REPUBLIC OF THE PHILIPPINES

BICOL UNIVERSITY POLANGUI CAMPUS

NURSING DEPARTMENT

CASE SCENARIO:
DIABETES MELLITUS TYPE II
GROUP 3
LEVEL III & IV

Benitez, Johannah Rose Federico, Jane Eyre Salvidar, Nicole Marie Capayas, Via Kate

Cataluña, Lea Mae Gallano, Nikki Xyrill Tuy, Lyka Mae Casulang, Cherry

Daguinod, Irish Mae Ricerra, Samantha Basquiñez, Angelo Florin, Kate Florence

Encisa, Luth Trazy Salingoran, Alexandra Camata, Kathlene Paula Mabana, Jeremy Pauline

Montemayor, Jonah Airah

A. NURSING HEALTH HISTORY
P E RSONA L DA T A
Name : A.B
Age : 61 y/o
Address : Casulda, Guinobatan Albay
Date of Birth : March 16, 1961
Civil Status : M
Religion : Roman Catholic
Educational Attainment : N/A

CHIE F C O MP LAINT
Dehydration
A. NURSING HEALTH HISTORY
HIS T OR Y O F T HE P R E S E NT ILLNE S S
Previously admitted to JBDAPH last 2020 Dx with IHD;
DM 2 on Clopidogrel, Trimetazidine, Linagliptin 1-day
body weakness; January 12 fall with injury and swelling of
R leg 3/500 status post massage therapy of left leg
followed by swelling.

FA MILY HE A LT H HIS T O R Y ( P R E D IS P OS ING F AC TOR S )

Has a family history of Diabetes Millitus Type II

A. NURSING HEALTH HISTORY
HIS T OR Y O F T HE P AS T IL LNE S S
There was no recorded history of past illness except
common colds
B. PHYSICAL EXAMINATION (HEAD TO TOE)
BODY PARTS TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
PROPORTIONAL TO THE SIZE OF THE BODY, ROUND PROPORTIONAL TO THE SIZE OF THE BODY, ROUND

SKULL INSPECTION, PALPATION WITH PROMINENCES IN THE FRONTAL AND OCCIPITAL WITH PROMINENCES IN THE FRONTAL AND OCCIPITAL
AREA, SYMMETRICAL IN ALL PLACE NORMAL
AREA, SYMMETRICAL IN ALL PLACE

WHITE, CLEAN, FREE FROM MASSES,

SCALP INSPECTION WHITE, CLEAN, FREE FROM MASSES,
LUMPS, SCARS AND LESIONS, NO AREAS
LUMPS, SCARS AND LESIONS, NO AREAS
OF TENDERNESS
NORMAL
OF TENDERNESS

OBLONG/ ROUND/ SQUARE OR HEART SHAPED, FACIAL

DRY, UNEVEN TONE AND COMPLEXION
FACE INSPECTION EXPRESSION THAT IS DEPENDENT ON THE MOOD OR
TRUE FEELINGS, NO INVOLUNTARY MUSCLE MOVEMENTS,
SYMMETRIC FACIAL MOVEMENTS.
AND NOTICEABLE FINE LINES. NOT NORMAL
PARALLEL AND EVENLY SPACED SYMMETRICAL,
NON-PROTRUDING, PINK PALPEBRAL
EYES INSPECTION CONJUNCTIVA, AND PUPILS BLACK IN COLOR,
EQUAL IN SIZE, ROUND AND CONSTRICTS IN
SUNKEN-APPEARING EYES NOT NORMAL
RESPONSE TO LIGHT

MIDLINE SYMMETRICAL AND PATENT, NO

NOSE INSPECTION MIDLINE SYMMETRICAL AND PATENT, NO
DISCHARGE DISCHARGE NORMAL

PARALLEL SYMMETRICAL, PROPORTIONAL TO PARALLEL SYMMETRICAL, PROPORTIONAL TO

EARS INSPECTION THE SIZE OF THE HEAD, BEAN SHAPED, SKIN IS

SAME COLOR AS THE SURROUNDING COLOR,
THE SIZE OF THE HEAD, BEAN SHAPED, SKIN IS
SAME COLOR AS THE SURROUNDING COLOR, NORMAL
CLEAN AND FIRM CARTILAGE CLEAN AND FIRM CARTILAGE
B. PHYSICAL EXAMINATION (HEAD TO TOE)
BODY PARTS TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
SYMMETRICAL, GUMS PINKISH IN COLOR,

