I.

INTRODUCTION

Diabetes is a disease in which the body does not produce or properly use insulin. Insulin

is a hormone that is needed to convert sugar, starches and other food into energy needed for daily

life. The cause of diabetes continues to be a mystery, although both genetics and environmental

factors such as obesity and lack of exercise appear to play roles.

There are 18.2 million people in the United States, or 6.3% of the population, who have

diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2

million people (or nearly one-third) are unaware that they have the disease.

The primary goals of treatment for patients with diabetes include controlling blood

glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for

diabetic patients must assist them to develop self-care management skills.

I chose the case for my case study. I have taken care of him for 2 consecutive days.

Let’s find out more about Diabetes Mellitus! My patient specifically has Type 2 (Non-

Insulin Dependent Diabetes Mellitus) I hope you will learn many things through my case study.

II. GENERAL DATA

Patient’s name: S., B. Z.

Address: No. GBA Pitogo Consolacion, Cebu

Birthday: October 4, 1952

Age: 54 years old

Birthplace: Poro, Camotes

Sex: Male

Citizenship: Filipino

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Occupation: None

Height: 5’ 6”

Weight: 140 lbs.

Religion: Roman Catholic

Status: Married

Wife’s name: Diomedes Sotto

Occupation: Teacher

III. HISTORY OF PRESENT ILLNESS

Twenty days prior to admission, patient noted onset of bullae at left foot dorsum about

the size of one peso coin. A days prior to admission, spontaneously ruptured, applied Betadine

one a day with no relief. Wound noted to ulcerate spreading over foot dorsum up to proximal

tibia. Fever admitted one day PTA at Ormoc Hospital, decided to transfer to VCMC for further

management.

One day prior to admission, admitted at VCMC for further management. Estimated date of

confinement was on November 12, 2006.

Vital signs taken: BP – 130/80 mmHg, HR – 117 beats / minute, RR – 19 cycles / minute and

temp. – 36.7 0C.

IV. PAST HEALTH HISTORY

Diabetic for 14 years with poor compliance to medications for diabetes like humulin and

claims no compliance for 5 years. Claim to be an alcoholic beverage and a smoker for 1 year. He

was also diagnosed with Hypertension. He has been operated for wound suturing at the left foot

2
dorsum last 2001 at CCMC. And on June 2002, he had undergone Below the Knee Amputation

at VCMC.

V. NURSING REVIEW OF SYSTEMS

1 General Appearance Patient is not having fever, conscious, coherent, responsive

when being asked. He has a slender body type; voice is clear when he talks and appears

relaxed and comfortable upon my visit.

2 Skin Patient has cool and has good skin turgor. There are no signs of skin lesions and

sores; there is absence of rashes and itchiness and no change in skin color.

3 Head Patient is normocephalic, proportion to the body. Sometimes he experienced

headache but was relieved by taking OTC medications. There is even distribution of hair and

has slightly dry hair but has no presence of flakes.

4 Eyes He has pinkish, palpable conjunctiva, does not wear glasses and has clear vision

with absence of eye infection.

5 Ears Symmetrical, non-tender and smooth texture.

6 Nose The nose is at the midline of the face, palpable, with no presence of swelling. He

also experienced colds due to weather conditions.

7 Mouth He does not wear any dentures but experiences toothaches sometimes due to

lack of oral care.

8 Neck There was no presence of neck stiffness or pain. It can move regularly and there

is no sign of swelling.

9 Upper Extremities Warm and has good skin turgor, smooth texture, and non-tender.

3
 10 Breast There was absence of lumps, nipple discharge, scales or cracks around the

nipples.

11 Lungs He has no cough, his not wheezing or having any lung disease.

12 Abdomen Flabby, soft and non-tender

13 Lower Extremities He had undergone Above the Knee Amputation at the left and

Below the Knee Amputation at the right due to Diabetes Mellitus. He has impaired mobility

thus he really needs assistance upon movement

14 GENITOURINARY SYSTEM No presence of sexually transmitted disease. Foreskin

retracts easily. The left sacral sac is lower than the right. Testicles are sensitive to pressure,

firm, smooth and equal in size. No swelling, lesions, itching noted in the reproductive area..

