintaion

Color Yellow
Transparency Clear
Specific Gravity 1.020

Urine Flow Cytometry

Parameter
RBC 24 u/L 0-17 u/L
WBC 37 u/L 0-11 u/L
Epith Cells 9 u/L 0-17 u/L
Hyaline Cast 0 u/L 0-1 u/L
Bacteria 4 u/L 0-278 u/L

PROCEDURES

PROCEDURES PURPOSE

12/12/16
Dressing on right foot  To prevent contamination of the wound
 To prevent infection
 To promote healing
 To provide dry environment (moist environment facilities growth and
multiplication of micro-organisms)

12/14/16
Monitoring of Random Blood Sugar  This is to check the individual patterns of glucose changes and helps in the
planning of meals and at what time of day to take medications
 Monitor for quick response to high blood sugar (hyperglycemia) or low blood
sugar (hypoglycemia)
 Nursing
Management
 PHYSICAL
ASSESSMENT
 HISTORY FINDINGS

I. INTEGUMENTARY SYSTEM

No know skin allergies. Scar noted on right lower quadrant (history of
appendectomy). Presence of a non-healing wound at right plantar area which
she claimed was a month ago. No problems or abnormalities on both nails and
hair & scalp.
A. SKIN
INSPECTION
Skin color is brown, no unusual odor, is saggy and wrinkly, presence of
moles (scanty) on her left arm, no edema noted. Non-healing wound at about
5mm in diameter with no discharges, golden brown in color. Skin was dry and
scaly in the surrounding area of the wound.

PALPATION

Skin is warm and equal bilaterally. Dry with minimal perspiration and
oiliness. Lifts easily and snaps back immediately to its resting position.

B. NAILS

INSPECTION

Nails are transparent, pinkish, and has translucent white tips. It is well
 rounded and convex with a 160 °, harder and thicker nails.

PALPATION

Nails are firm and has a good capillary refill (prompt return of pink or
usual color not greater than 4 seconds)

C. HAIR and SCALP

INSPECTION

Hair is black in color, thick, and is equal in distribution, is coarse. No

presence of lice, no presence of scaliness.
Scalp is lighter than the face, inelastic and has a minimal amount of
dandruff.

PALPATION

No deformities, tenderness and lumps noted.

II. RESPIRATORY SYSTEM (Posterior Chest)

No surgeries. No history for any lung complications (e.g. Tueberculosis, INSPECTION

asthma, etc.). Claimed that there are no tendencies of her in difficulty
breathing. Spine is straight without lateral deviation, slightly lordotic, scapula is
symmetrical, ICS without bulging.

III. ABDOMEN
Had TAHBSOO due to twisted ovarian last 2012. Had appendectomy last June
2016; Scar noted on right lower quadrant noted. Prior to admission, patient had
abdominal pain after eating 2 lumpia shanghai. Persistent LBM followed by a
body malaise and loss of appetite. Took a dose of Diatabs which afforded no
relief. Persistence of the symptoms prompted to this admission. Diagnosed of
Acute Gastroenteritis with moderate dehydration.
PALPATION
No masses, tenderness, and crepitus noted.
 There is symmetrical movement of the thumbs during respiratory
excursion
 Fremitus is equal bilaterally and diminish in the midthorax
INSPECTION
Abdomen is not enlarged and I proportional to the body. It is round with
no abdominal distension. Symmetrical bilaterally. Color is lighter than patient’s
exposed skin and is same throughout the abdomen. Hair is equally distributed.
No lesions noted, no rashes. Umbilicus is at the midline, inverted and the color
is same at the surrounding area
AUSCULTATION
Bowel sounds noted (5x). no vascular sounds above umbilicus.
PERCUSSION
Tympany in all quadrants over the organs. Dullness over organs
PALPATION
No tenderness and masses noted
 NURSING CARE PLAN FOR PHYSICAL ASSESSMENT
Cues and Evidences Nursing Diagnoses Objectives Interventions Rationale Evaluation