MOUTH INSPECTION LIPS MARGIN IS SYMMETRICAL, NO

LESION AND TENDERNESS, WITHOUT
THE TONGUE HAS ROUGH SURFACE AND
DEVELOP WHITE LAYER AND DRY. NOT NORMAL
INVOLUNTARY MOVEMENT

VARIES FROM LIGHT TO DEEP BROWN,

POOR SKIN TURGOR
SKIN INSPECTION, PALPATION FROM RUDDY PINK TO LIGHT PINK,
NOT NORMAL
GENERALLY UNIFORM SKIN
TEMPERATURE

THICK, SILKY, RESILIENT, FREE FROM

SLOW GROWTH, HAS SPLIT ENDS AND
HAIR INSPECTION INFESTATION, EVENLY DISTRIBUTED AND
COVERS WHOLE SCALP BRITTLE NOT NORMAL

NAILS INSPECTION, PALPATION CONVEX CURVATURE SMOOTH TEXTURE, HIGHLY

VASCULAR AND PINK, PROMPT RETURN OF PINK
LESS THAN 3 SECONDS
YELOLOWISH NAILS NOT NORMAL
SYMMETRICAL AND STRAIGHT, NO
NECK REGION INSPECTION, PALPATION PALPABLE LUMPS AND SUPPLE, TRACHEA
IS ON MIDLINE OF NECK, AND SPACES
DARKENING AND THICKENING AT THE
BACK OF THE NECK .
NOT NORMAL
ARE EQUAL ON BOTH SIDES

LUNGS AUSCULTATION SYMMETRICAL CHEST EXPANSION, CLEAR

BREATH SOUNDS
ASYMMETRICAL CHEST EXPANSION. NOT NORMAL
B. PHYSICAL EXAMINATION (HEAD TO TOE)
BODY PARTS TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
IRREGULAR HEART RHYTHM,
HEART AUSCULTATION A DYNAMIC PERICARDIUM, NORMAL
RATE REGULAR RHYTHM, NO MURMUR INCREASED HEART RATE NOT NORMAL

HAS PAINLESS MASSES IN ONE OR BOTH

BREAST AND INSPECTION, PALPATION NO TENDERNESS, MASSES, NODULES AND
DISCHARGE. WIDER AND DARK AREOLA, BREAST NOT NORMAL
AXILLA PROMINENT VEINS.

GENERAL CONTOUR, NO DISCOLORATION IN GENERAL CONTOUR, NO DISCOLORATION IN

ABDOMEN INSPECTION, AUSCULTATION,
PERCUSSION, PALPATION
THE ABDOMINAL WALL, PRESENCE OF
STRIAE, NO MASSES, NO SWISHING HEARD
THE ABDOMINAL WALL, PRESENCE OF
STRIAE, NO MASSES, NO SWISHING HEARD
NORMAL

UPPER AND LOWER INSPECTION EQUAL SIZE ON BOTH SIDES OF THE BODY, NO
CONTRACTURES, DEFORMITIES AND
SWELLING ON THE RIGHT AND LEFT LEG
NOT NORMAL
EXTREMITIES TENDERNESS, NORMALLY FIRM JOINTS MOVE
SMOOTHLY
 C. DEFINITION AND DESCRIPTION OF THE DISEASE
(COMPREHENSIVE)
A disorder in the body's ability to control and utilize sugar (glucose) as fuel
is type 2 diabetes. This chronic (long-term) disorder causes the
bloodstream to circulate with an excessive amount of sugar. Over time,
cardiovascular, neurological, and immune system issues might result from
excessive blood sugar levels.

There are basically two interconnected issues at work in type 2 diabetes.

Insulin, a hormone that controls how much sugar enters cells, is not
produced by the pancreas in sufficient amounts, which causes cells to
react poorly to insulin and absorb less sugar
 C. DEFINITION AND DESCRIPTION OF THE DISEASE
(COMPREHENSIVE)
Although type 1 and type 2 diabetes can start in childhood and adulthood,
respectively, type 2 diabetes used to be classified as adult-onset diabetes. Type
2 diabetes most often develops in people over age 45, but more and more
children, teens, and young adults are also developing it.Although type 2 is
more prevalent in elderly adults, type 2 instances have increased in younger
people as a result of the rise in childhood obesity.