15 NEUROLOGIC SYSTEM Has clear thinking and has slight changes in emotional

state such as changes in mood and sometimes being irritable because of his health condition.

Has a good sense of memory and shows no signs of speech problems.

16 ENDOCRINE SYSTEM He is able to tolerate cold and hot temperature; he is above

the normal appropriate body mass index and has a history of diabetes.

VI. FAMILY, PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY

A. MEMBERS OF IMMEDIATE FAMILY

Name Age Position in Educational Occupation General

the family attainment Health status
Benito Sotto 54 yrs old Father 2nd yr H.S. None Unhealthy

Diomedes 66 yrs old Mother College of Teacher Healthy

Sotto Education
graduate
Vincent Sotto 31 yrs old Eldest child 2nd yr College N/A Healthy

Debbie Sotto 30 yrs old 2nd child College of Teacher Healthy

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 Education
graduate
Larrafe Sotto 27 yrs old 3rd child 2nd yr College N/A Healthy

Disebel Sotto 25 yrs old 4th child 3rd yr College N/A Healthy

Adelfa Sotto 23 yrs old 5th child College of Teacher Healthy

Education
graduate
Domagit 22 yrs old Youngest College of Seaman Healthy
Sotto child Marine Trans.
graduate

B. PERSONAL AND SOCIAL HISTORY

Date of birth: October 04, 1952

Place of Birth: Poro, Camotes

Nationality: Filipino

Civil Status: Married

Home address: GBA Pitogo Consolacion, Cebu

Name of Father: Bienvinido Sotto

Name of Mother: Julia Sotto

Personal Habits: Driving

Dialects Spoken: Cebuano, Tagalog, English

C. ENVIRONMENTAL HISTORY

They once lived in Poro, Camotes where the patient’s parents lived but transferred in

Consolacion, Cebu together with his eldest son and family. He described his neighborhood as a

clean place and peaceful. Garbage disposal are properly taken cared of by government garbage

collectors. They secure water by means of the faucet from MCWD

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D. HEREDO-FAMILIAL HISTORY

He verbalized that his father is diagnosed with mild hypertension. And his mother is also

a diabetic. She has no food and drug allergies.

VII. PHYSICAL ASSESSMENT

The patient was observed lying on bed, able to tolerate light movements, afebrile,

comfortable and no headache. Vital signs were noted to be; BP – 130/90 mmHg, HR – 96 bpm,

RR – 25 cpm and temp. – 35.90C.

1 SKIN Shows no signs of erythema, jaundice or cyanosis. Generally has uniform

pigmentation except in areas around the neck and areas exposed to the

sun. No signs of skin interruptions. Have warm and good skin turgor.

2 HAIR Variable, no infestation, slightly dry hair, evenly distributed hair.

3 NAILS Has smooth texture, highly vascular and pink in color, and intact epidermis

4 HEAD Normocephalic and smooth skull contour, absence of nodules, symmetric facial

features, symmetric facial movements

5 EYES Eyebrows symmetrically aligned and equal movement, skin intact, no discharge,

no discoloration, lids closed symmetrically, approximately 15 to 20

involuntary blinks per minute, sclera appears white, shiny, smooth and

pink conjunctiva, pupils black in color, equal in size, positive reaction to

light and accommodation able to read at a regular distance

6 EARS Color is same as facial skin, symmetric position, mobile, firm and not tender, able

to hear ticking sounds on both ears, has smooth texture and no signs of

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 discharges

7 NOSE Symmetric and straight, no discharge but manifests slight flaring due to post-

operative pain, has uniform color, not tender and has no lesions, nasal

septum intact and in the midline, breaths freely and regularly

8 MOUTH AND BUCCAL CAVITY Uniform pink color, ability to purse lips, no

retraction of gums, pink gums, smooth, white, shiny tooth enamel, lips

were red, soft and symmetrical in shape, no lesions, no bleeding noted on

gums, tongue is in central position, pink color, smooth lateral margins,

moves freely and has no lesions.