Subjective: Impaired Skin Within our 8-hour care, Independent: Within our 8-hour care,
 “Natunok kog Integrity caused by able to manifest wound  Assess skin, especially  To determine goal partially met as
lansang. Dugay na nail puncture r/t slow healing the wound for any healing or evidenced by:
ni,” as verbalized. wound healing s/t
as evidenced by: signs of infection infection.
 Encourage to consume 1. Wound healing
hyperglycemia
Objective: 1. Lessened redness Vitamin C and  Vitamin C and because of proper
 Skin on plantar on wound area protein-filled diet. Protein promotes wound care,
area is dry with 2. Lowered blood Such as Kalamansi wound healing adequate nutrition
callus formation sugar compared Juice and Fish. therapy (Low
around wound to level upon  Encourage to increase Purine, Low
 Skin puncture admission fluid intake. Cholesterol, Soft,
noted at plantar (RBS: 350  Encourage to practice  Promote hydration DB diet) and timely
area mg/dL) proper hygiene. administration of
 Localized redness  To promote wound Gliclazide.
 Wound is Dependent: healing 2. FBS:
approximately  Monitor FBS q 6-11-6- 12/11
1mm in diameter 11 6PM – 146
 FBS: 169.38  Administer Gliclazide 6AM – 145
mg/dL (N: 60-100 (Diamicron MR) 60  Baseline data for 12NN – 224 (POST
mg/dL) mg 1 tab OD; 30 comparison LUNCH)
 Glycated minutes before  Stimulates beta 6PM – 224 (TOOK
hemoglobin: breakfast cells of pancreas to A SNACK)
13.5% release insulin 12/12
 Estimated average 11PM – 182
glucose: 340.8 12/13
mg/dL 6AM – 170
11AM – 150
6PM – 192
11PM – 181