Although there is no cure for type 2 diabetes, individuals can manage the
condition by decreasing weight, eating healthy foods, and exercising. One may
also require diabetic drugs or insulin therapy to manage the blood sugar levels
if diet and exercise are insufficient.
D. ANATOMY AND PHYSIOLOGY
 D. ANATOMY AND PHYSIOLOGY
FUNCTIONS OF PANCREAS:
SECRETES HORMONES, INCLUDING THE BLOOD SUGAR-
REGULATING HORMONES: INSULIN AND GLUCAGON.
SECRETES ENZYMES INTO YOUR DIGESTIVE TRACT THROUGH A
DUCT INTO YOUR DUODENUM.
Enzymes produced by the pancreas for digestion include:
lipase
amylase
chymotrypsin and trypsin
E. PATHOPHYSIOLOGY
PREDISPOSING FACTORS PRECIPITATING FACTORS

Reducing the volume of fatty

tissue
 Osmotic Diuresis

Electrolyte imbalance
F. DIAGNOSTIC PROCEDURES:

NAME OF DIAGNOSTIC PROCEDURE SPECIFIC INDICATION

COMPLETE BLOOD COUNT (CBC) Beyond or under the normal limits
in the CBC may indicate underlying
DEFINITION/DESCRIPTION medical condition that requires
further confirmatory evaluation
Series of tests to utilize and
determine the evaluation of
composition and concentration of
the cellular components of blood
F. DIAGNOSTIC PROCEDURES:
NURSING RESPONSIBILITY

EXPLAIN THE PROCEDURE AND ASSIST THE PT BEFORE, DURING

AND AFTER THE PROCEDURE
MONITOR VS
REVIEW AND NOTIFY THE ROD REGARDING THE RESULT FOR
FURTHER INTERVENTIONS
F. DIAGNOSTIC PROCEDURES:

NAME OF DIAGNOSTIC PROCEDURE SPECIFIC INDICATION

Blood Urea Nitrogen (BUN) Indicates if the patient need
his/her kidney function checked,
DEFINITION/DESCRIPTION especially if there is a history of
chronic illness such as diabetes or
utilized to assess the efficiency of hypertension
your kidneys. It accomplishes this
by calculating the blood's urea
nitrogen content.
F. DIAGNOSTIC PROCEDURES:
NURSING RESPONSIBILITY
BEFORE
INFORM THE PATIENT ABOUT HOW THE PROCEDURE IS DONE AND ITS PURPOSE
INFORM THAT THERE WILL BE A SLIGHT PAIN WHEN NEEDLE IS INSERTED AT THE SITE
ADVICE PT TO RELAX WHILE THE BLOOD IS BEING EXTRACTED
CLEAN THE SITE WHERE THE NEEDLE WILL BE PRICKED
DURING
MONITOR THE PT'S CONDITION
ASSIST THE PT DURING THE PROCEDURE
AFTER
APPLY PRESSURE DRESSING ON THE SITE
INFORM THE SO THAT THE PT CAN ALREADY EAT AND DRINK AFTER THE TEST
F. DIAGNOSTIC PROCEDURES:

NAME OF DIAGNOSTIC PROCEDURE SPECIFIC INDICATION

Creatinine Test The values of this test will evaluate
if your kidneys are working well
DEFINITION/DESCRIPTION

Measures the level of creatinine in

the blood. Creatinine is a waste
product which is found in your
muscle. The levels of creatinine will
allow information on how well
your kidneys are working.
F. DIAGNOSTIC PROCEDURES:
NURSING RESPONSIBILITY
BEFORE
INFORM THE PATIENT ABOUT HOW THE PROCEDURE IS DONE AND ITS PURPOSE
INFORM THAT THERE WILL BE A SLIGHT PAIN WHEN NEEDLE IS INSERTED AT THE SITE
ADVICE PT TO RELAX WHILE THE BLOOD IS BEING EXTRACTED
CLEAN THE SITE WHERE THE NEEDLE WILL BE PRICKED
DURING
MONITOR THE PT'S CONDITION
ASSIST THE PT DURING THE PROCEDURE
AFTER
APPLY PRESSURE DRESSING ON THE SITE
INFORM THE SO THAT THE PT CAN ALREADY EAT AND DRINK AFTER THE TEST
F. DIAGNOSTIC PROCEDURES:

NAME OF DIAGNOSTIC PROCEDURE SPECIFIC INDICATION

Random Blood Sugar (RBS) A positive RBS test indicates
diabetes mellitus.
DEFINITION/DESCRIPTION