9 NECK Muscles equal in size, head centered, coordinated, smooth movements with no

discomfort, has equal strength, lymph nodes not palpable.

10 LUNGS AND THORAX Chest is symmetrical, skin intact, uniform temperature, full

symmetric chest expansion, clear breath sounds, respiratory rate is 25

cycles/min.

11 PERIPHERAL VASCULAR SYSTEM Full pulsations, symmetric pulse volumes,

blood pressure is noted to be 140/80; extremities show no sign of redness,

tenderness and edema.

12 BREAST AND AXILLAE Skin is uniform in color, it is also smooth and intact, no

lesions and absence of discharges. No presence of tenderness and masses

on the axillae.

13 ABDOMEN Unblemished skin, uniform in color, symmetric contour, flabby and soft,

no rashes or skin lesions, no appearance of bulges.

14 MUSCOSKELETEL SYSTEM

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 UPPER EXTREMITIES Has an equal size on both sides of the

body, no contractures, no tremors, normally firm, smooth coordinated

movements, equal strength on each body’s side.

LOWER EXTREMITIES He had undergone Above the Knee

Amputation at the left and Below the Knee Amputation at the right due to

Diabetes Mellitus. He has impaired mobility thus he really needs

assistance upon movement.

15 NEUROLOGIC SYSTEM Conscious and coherent, no language deficiency, well

oriented to time and place, coordinated body movements, smooth and

steady

16 MALE GENITALS AND REPRODUCTIVE TRACT Even distribution of pubic hair,

pubic skin intact and has no lesions.

VIII. DEVELOPMENTAL DATA

Age Development Patient’s Behavior

Infancy Trust vs. Mistrust Reported that he grew up normally as a young

(birth to 18 months) kid, demonstrated a normal steady growth.

Nourished with breast milk for a year and a half.

Toddler Autonomy vs. Shame Can fully walk alone without holding onto

(18 months to 3 and Doubt support bars at the age of 1 year and 8 months.

years) Was claimed to be very anxious about many

things and enjoys playing alone. Very

negativistic about many things.

Preschooler Initiative vs. Guilt Play was the most important activity of the day.

(4 to 5 years old) Started to go along with peers and look for

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 adventures. At this age, she can manage to wash

himself alone and toilet training was established.

School Age Industry vs. Started grade 1 at the age of 6 years old. He

(6 to 12 years old) Inferiority enjoyed the company of his friends and also

loves to study. Shows interest in studying and

playing.
Adolescent Self-Identity vs. Role This was marked as the most memorable time of

(12 to 18 years old) confusion the patient’s life especially that at this stage, she

had already experienced boy to girl relationship.

Early adult Intimacy vs. Isolation Already go married at the age of 22 years old.

(20 to 40 years old) And he had 6 children; some were already

professional and some got married and have

children too.
At Present Now, it’s his concern to have more grandchildren

and his children would raise them properly. He is

ever glad that his family has been very

supportive in these times.

IX.

A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED

PANCREAS

Glandular organ are organs that secretes digestive enzymes and hormones. In humans, the

pancreas is a yellowish organ about 7 in. (17.8cm) long and 1.5 in., 1.5 in.(3.8cm) wide. It lies

beneath the stomach and is connected to the small intestine at the duodenum. Most of the

pancreatic tissue consists of grapelike clusters of cells that produce a clear fluid (pancreatic

juice) that flows into the duodenum through a common duct along with bile from the liver.

9
Pancreatic juice contains three digestive enzymes: tryptase, amylase, and lipase that, along with

intestinal enzymes, complete the digestion of proteins, carbohydrates, and fats, respectively.