12/14
6AM – 152
11AM - 219
Subjective: Risk for increased Within our 8-hour care, Independent: Within our 8-hour care,
 Verbalization that hydrochloric acid our patient will have no  Monitor bowel  To know whether goal met as evidenced
being hospitalized production r/t complaints of abdominal sounds there are still by:
is stressful stressful conditions discomfort as evidenced colicky sounds  Verbalization
because of (hospitalization and by: present that she feels less
expenses disease)  Absence of  Tell patient to
 To have immediate stress when she
colicky sounds report any feelings prays and
management in
Objective: upon auscultation of discomfort in communicate
relieving pain
 12/12/2016 P.E.:  Verbalization the abdomen with the
abdominal pain, that stress is  Encourage patient
colicky in  To lessen acid Beholder
lessened to eat less acidic  Bowel sounds
character, watery secretion in the
food like egg are with in
stools stomach
 Encourage patient normal range
 Omeprazole was to do usual ways in
ordered by  To lessen stress and no colicky
coping up stress sounds
physician prior to and anxiety
like praying to God  Did not have any
our care
Dependent: complaints of
 Administer abdominal
Omeprazole 40 mg 1 discomfort
cap/day
 suppresses acid
secretion which will
relieve
gastrointestinal
distress
 USUAL FUNCTION PATTERN
I. Health Perception- Health Management
Pattern
 Diagnosed with Hypertension for 4 years and
found out she was Diabetic due to poor wound
healing; diagnosed with DM type 2 recently
 Had TAHBSOO due to twisted ovarian last 2012
 Had appendectomy last June 2016
 Eats a full Diabetic diet after being diagnosed
with DM
 Maintenance medications:
 Metformin 500 mg BID
 Losartan 50 mg OD
 Does not find any difficulty from
doctor’s/nurse’s instructions
II. Nutritional-Metabolic Pattern
 Takes a full diabetic diet as claimed
 Does not take any food supplements
 Eats one cup of rice per meal and consumes
whole share of meal
INITIAL APPRAISAL
I. Health Perception- Health Management
Pattern
 Prior to admission, patient had abdominal pain
after eating 2 lumpia shanghai
 Persistent LBM followed by a body malaise and
loss of appetite
 Took a dose of Diatabs which afforded no relief
 Persistence of the symptoms prompted to this
admission
 Wound, approximately 5 mm in diameter, no
discharges, dry and is golden brown in color
because of iodine, on the right plantar area from
stepping on a nail; “Natusok ko ug lansang,
dugay na ni”, as claimed
II. Nutritional-Metabolic Pattern
 Consumed whole meal share
 Low purine, low cholesterol soft, Diabetic diet
with Banana
 No discomfort in eating
ON-GOING APPRAISAL
I. Health Perception- Health Management
Pattern
 Verbalized no abdominal pain
 Claimed feeling relieved compared yesterday
 Wound, approximately 5 mm in diameter, no
discharges, dry and is golden brown in color
because of iodine, on the right plantar area from
stepping on a nail
 Complained of numbness at the wound area
II. Nutritional-Metabolic Pattern
 Consumed full meal share
 Low purine, low cholesterol soft, Diabetic diet
with Banana
 Has a good appetite
 Weight loss since diagnosed with DM recently as
claimed due to controlled eating of sweets, soft
drinks, and etc.
 Eats lots of fruits and vegetables (e.g. mangoes,
lansonez) because they grow them in their back
and front yard
 Has poor wound healing
 Drinks 8-10 glasses of water as claimed
 Scaly and dry skin surrounding wound
 Eats q cup of rice per meal and 1 serving of meat
 Drank 2L of water
 On her #5 1L PNSS at 44 gtts/min
 Medications:
 Metoclopramide 10 mg IVT q 8h
 Omeprazole 40 mg IVT OD
 Paracetamol 500 mg 1 tab q4h for T
>38°C
 Losartan 50 mg tab OD
 Metronidazole 500 mg IV infusion q
6h
 Cefuroxime 750mg IVT q 8h
 Lipanthyle NT 145 mg cap 1 cap OD
HS
 Diamicron 60 mg 1 tab 30 minutes
before BF
 RBS result = 169.38 mg/dl
 Has a poorly healed wound on the right plantar
area (heel part)
 Skin was scaly and dry with callus formation
surrounding the poorly healed wound
 T= 36.8 °C
 Drank 1 L of water
 On her #7 1L PNSS reduced to 33 gtts/min as
ordered
 Medications:
 Metoclopramide 10 mg IVT q 8h
 Omeprazole 40 mg IVT OD
 Paracetamol 500 mg 1 tab q4h for T >38°C
 Losartan 50 mg tab OD
 Metronidazole 500 mg IV infusion q 6h
 Cefuroxime 750mg IVT q 8h
 Lipanthyle NT 145 mg cap 1 cap OD HS
 Diamicron 60 mg 1 tab 30 minutes before BF
 Skin was scaly and dry with callus formation
surrounding the poorly healed wound
 T= 36.8 °C

III. Elimination Pattern III. Elimination Pattern III. Elimination Pattern

 Defecates 1-2x a day, stool is brown, cylindrical
and is approximately 1 cup
 Keeps on urinating due to drinking lots of water
 No odor and excessive perspiration
 Had LBM; stool is watery as claimed  Haven’t defecated since admission
 Urinated 3x,yellow in color and was  Urinated twice, yellow, 600 cc
approximately 1 glass
 STOOL EXAM:
 Color: yellowish brown
  Consistency: mushy
 URINALYSIS:
 RBC= 24/ul
 WBC= 37/ul

IV. Activity-Exercise Pattern IV. Activity-Exercise Pattern

IV. Activity-Exercise Pattern

 Often sits at the bedside  has no problem with self-morning care

 Stays at home and looks out for her 8 month old
 Can do self-morning care  Was afraid to walk due to numbness on her right
grandchild
 Slight difficulty walking because of wound on foot
 Watches TV
left plantar area  PR= 70 bpm
 “wala ra kaayo ko gam’on sa balay”, as claimed
 PR= 75 bpm  RR= 19 cpm
 RR= 20 cpm  BP= 150/100 mm Hg
 BP= 150/100 mm Hg