Rapid identification of increased

blood sugar levels associated with
diabetes.
F. DIAGNOSTIC PROCEDURES:
NURSING RESPONSIBILITY
BEFORE
INFORM THE PATIENT ABOUT HOW THE PROCEDURE IS DONE AND ITS
PURPOSE
INFORM THAT THERE WILL BE A SLIGHT PAIN WHEN NEEDLE IS INSERTED AT THE
SITE
ADVICE PT TO RELAX WHILE THE BLOOD IS BEING EXTRACTED
CLEAN THE SITE WHERE THE NEEDLE WILL BE PRICKED
DURING
MONITOR THE PT'S CONDITION
ASSIST THE PT DURING THE PROCEDURE
AFTER
APPLY PRESSURE DRESSING ON THE SITE
INFORM THE PT THAT HE/SHE WILL BE UPDATED ABOUT THE RESULT OF THE
TEST
F. DIAGNOSTIC PROCEDURES:

NAME OF DIAGNOSTIC PROCEDURE SPECIFIC INDICATION

Fasting Blood Sugar (FBS) An indicative test for Diabetes

DEFINITION/DESCRIPTION

Test performed to assess the level

of sugar in a blood sample after a
person has fasted for the previous
night.
F. DIAGNOSTIC PROCEDURES:
NURSING RESPONSIBILITY
BEFORE
BEFORE PREPARING THE PATIENT FOR THE LABORATORY PROCEDURE,
GET THEIR PERMISSION BY EXPLAINING FBS.
EMPHASIZE THAT THE PATIENT NEED TO FAST FOR 8 HOURS
EXPLAIN THAT THE BLOOD TEST USUALLY TAKES FOR ABOUT 5
MINUTES AND SLIGHT PAIN WILL BE FELT DUE TO THE EXTRACTION
IF THE PT EXPERIENCES RESTLESSNESS, ADVICE TO STAY AND REST FOR A
WHILE
 NAME OF DATE NORMAL VALUES VALUES OBTAINED CLINICAL INTERPRETATION
PROCEDURE

CBC - RBC - 3.92-5.13

million cells/mcL All within Normal
WBC - 3,400 to normal limits
9,600 cells/mcL
Hemoglobin - 12.0
- 15 g/dL
Hematocrit
35.5%-45%
Platelet - 157-371
billion/L

Creatinine Test 74.3 to 107 51.30 umol/L Decreased

(umol/L)
 NAME OF DATE NORMAL VALUES VALUES OBTAINED CLINICAL INTERPRETATION
PROCEDURE

Within normal
BUN - 8 to 24 mg/dL
limits Normal

RBS
80 mg/dl and 130 237 mg/dL Elevated
mg/dl
 NAME OF DATE NORMAL VALUES VALUES OBTAINED CLINICAL INTERPRETATION
PROCEDURE

99 mg/dL or lower
FBS - 300 mg/dL
is normal Elevated
NURSING CARE PLAN
 NURSING
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION WITH EXPECTED
OR CUES RATIONALE OUTCOME/EVALUATION

Subjective Ineffective Tissue Short Term Goal: Independent: Short Term Goal:
Perfusion related to After 8 hours of intervention, the
Establish rapport.
After 8 hours of
Pag naglalakad ako
patient will: intervention, the patient
papunta kusina, hypovolemia as demonstrate increased
-to promote nurse and patient
demonstrated
halimbawa para relationship
uminom tubig,
evidenced by increased perfusion as evidenced by increased perfusion
hinihingal na agad BP, hypothermia, stable vs, capillary refill of < 3 Monitor the patient's VS every 4 hours as evidenced by
ako.'" as stated by seconds. stable vs, capillary
general weakness, Monitor patient's capillary refill.
the patient. refill of < 3 seconds.
edema, SOB, and Long-Term Goal:
Objective : Monitor patient's intake and output
confusion. every shift. Long-Term Goal:
After 1 week of interventions, the
capillary refill of
patient will maintain tissue perfusion
> 3 seconds Encourage the patient to increase fluid After 1 week of
as evidenced by the absence of
cold and intake. interventions, the patient
edema and level of consciousness
clammy skin maintained tissue
and balanced I & O Monitor the patient's skin and tongue
turgor.
perfusion as evidenced
VS: by the absence of
BP: 140/100 edema and level of
Turn the patient every 30 minutes to
T: 36.9 C
prevent skin ulcerations. consciousness and
RR: 27
balanced I & O
Elevate site with edema.

Encourage the patient to ambulate.