Scattered among the enzyme producing cells of the pancreas are small groups of endocrine cells,

called the islets of langerhans that secrete two hormones, insulin and glucagons. The pancreatic

islets contain several types of cells: alpha-2 cells, which produce the hormone glucagons; beta

cells, which manufacture the hormone insulin; and alpha-1 cells, which produce the regulatory

agent glucagons has the opposite action. Failure of the insulin-secreting cells to function properly

results in which can occur in two major forms, the division being between juvenile onset and

onset in maturity.

B. CONCEPTUAL FRAMEWORK ON THE PATHOPHYSIOLOGY OF DIABETES

MELLITUS TYPE 2

Destruction of alpha and beta cells of the pancreas

↓
↓ ↓
Ineffecient to produce insulin Production of excess glucagons
↓ ↓
Increased ← elevated blood glucose Production of glucose → acidosis → acetone
osmolarity protein and fat stores breath
due to glucose ↓
↓ Wasting of lean body mass → fatigue
↓ ↓ ↓ ↓
Polydipsia Polyuria Polyphagia Weight loss
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C. DISCUSSION OF THE PATHOPHYSIOLOGY

Regardless of the cause, insulin deficiency produces generally predictable consequences.

In the normal state, insulin (formed by the beta cells of the pancreas by the precursor proinsulin)

acts to facilitate transport of glucose, some amino acids, and some fatty acids across cell

membranes of tissue that are insulin sensitive, namely, liver, skeletal muscle and adipose tissue.

In the liver, glucose is used as glucose or stored as glycogen. In the absence of sufficient insulin,

excess glucose accumulates and circulates in the bloodstream (hyperglycemia) and spills into the

urine (glucosuria). Muscle cells require insulin to incorporate amino acids into muscle protein.

Insulin deficiencies cause withdrawal of amino acids and subsequent increases in serum amino

acid levels. Finally, insulin is needed to facilitate transport of glucose into the cells to maintain a

balance of lipolysis between stored triglycerides and esterification of fatty acids to triglycerides.

In insulin, deprived states there is an increase in release of fatty acids and glycerol.

The interference with glucose transported to the liver, muscle and adipose tissue, and

resulting serum elevations of glucose, amino acids, fatty acids, and glycerol, precipitate further

metabolic changes. There is hypertonic dehydration as water leaves the cells, osmotic diuresis

brought about by glucosuria, and limited tubular re-absorption, causing polyuria and loss of

electrolytes, notably sodium and potassium. Finally, fatty acids breakdown into ketone bodies,

acetoacetic acid, beta hydrobutyric acid, and acetone, causing a state of ketoacidosis.

DIABETES MELLITUS

Somatostatins are hormones secreted directly into the bloodstream, and together, they

regulate the level of glucose in the blood. Insulin lowers the blood sugar level and increases the

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amount of glycogen (stored carbohydrate) in the liver; Diabetes mellitus is a metabolic disorder,

specifically affecting carbohydrate metabolism. It is a disease characterized by persistent

hyperglycemia (high glucose blood sugar). It is a metabolic disease that requires medical

diagnosis, treatment and lifestyle changes. The World Health Organization recognizes three main

forms of diabetes: type 1, type 2 and gestational diabetes (or type 3, occurring during

pregnancy), although these three "types" of diabetes are more accurately considered patterns of

pancreatic failure rather than single diseases. Type 1 is generally due to autoimmune destruction

of the insulin-producing cells, while type 2 and gestational diabetes are due to insulin resistance

by tissues. Type 2 may progress to destruction of the insulin-producing cells of the pancreas, but

is still considered Type 2, even though insulin administration may be required.