 LABORATORY RESULTS
 Glycated Hemoglobin= 13.5 %
 Estimated Average Glucose= 340.8
mg/dl
 Triglycerides= 294.14 mg/dl (<150
mg/dl)
 Hemoglobin= 15.59 gm% (12-14
gm%)
 Hematocrit= 47 % (37-44 %)
 WBC= 11, 780 / cumm (4500-11000 /
cumm)
 Monocyte= 9 % (1-6 %)
 V. Sleep-Rest Pattern V. Sleep-Rest Pattern V. Sleep-Rest Pattern

 Sleeps ta 8pm and wakes up at 2-3 am
 Feels generally rested and refreshed after
sleeping
 No problems in sleeping
 Naps during the afternoon at around 1-3pm
 Sleep is interrupted during nurse’s rounds  Complains with the lights on and nurse’s rounds
 Prefers to be at home to rest  Sleeps at 9-10 pm and wakes up at 5-6 am
 Naps at 10 am in the morning and at 1pm

VI. Cognitive-Perceptual Pattern VI. Cognitive-Perceptual Pattern VI. Cognitive-Perceptual Pattern

 Loving mother to her 6 children  Feels weak because of the perception of being in  Feels relieved to be going home
 Widow for year now a hospital  Complained of numbness on right foot because
 No difficulty hearing  Verbalized, “makastress ning hospital kay of the wound
 Not wearing any eyeglasses daghang balayran”
 Complains about having an IV line because she
cannot move her hand freely

VII. Role-Relationship Pattern VII. Role-Relationship Pattern

 Children are there to support financial needs
 Husband died last year April
 A mother of 6 children
 Lives with her 4 children since the 2 children are
working in Manila
VII. Role-Relationship Pattern
 Daughter still attending to her needs
 Daughter attains to her needs in the hospital  Not able to look after her 8 month old
 Children often calls to check on her condition grandchild
 Not able to look after her 8 month old
grandchild

VIII. Self-Perception Pattern VIII. Self-Perception Pattern

VIII. Self-Perception Pattern
 Describes herself as a loving mother and  Feels well and has no problems
grandmother  Describes herself as a weak person and is willing  Still anxious because she has not yet defecated
 “Kaon ra ako bisyo”, as claimed to be well since admission

IX. Sexual-Reproductive Pattern
 Does not do self-breast examination
 Washes her genitalia when she bathes
 Age of Menarche: 12 years old
 Age of Menopausal: 52 years old
 Never tried using contraceptives
 Claimed that she had an irregular pattern of
menstruation
X. Coping Stress Tolerance Test
 Talks to children when problem arise
 Prays to God whenever problems arises or when
she feels stressed
XI. Value-Belief Pattern
 Believes that God is always there
 Goes to church every Sunday
 Has no superstitious beliefs
 Sees herself as a loving mother and
grandmother
IX. Sexual-Reproductive Pattern
IX. Sexual-Reproductive Pattern
 Sexual relationship does not apply
 Washes/wipes her genitalia after urinating  G6P6
 G6P6
X. Coping Stress Tolerance Pattern
X. Coping Stress Tolerance Test
 Children reassuring well-being
 Anxious because she hasn’t defecated for 2  Does not feel tense
days; sleeps to overcome anxiousness  Anxious because she hasn’t defecated for 2
 Prays to God whenever problems arises or when days; sleeps to overcome anxiousness
she feels stressed
XI. Value-Belief Pattern
XI. Value-Belief Pattern
 Prays to God that she will be released
 Believe that God will heal her
 COLLEGE OF NURSING
Silliman University
Dumaguete City

Cues and Evidences Nursing Diagnoses Objectives Interventions Rationale Evaluation