 NURSING
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION WITH EXPECTED
OR CUES RATIONALE OUTCOME/EVALUATION

Subjective Dependent:
Administer Isotonic IVF as
Pag naglalakad ako prescribed.
papunta kusina,
halimbawa para
uminom tubig, Perform BT as ordered.
hinihingal na agad
ako.+'" as stated by
the patient.

Objective :

capillary refill of
> 3 seconds
cold and
clammy skin

VS:
BP: 140/100
T: 36.9 C
RR: 27
 NURSING
ASSESSMENT DIAGNOSIS EXPECTED
OR CUES PLANNING INTERVENTION WITH
RATIONALE OUTCOME/EVALUATION

Subjective: Fluid Volume Deficit Independent The goals are met.

Short term goal:
"Nanghihina po related to Monitor vital sign
After 8 hours, the Short term goal:
ako at medyo movement of fluid into To keep track of the
patient will be able to: After 8 hours, the
nahihilo" as the third space as patient's condition patient was able to:
verbalized by the
Display stable
evidenced by body
pt vital sign Display stable vital
weakness, edema. Monitor I and O
Verbalize sign
Objective: fatigue, shortness of To keep track of the Verbalize measures
measures to fluid balance
VS taken as follows: breath, muscle cramps to prevenf fluid loss.
and confusion prevent fluid loss.
BP - 140/100
Dependent Long term goal:
RR - 27 After 1 week, the pt was
T -36.9 Long term goal: Administer Isotonic IVF nonvolemic as
SOB After 1 week, the pt as ordered evidenced by normal vs
Weakness will be nonvolemic as To provide adequate
Muscle cramps evidenced by normal fluid and hydrate the pt
Confusion vs
Edema
Cold, clammy skin
 NURSING EXPECTED
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION WITH OUTCOME/EVALUAT
OR CUES RATIONALE
ION

Activity Intolerance Short term goal: After 4 Independent

Subjective Goals are met.
related to immobility hours of nursing Evaluate client’s response to After 8 hours of nursing
data:
as evidenced by body interventions, the patient
activities . Note reports of dyspnea, intervention, the pt was
1-day Body increase d weakness and fatigues
be able to identify
weakness, injury, and will be able to identify -To facilitate to the choice of
weakness intervention measures to reduce
swelling of the right measures treduce activity activity intolerance
Objective leg. intolerance Explain the importance of rest in
treatment plan to relatives
data: -Bed rest is maintained to decrease
Long term goal: After a metabolic After one week of
61 y/o nursing intervention,
Injury month of nursing Raise railings of the bed the patient had
-To prevent the risk for fall
Swelling interventions, the progress activity to
of the small activities like
patient will progress
Instruct the pt. to dangle legs on the walking, voiding,
Right activity to small bed side for 5 to 10 minutes. bathing, eating, and etc.
Leg activities like walking, -To prevent orthostatic hypotension

Poor skin voiding, bathing, eating,

Encourage s
turgor and etc.
Chapter III: Implementation

A. Medical Management
Medications
- Insulin Therapy - Metronidazole
- Omeprazole - Ciprofloxacin
- Furosemide - Spironolactone
- Ceftriaxone - Racecadotril
Diet
- Low calorie and high fiber diet, especially vegetables
- Complex carbohydrates like rice, bread, pasta, root crops are preferred
Activity and Exercise
- Regular aerobic exercise
Exercise precaution: If blood glucose levels exceeding 250 mg/dL (14 mmol/L) and
who have ketones in urine should not begin exercise until blood glucose are normal
and urinary ketones are absent
Regular monitoring of glucose levels and ketones
Blood transfusion
B. Nursing Management (general intervention related to disease process)

Establish rapport
Ratioanale:
- To gain the trust and cooperation of the patient. For better nurse-patient relationship
Monitor for vital signs
Rationale:
- For BP, Note for changes in BP especially when the diastolic pressure drops more than 10mmHg as this may cause hypovolemia as
manifested by hypotension

Assess for peripheral pulses, capillary refill, skin turgor, and mucous membrane
Rationale:
- This indicates level of hydration and adequacy of circulating volume

Monitor I&O
Rationale:
- This will provide data for the kidney function, effectiveness of therapy and need of fluid replacement

Daily monitoring of the weight

Rationale:
- This will serve as best data to identify and assess of the current fluid status and adequacy of fluid replacement
B. Nursing Management (general intervention related to disease process)