Since the first therapeutic use of insulin (1921) diabetes has been a treatable but chronic

condition, and the main risks to health are its characteristic long-term complications. These

include cardiovascular disease (doubled risk), chronic renal failure (it is the main cause for

dialysis in developed world adults), retinal damage which can lead to blindness and is the most

significant cause of adult blindness in the non-elderly in the developed world, nerve damage,

erectile dysfunction (impotence) and gangrene with risk of amputation of toes, feet, and even

legs.

TYPE 1 DIABETES MELIITUS

Type 1 diabetes mellitus formerly known as insulin-dependent diabetes (IDDM),

childhood diabetes, or juvenile-onset diabetes - is characterized by loss of the insulin-producing

beta cells of the islets of Langerhans of the pancreas leading to a deficiency of insulin.

Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. This

type comprises up to 10% of total cases in North America and Europe, though this varies by

12
geographical location. This type of diabetes can affect children or adults, but has traditionally

been termed "juvenile diabetes" because it represents a majority of cases of diabetes affecting

children. The most common cause of beta cell loss leading to type 1 diabetes is autoimmune

destruction, accompanied by antibodies directed against insulin and islet cell proteins. The

principal treatment of type 1 diabetes, even from the earliest stages, is replacement of insulin.

Without insulin, ketosis and diabetic ketoacidosis can develop and coma or death will result.

Currently, type 1 diabetes can be treated only with insulin, with careful monitoring of

blood glucose levels using blood testing monitors. Emphasis is also placed on lifestyle

adjustments (diet and exercise). Apart from the common subcutaneous injections, it is also

possible to deliver insulin via a pump, which allows infusion of insulin 24 hours a day at preset

levels, and the ability to program a push dose (a bolus) of insulin as needed at meal times. This is

at the expense of an indwelling subcutaneous catheter. It is also possible to deliver insulin via an

inhaled powder.

Type 1 treatment must be continued indefinitely at present. Treatment does not impair

normal activities, if sufficient awareness, appropriate care, and discipline in testing and

medication. The average glucose level for the type 1 patient should be as close to normal (80–

120 mg/dl, 4–6 mmol/l) as possible. Some physicians suggest up to 140–150 mg/dl (7-7.5

mmol/l) for those having trouble with lower values, such as frequent hypoglycemic events.

Values above 200 mg/dl (10 mmol/l) are often accompanied by discomfort and frequent

urination leading to dehydration. Values above 300 mg/dl (15 mmol/l) usually require

immediate treatment and may lead to ketoacidosis. Low levels of blood glucose, called

hypoglycemia, may lead to seizures or episodes of unconsciousness.

TYPE 2 DIABETES MELLITUS

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 Type 2 diabetes mellitus is previously known as adult-onset diabetes, maturity-onset

diabetes, or non-insulin dependent diabetes mellitus (NIDDM) - is due to a combination of

defective insulin secretion and defective responsiveness to insulin (often termed insulin

resistance or reduced insulin sensitivity), almost certainly involving the insulin receptor in cell

membranes. In early stages, the predominant abnormality is reduced insulin sensitivity,

characterized by elevated levels of insulin in the blood. In the early stages, hyperglycemia can be

reversed by a variety of measures and medications that improve insulin sensitivity or reduce

glucose production by the liver, but as the disease progresses the impairment of insulin secretion

worsens and therapeutic replacement of insulin often becomes necessary. There are numerous

theories as to the exact cause and mechanism for this resistance, but central obesity (fat

concentrated around the waist in relation to abdominal organs, not it seems, subcutaneous fat) is

known to predispose for insulin resistance, possibly due to its secretion of adipokines (a group of

hormones) that impair glucose tolerance. Abdominal fat is especially active hormonally. Obesity

is found in approximately 90% of Developed world patients diagnosed with type 2 diabetes.

Other factors may include aging and family history, although in the last decade it has

increasingly begun to affect children and adolescents.

Type 2 diabetes may go unnoticed for years in a patient before diagnosis, since the

symptoms are typically milder (e.g. lack of ketoacidotic episodes) and can be sporadic. However,

severe complications can result from unnoticed type 2 diabetes, including renal failure, vascular

disease (including coronary artery disease), vision damage, etc.