Subjective: Impaired Skin Within our 8-hour care, Independent: Within our 8-hour
 “Natunok kog Integrity caused by able to manifest wound  Assess skin, especially  To determine care, goal partially
lansang. Dugay na nail puncture r/t slow healing the wound for any healing or infection. met as evidenced by:
ni,” as verbalized. wound healing s/t as evidenced by: signs of infection
hyperglycemia  Encourage to consume  Vitamin C and 3. Wound healing
Objective: 3. Lessened redness Vitamin C and Protein promotes because of proper
 Skin on plantar on wound area protein-filled diet. wound healing wound care,
area is dry with 4. Lowered blood Such as Kalamansi adequate
callus formation sugar compared Juice and Fish. nutrition therapy
around wound to level upon  Encourage to increase (Low Purine, Low
 Skin puncture admission fluid intake.  Promote hydration Cholesterol, Soft,
noted at plantar (RBS: 350  Encourage to practice DB diet) and
area mg/dL) proper hygiene.  To promote wound timely
 Wound is healing administration of
approximately 5 Dependent: Gliclazide.
mm in diameter,  Monitor FBS q 6-11-6- 4. FBS:
no discharges, dry 11 12/11
and is golden  Administer Gliclazide 6PM – 146
 Baseline data for
brown in color (Diamicron MR) 60 mg 6AM – 145
comparison
because of iodine 1 tab OD; 30 minutes 12NN – 224
 Stimulates beta cells
 FBS: 169.38 before breakfast of pancreas to (POST LUNCH)
mg/dL (N: 60-100 release insulin 6PM – 224
mg/dL) (TOOK A
 Glycated SNACK)
hemoglobin: 12/12
13.5% 11PM – 182
 Estimated average 12/13
glucose: 340.8 6AM – 170
mg/dL 11AM – 150
6PM – 192
11PM – 181

12/14
6AM – 152
11AM - 219
Subjective: Altered Sensory Within our 8-hour care, Independent: Within our 8-hour
 Complained of Perception r/t altered able to lower blood  Teach about the  Helps lower blood care, goal met as
numbness at the insulin and glucose glucose as evidenced by: importance of glucose evidenced by:
right foot metabolism adherence to diet.
 RBS within normal (Low Purine, Low
Objective: limits or lower than Cholesterol, Soft, DB  RBS: 150 mg/dL
 12/12 RBS upon admission Diet)
RBS: 169.38 which is 350 mg/dL
mg/dL Dependent:
 Monitor FBS every 6-
11-6-11  Baseline data and
 Administer Diamicron comparison
60 mg 1 tab OD 30  Stimulates beta cells
minutes before of the pancreas to
breakfast release insulin
Subjective: Knowledge Deficit r/t Within our 8-hour care, Independent: Within our 8-hour
 Verbalized that lack of information of able to explain and  Health teach on the  Helps lower blood care, goal met as
she just learned the disease condition understand disease importance of glucose evidenced by:
that she have condition as evidenced adhering to proper diet
diabetes mellitus by: (Low Purine, Low  Verbalized
 Claimed that her Cholesterol, Soft, DB
avoiding soft
only vice is eating  Explains disease state Diet)
everything her  Health teach on the drinks and sweets
in her own
eyes could lay importance of  Understanding the and other
upon understanding adherence to actions of the restricted foods
 Recognizes need for prescribed medicines enables
medications. her to religiously that may increase
medications such as
Objective: take it. her blood glucose.
 FBS: 350 mg/dL the prescribed 
 Health teach on Decreases  Resistance not
 BP: 150/100 Diamicron lifestyle modification exacerbation of the
noted upon giving
mmHg  Understands such as walking at disease condition.
 Took a snack even treatments and
least 3x a week or by of medications.
when FBS is due simply avoiding sweets  Understands
routine monitoring of and fatty foods. treatments and
blood glucose.
routine
monitoring of
blood glucose.
Altered metabolism related to poor insulin supply