Patient teaching about diet, activity and exercise, and proper foot care;
Rationale:
- Diet, Low calorie and high fiber diet, complex carbohydrates
- Exercise, Regular aerobic exercise
- Foot care, Advise patient to avoid walking barefoot, avoid use of tight girdles,stocking, cotton sac, Avoid
crossing legs to prevent peripheral ischemia, Cut the toe nails straight across and not remove ingrone toenail,
teach to apply genty cream, lotion, oil over the dorsum & sole of the foot not on the digital spaces, use well fitted
shoes
Encourage verbalization of feelings and offer emotional support
Collaborative
- Administer prescribed drugs.
- Administer IV fluids and insulin replacement for hyperglycemic crisis, as ordered.
Teach patient for regular insulin administration
DRUG STUDY, TREATMENT, DIET
AND ACTIVITY/EXERCISES
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES
Monitor improvements in GI
Prilosec Omeprazole 40 mg IV OD This drug is a CNS: Asthenia, symptoms (gastritis, heartburn, and
proton pump dizziness, so forth) to help determine if drug
headache therapy is successful.
inhibitor. it Assess dizziness that might affect
inhibits the GI: abdominal gait, balance, and other functional
pain, activities (See Appendix C). Report
parietal cell pump,
constipation, balance problems and functional
the final step of limitations to the physician, and
diarrhea, caution the patient and
acid production.
flatulence, family/caregivers to guard against
in turn nausea, falls and trauma.
omeprazole Monitor other CNS side effects
vomitting acid
(drowsiness, fatigue, weakness,
suppresses regurgitation headache), and report severe or
gastric basal and Muscoskeletal: prolonged effects.
stimulated acid Back pain Monitor any chest pain and attempt to
determine if pain is drug induced or
secretion Respiratory: caused by cardiovascular dysfunction
Cough, URI (e.g., angina that occurs during
Skin: Rash exercise).
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES

Lasix Furosemide 20 mg IV q8 Inhibits CNS: Assess the weight, input and

reabsorption Headache, ouput daily to determine fluid
loss
of sodium fatigue, Assess the blood pressure
and chloride weakness, when lying or standing
at proximal vertigo, Assess for full risk in older
adults, and implement fall
and distal paresthesias
prevention strategies
tubule and in ENDO: Assess the glucose in urine
the loop of Hyperglycem Assess the level of
ia consciousness if
Henle experiencing confusion,
GU: Polyuria, especially in geriatric
renal failure, patients; take safety
glycosuria, precautions if needed
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES
Ceftriaxone works by
inhibiting the CNS: BEFORE:Do Skin Testing intothe
Rocephin Ceftriaxone 750mg IV q8 IV q8 mucopeptide synthesis Headache,diz intradermal area
in the bacterial cell Protect Drug from light
wall.10,11 The beta-
ziness,
Do not mix ceftriaxone with other
lactam moiety of lethargy
ceftriaxone binds to
antimicrobial drug
carboxypeptidases,
GI: Nausea,
endopeptidases, and Vomiting, DURING:Use a separate
transpeptidases in the
diarrhea, syringewhen giving this drug
bacterial cytoplasmic Have Vitamin K available in case
membrane. These anorexia of hypoprothrombinemia occurs
enzymes are involved Hematologic:
in cell-wall synthesis
and cell division. bone marrow AFTER:Discontinue if
Binding of ceftriaxone depression, hypersensitivityoccursMonitor
to these enzymes Blood levelsin patients taking
causes the enzyme to decrease thisdrug
lose activity; therefore, WBC,
the bacteria produce
defective cell walls, platelets, Hct
causing cell death Local: Pain,
Inflammation
of IV site
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES

Flagyl Metronidazole 500 mg IV q8 Antibacterial Oral therapy Question for history of