Type 2 diabetes is usually first treated by changes in physical activity (usually increase), diet

(generally decrease carbohydrate intake, especially glucose generating carbohydrates), and

through weight loss. These can restore insulin sensitivity, even when the weight loss is modest,

14
for example, around 5 kg (10 to 15 lb), most especially when it is in abdominal fat deposits. The

next step, if necessary, is treatment with oral antidiabetic drugs. As insulin production is initially

unimpaired, oral medication (often used in combination) can still be used that improves insulin

production (eg, sulfonylureas) and regulate inappropriate release of glucose by the liver (and

attenuate insulin resistance to some extent (eg, metformin), and substantially attenuate insulin

resistance (eg, thiazolidinediones). If these fail, insulin therapy will be necessary to maintain

normal or near normal glucose levels. A disciplined regimen of blood glucose checks is

recommended in most cases, most particularly and necessarily when taking most of these

medications.

GESTATIONAL DIABETES

Gestational diabetes, Type 3, also involves a combination of inadequate insulin secretion

and responsiveness, resembling type 2 diabetes in several respects. It develops during pregnancy

and may improve or disappear after delivery. Even though it may be transient, gestational

diabetes may damage the health of the fetus or mother, and about 20%–50% of women with

gestational diabetes develop type 2 diabetes later in life.

Gestational diabetes mellitus occurs in about 2%–5% of all pregnancies. It is temporary,

and fully treatable, but, if untreated, may cause problems with the pregnancy, including

macrosomia (high birth weight) of the child. It requires careful medical supervision during the

pregnancy.

D. SYMPTOMATOLOGY

SIGNS AND SYMPTOMS OF DIABETES MELLITUS

15
 Type 2 diabetes almost always has a slow onset (often years), but in Type 1, particularly

in children, onset may be quite fast (weeks or months). Early symptoms of Type 1 diabetes are

often polyuria (frequent urination) and polydipsia (increased thirst and consequent increased

fluid intake). There may also be weight loss (despite normal or increased eating), increased

appetite, and unreduceable fatigue. These symptoms may also manifest in Type 2 diabetes,

though this seldom happens for some years, and sometimes not at all. Clincally, it is most

common in Type 2 patients who appear at the doctor with frank poorly controlled diabetes.

Another common presenting symptom is altered vision. Prolonged high blood glucose

causes changes in the shape of the lens in the eye, leading to blurred vision and, perhaps. All

unexplained quick changes in eyesight should force a fasting blood glucose test.

Especially dangerous symptoms in diabetics include the smell of acetone on the patient's

breath (a sign of ketoacidosis), Kussmaul breathing (a rapid, deep breathing), and any altered

state of consciousness or arousal (hostility and mania are both possible, as is confusion and

lethargy). The most dangerous form of altered consciousness is the so-called "diabetic coma"

which produces unconsciousness. Early symptoms of impending diabetic coma include polyuria,

nausea, vomiting and abdominal pain, with lethargy and somnolence a later development,

progressing to unconsciousness and death if untreated.

Signs and symptoms of diabetes mellitus are due to the high amounts of sugar in the

body. The signs and symptoms of Type 1 diabetes develop quicker and become more severe than

those of Type 2 diabetes. However, the symptoms of Type 2 diabetes may not be noticed until a

regular medical checkup. The more severe the diabetes is, the more sugar is in the blood and the

longer high blood sugar levels last. The high amount of sugar in the blood means that more urine

is needed to carry it out of the body. As a result, people with diabetes usually experience a strong

16
urge to pee, high amounts of urination (peeing), and constant thirst. The strong urge to pee can

occur at night and lead to low amounts of sleep. A high amount of peeing also leads to high

amounts of water and electrolyte loss. Electrolytes are chemical substances that are able to

conduct electricity after they are melted or dissolved in water.