Altered sensory perception in the lower extremities related to poor blood circulation due to high blood glucose

Altered health maintenance related to inadequate health practice in eating a balanced diet

Risk for Injury related to damage of blood vessels that carry oxygen and nutrients to nerves

Risk for Infection related to accumulation of pathogens in slow healing wound

Risk for fluid volume deficit related to frequent nausea and vomiting and defecation
ANNOTATED
READINGS
SUMMARY

In the article “Type 2: A System Breakdown”, it states that type 2 accounts for 90 to 95 percent of all cases of diabetes and it's also far more complex but high
blood sugar is still the basic problem. The major symptoms of type 2 mirror those of type 1, but type 2 is different in other ways: It takes time. Adults suffer most.
Blood sugar is more stable.

The causes of type 2 diabetes have much more to do with lifestyle issues, particularly obesity. But weight doesn’t tell the whole story. In fact, it’s unlikely that
type 2 develops because of any one thing. Instead, a number of factors appear to come together, potentially even magnifying each other, with unhealthy results.
Among the factors that may come into play: Genetics. Inactivity. Poor diet. Age.

Being overweight is the single most important contributor to type 2 diabetes. Not all flab is created equal, though. Research studies have made it clear that fat
around the midsection-what scientists call visceral adipose tissue and the rest of us call a spare tire-contributes to diabetes more than fat located on the hips,
thighs, or other parts of the body.

Obesity doesn’t just contribute to diabetes; it’s also linked with high blood pressure and elevated levels of cholesterol and triglycerides. And it very often goes
hand in hand with high blood sugar. In fact, these health problems appear together so often, researchers call the group of them metabolic syndrome. Insulin
resistance lies at the core of the problem.

Like diabetes itself, obesity seems to run in families. Scientists believe that genes play a role in how well hormones, enzymes,
and other chemicals are able to control appetite by, say, signaling the brain to stop eating or establishing how heavy the body
thinks it ought to be. Does that mean you’re a victim of genetic fate and can’t do anything about your weight? Absolutely not.
Genes may contribute to weight, but they don’t tell the whole story. Some of the ethnic groups in which obesity and diabetes
rates are highest, such as Native Americans and Asian Americans, are not historically heavy people. Only when they took up a
high-fat, high-calorie diet and became more sedentary did they “adopt” obesity and diabetes, too.
REACTION

The article differentiates type 2 from type 1 mainly because it takes time, adults suffer most and blood sugar is more stable. It also emphasizes on having an active
lifestyle rather than a sedentary one because the single most important contributor of type 2 DM is obesity. Other factors include genetics, inactivity, poor diet
and age. Most of the members of our group have grandmothers or great grandmothers that suffered from diabetes and although genes play a role in DM, we are
at risk of suffering from the same condition. But it does not mean that we cannot prevent it. This is where lifestyle modification comes in from having a balanced
diet, active lifestyle. This only implies that Diabetes Mellitus is a preventable disease condition. If we only eat less sweets and move more, we can prevent
diabetes from occurring. Also, not only diabetes but also heart disease. The bottom line is that if diabetes and obesity go hand in hand with heart disease, we
have to take control of our blood sugar and lose weight to help protect us from both.

REFERENCE:

Reader’s Digest Canada. Type 2: A System Breakdown. Retrieved from http://www.readersdigest.ca/health/conditions/type-2-system-breakdown/

What is the best exercise to control high blood pressure?
09/22/2015

SUMMARY

Exercise is one of the best treatments for hypertension where you can do walking, cycling, and etc. Exercise lowers blood pressure in large part by altering
blood vessel stiffness so blood flows more freely. This effect occurs during and immediately after workout, so the blood pressure benefits from exercise are most
pronounced after working out.

As a result, the best way to fight hypertension may be to divide and spend your workout into bite-size pieces. In a 2012 study by Dr. Gaesser, three 10-
minute walks spread throughout the day were better at preventing subsequent spikes in blood pressure — which can indicate worsening blood pressure control
— than one 30-minute walk. And if even a 10-minute walk sounds daunting, try standing more often.