and may result in hypersensitivity to
furry tongue, metronidazole.
antiprotozoal glossitis, Obtain specimens for
activity may cystitis, diagnostic tests, cultures
before giving first dose
result from dysuria,
Assess for any allergic
interacting pancreatitis.
reaction and for
Peripheral
with DNA hypersensitivity
neuropathy Age-related hepatic
(manifested as impairment may require
numbness, dosage adjustment.
tingling of
hands/feet)
Seizures
occur
occasionally.
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES
Inhibits
Ciloxan Ciprofloxacin 500 mg IV q12 bacterial DNA
CNS: Seizures, Assess for infection prior to and
dizziness,
during therapy
synthesis by drowsiness,
Obtain specimen before
headache, insomia,
inhibiting acute pyschoses, initations for culture and
DNA gyrase agitation, sensitivity beofre initiatiing
confusion, therapy.
hallucinations, forst dose maybe given before
increased receiving the results. to prevent
Therepeutic
intracranial
Effects: Death development of resistant
pressure, tremores
GI: Abdominal pain,
bacteria, theraphy should only
of susceptible diarrhea, nausea, be use to treat infections that
bacteria altered taste, are proven or strongly
GU: Intertistial suspected to be caused by
cystitis, vaginitis susceptible bacteria.
Spectrum: Derm: Rash
Endo:
Broad Activity Hyperglycemia,
includes hypoglycaemia
Local: Ph;ebitis at
many gram- Iv Site
positive
pathogens
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES

Hidrasec Racecadotril 100 mg tab TID Racecadrotril is

an Assess patient's diarrhea and
enkephalinase Drowsiness, bowel pattern before starting
inhibitor that nausea and theraphy
Assess hydration status and
reduces vomitting electrolytes level
pathologically constipation
increased
dizziness
secretion within
headache
a few hours in
glucose and
diarrhea of either
viral or bacterial galactose
origin. als an oral malabsoprtio
rehydration in n syndrome
treating acute
watery diarrhea
in children
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES

Aldactone Spironolactone 25 mg 1tab OD Spironolactone CNS:

competitively Dizziness,
Monitor intake and output
inhibits aldosterone clumsiness, rations and daily weight
dependant sodium headache Monitor response of signs and
potassium CV: symptoms of hypokalemia
exchange channels
Arrhythmias Assess patient frequently for
in the distal development of hyperkalemia
convoluted tubule.
GU: Erectile
This action leads to Dysfunction
increased sodium Endo: Breast
and water excretion, tenderness,
but more potassium gynecomastia,
retention. The irregular
increased excretion
menses, voice
of water leads to
deepining
diuretic and also
antihypertensive F and E:
effects Hyperkalemi,
hyponatremia
 DRUG STUDY
BRAND GENERIC FREQUENCY/MODE
/ROUTE OF
MECHANISM OF
ADVERSE
REACTION/
NURSING
ACTIONS
NAME NAME ADMINISTRATION EFFECTS RESPONSIBILITIES
blurred vision
Lantus Insulin Glargine 12u SQ OD AM Binds to the cough or FREQUENT MONITORING OF
insulin hoarseness THE PATIENT'S VITAL SIGNS
decreased MONITOR PATIENT'S BLOOD
receptor, a
vision GLUCOSE LEVEL
heterotetrame MONITOR PATIENT'S
diarrhea
ric protein dizziness
consisting of fever or chills
two general
extracellular feeling of
discomfort or
alpha units
illness
and two headache
transmembra joint pain
ne beta units. lower back or
side pain
loss of
appetite
 TREATMENT
FREQUENCY/MODE
EXPECTED
DATE NAME /ROUTE OF REGULATION
OUTCOME NURSING RESPONSIBILITIES
ADMINISTRATION

increased
Blood IV
10/22/22 30 gtts/min /improved CHECK FOR CROSS
Transfusion RH MATCHING AND TYPING
RBC
MONITOR THE PATIENT'S
VITAL SIGNS EVERY HOUR
UNTIL CONSUMED.
MONITOR FOR ANY
UNTOWARD REACTIONS TO
BT

STOP THE BLOOD

TRANSFUSION IF ANY
REACTION OCCURS
 DIET
KIND OF ROUTE OF
FREQUENCY NURSING RESPONSIBILITIES
DATE ADMINISTRATION
DIET
ADVISED PATIENT OT EAT FOOD
HIGH IN FIBER AND LOW IN FAT
DM DIET
SMALL FREQUENT
10/22/22 ORAL ADVISED PATIENT TO DRINK
MEALS
WATER OR LOW CALORIE
DRINKS
MONITOR PATIENT'S VITAL SIGNS
MONITOR PATIENT'S DAILY
WEIGHT
MONITOR PATIENTS INTAKE AND
OUTPUT
MONITOR PATIENT'S CALORIE
INTAKE
MONITOR PATIENT'S BLOOD
GLUCOSE LEVEL
 ACTIVITY/EXERCISES
DATE
SPECIFIC DATE PERFORMED/ CLIENTS’
DATE DEFINITION INDICATION ORDERED REACTION NURSING RESPONSIBILITIES
GIVEN

MONITOR
10/22/22 Moderate October 20, 2022 October 22, Complied with
PATIENT'S VITAL
aerobic exercise 5-30 mins of 2022 the ordered
walking SIGNS
exercise and
MONITOR
continually
PATIENT'S BLOOD
practiced as part
GLUCOSE LEVEL
of daily routine
PRIOR TO
EXCERCISE
OBSERVE SIGNS
AND SYMPTOMS
OF FATIGUE AN
INABILITY TO
CONTINUE
DISCHARGE PLANNING INSTRUCTION

M
EDUCATE THE CLIENT ABOUT THE IMPORTANCE AND
THE SIDE EFFECTS OF THE PRESCRIBED DRUGS
INFORM THE PATIENT WHEN TO TAKE THEIR
PRESCRIPTION AS DIRECTED.
ADVISE PATIENT TO TAKE MEDICINES ON TIME AND IN
MEDICATION THE RIGHT DOSE
DISCHARGE PLANNING INSTRUCTION

E
ADVISE ENGAGING IN MODERATE EXERCISES
FOR AT LEAST 2-3 TIMES A WEEK, IN 15-30
MINUTES PER SESSION
INFORM THE PATIENT THAT ANY TYPE OF
EXERCISE IS USEFUL, INCLUDING DOING
EXERCISE HOUSEHOLD CHORES, WALKING
DISCHARGE PLANNING INSTRUCTION

T
INFORM THE PATIENT OF THE SIGNIFICANCE OF THE
TREATMENT AND THE NEED TO TAKE IT SERIOUSLY.
DISCUSS THE PURPOSE OF THE TREATMENTS TO BE
DONE AND CONTINUED AT HOME.
ASSIST THE PATIENT’S FAMILY ON HOW TO
ADIMINISTER MEDICATION AND GIVE A STRONG
TREATMENT
SUPPORT SYSTEM WHILE UNDERGOING TREATMENT
DISCHARGE PLANNING INSTRUCTION

H
DISCUSS THE IMPLICATION AND COMPLICATIONS OF DIABETES
INSTRUCT THE PATIENT ABOUT THE DIET NEED TO BE
FOLLOWED
EDUCATE THE PATIENT ABOUT THE APPROPRIATE
MEASUREMENT TECHNIQUE AND THE NEED OF PURCHASING
GLUCOMETER
CBG MONITORING
HEALTH ADVISE THE PATIENT TO STRICTLY MONITOR HER BLOOD
TEACHING SUGAR LEVEL EVERY MORNING BEFORE MEALS AND AT
BEDTIME
DISCHARGE PLANNING INSTRUCTION

H
ENCOURAGE PATIENT TO DRINK EXTRA FLUIDS TO
PREVENT DEHYDRATION. THESE INCLUDE WATER,
BROTH, AND SUGAR-FREE DRINKS.

HEALTH
TEACHING
DISCHARGE PLANNING INSTRUCTION

O
ENCOURAGE THE PATIENT TO ATTEND THE SCHEDULED
FOLLOW-UP APPOINTMENTS ON TIME.

REFER PATIENT TO AN OUTPATIENT DIABETES CENTER

FOR FOLLLOW UP EDUCATION BY A CERTIFIED
OUTPATIENT DIABETES EDUCATOR.
DEPARTMENT
DISCHARGE PLANNING INSTRUCTION

D
ADVISED PATIENT TO EAT FOODS HIGH IN FIBER AND LOW
IN FAT
ADVISED PATIENT TO WATCH CALORIE INTAKE
ADVISED PATIENT TO EAT FRUITS, VEGETABLES, WHOLE
GRAINS, AND LEAN PROTEIN
ADVISED PATIENT TO AVOID PROCESSED FOODS AND EAT
FODS RICH IN NUTRIENTS.
DIET ADVISED PATIENT TO DRINK WATER OR A LOW CALORIES
DRINK
ADIVSED PATIENT TO HAVE A SMALL FREQUENT MEAL
DISCHARGE PLANNING INSTRUCTION

S
ENCOURAGE PATIENT TO ENGAGE IN CHURCH
ACTIVIES TO DEVELOP A SENSE OF FAITH IN THE
TREATMENT AND A POSITIVE ATTITUDE TOWARDS
LIFE, DEPENDING ON THE RELIGIOUS PREFERENCE
ENHANCE THE IMPORTANCE OF PRAYER IN THE
SPIRITUAL HEALING AND ACCEPTANCE OF THE DISEASE
COUNSELING