In another study led by Dr. Gaesser and published in August, overweight volunteers with blood pressure problems were asked to sit continuously during an
eight-hour workday while their blood pressure was monitored. The readings were, as expected, unhealthy. But when, during another workday, those volunteers
stood up every hour for at least 10 minutes, their blood pressure readings improved substantially. The readings were even better when, on additional workdays,
the volunteers strolled at a pokey 1-mile-per-hour pace at treadmill desks for at least 10 minutes every hour or pedaled under-desk exercise bikes for the same
number of minutes every hour.

“Exercise intensity does not appear to play any significant role” in helping people control blood pressure, Dr. Gaesser
said. Movement is what matters. So go for a stroll a few times during the day or simply stand up more often to develop
healthier blood pressure.
Reaction:

The study made by Dr. Gaesser emphasized and showed the difference between a 30-min walk in a day and a three 10-min walk. This may all sum up in to
30 minutes of working out in one day but according to his study, it is much more better and beneficial to spend your work out in bite size pieces or dividing it up in
three. This can actually prevent spiking up of your high blood pressure.

Studies have shown that a minimum of 30 minutes of exercise is good to lower down hypertension and keep you healthy. In this article, it showed that
instead of consuming the 30 minutes of working out or exercising a day, why not divides it into 3 and your work out every 10 minutes. Dr. Gaesser emphasized the
need to always move or even stand up rather than sit down all day and do nothing (which can be of a great risk for hypertension). You can spend your 30 minutes
or divide it accordingly so as to let your body move and function.

Also, he had done a study and observed overweight people who did nothing but sit down in an 8-hour workday and those who were overweight who
stood up for at least 10 minutes and noticed a great difference between the two groups where those who sat had an unhealthy blood pressure reading than those
who spend their day standing up or move their body.

REFERENCE

The New York Times.(2015 September 22). Retrieved from http://well.blogs.nytimes.com/2015/09/18/ask-well-the-best-exercise-to-reduce-blood-pressure/.

SUMMARY:

This article talks about the increasing number of people suffering from AGE with a vast majority of children specifically pre-schoolers because of the lack of hygiene and not
washing their hands properly. A new type of norovirus has been discovered by CDC which caused the outbreak of AGE amongst the people in Vietnam and South Korea. CDC
strongly emphasize on the importance of good hygiene and most especially proper hand washing to prevent AGE and minimize the number of the outbreak.

REACTION:

As a future health worker, I would strongly encourage the people especially the children and not just patients to practice good hygiene and proper hand washing because I
believe that through hand washing alone, we can prevent a widespread of diseases. Caring for ourselves holistically is the key to be healthy.

REFERENCE

Taipei Times. (2017 January 16). Caution urged, with acute gastroenteritis cases rising . Retrieved from
http://www.taipeitimes.com/News/taiwan/archives/2017/01/04/2003662490
REFERENCES

Bucher, Dirksen, Heitkemper, & Lewis. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9th ed.). Missouri, USA: Mosby, Elsevier Inc.

Ignativicus, D., & Workman, L. (2010). Medical surgical nursing: Patient-centered collaborative care (6th ed.).
Missouri, USA: Saunders Elseviers.

Smeltzer, S. & Bare, B. (2008). Brunner & Suddarth’s Textbook of Medical- Surgical Nursing. 11th ed. USA:
Lippincott.

Kenny, T. (2014 January 11). Gastroenteritis in adults. Retrieved from http://patient.info/health/gastroenteritis-

in-adults.

Mayo Clinic Staff. (2016 September 9). High blood pressure (hypertension). Retrieved from
http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/definition/con-20019580.

Medscape.(2017 January 12). Type 2 Diabetes Mellitus. Retrieved from

http://emedicine.medscape.com/article/117853-overview.