For people with diabetes mellitus, the urine smells sweet because the extra sugar comes

out in the urine flow. Weakness and tiredness occur because the cells in the body are not able to

store or use the sugar that they need for energy. Thus, the body is being starved of one its main

energy sources. The body still gets some energy, however, from breaking down stored fat. The

breaking down of stored fat, in turn, leads to weight loss.

Although people with diabetes mellitus can break down stored fat for energy, the body

has a difficult time doing so. People with diabetes mellitus also have a difficult time breaking

down proteins. The difficulty in breaking down fats, especially when the body does not produce

insulin, can lead to the production of acids and poisonous chemical substances called ketones.

This condition is known as ketoacidosis. Ketoacidosis is a medical emergency because it can

cause coma, severe loss of body fluids, and even death. A coma is a state of deep

unconsciousness in which there are no voluntary movements, no responses to pain, and no verbal

speech. The signs and symptoms of ketoacidosis are nausea, vomiting, abdominal pain,

confusion, deep breathing, and foul-smelling breath. The foul-smelling breath smells like nail

polish remover.

Emergency treatment for ketoacidosis includes giving the person fluids to correct for

fluid loss and to bring back a normal chemical balance in the blood. Insulin injections are also

given to allow cells to better absorb glucose from the blood. Ketoacidosis can occur in people

with Type 1 and Type 2 diabetes. The difficulty with breaking down fats is especially true for

17
people with Type 1 diabetes (see two sections down for a description) if they miss several doses

of insulin or develop another disease. The reason for this is that developing another disease

increases the body's use of insulin. Other symptoms of diabetes mellitus are blurry vision,

increased hunger, boils, as well as tingling and loss of sensation in the feet and hands. Boils are

inflamed, pus-filled areas of the skin. Pus is a yellow or green creamy substance sometimes

found at the site of infections.

X. MEDICAL MANAGEMENT

A. TREATMENT AND PROCEDURES

Name: Sotto Benito Z., 54 years old, Filipino

Hospital no: N98361

Date: 11 – 12 – 06

Ward: Surgical Ward, MS-04

Preoperative diagnosis: Diabetic Foot Gangrene at the left

Operation: Below the Knee Amputation

Post-operative diagnosis: Diabetic Foot Gangrene at the left

Anesthetic: Spinal/ Saddle Analgesia

Anesthetic started: 1:15 pm

Operation started: 1:40 pm Ended: 3:08 pm

B. MEDICATIONS

Atenolol 50mg/tab 1 tab OD q 8am

Tramadol 50mg/amp 1 amp IVTT q 6 hrs RTC

18
Clindamycin 300mg/cap 1 cap q 6 hrs

Humulin 70/30 35 ‘u’ SQ ACBF 15’u’ SQ AC supper

Cataflam 50mg/tab 1 tab BID

C. DIAGNOSTIC PROCEDURES

HEMATOLOGY

Patient: Benito Z. Sotto Room: MS-04

Physician: Dr. Luis Carlos Fanlo November 12, 2006

LABORATORY RESULTS

TEST RESULT UNIT REFERENCE

WBC 25.8 10^3/ul 4.8-10.8
NEU 23.2
LYM 1.65
MONO .857
EOS .020
BASO .083

RBC 3.99 10^6/ul M 4.7-6.1; F 4.2-5.4

HGB 11.7 g/dl M 14.0-18.0; F 12.0-16.0
HCT 33.6 % M 42.0-52.0; F 37.0-47.0
MCV 84.2 Fl M 80-94; F 81-99
MCH 29.4 Pg 27.0-31.0
MCHC 34.9 g/dl 33.0-37.0
Platelet 612 10^3/ul 130-400

Fasting Blood Glucose 252 Mg/dl

Total Cholesterol 186 Mg/dl
HDL Cholesterol 10 Mg/dl
Triglycerides 120 Mg/dl
VLDL Cholesterol 24 Mg/dl
LDL Cholesterol 152 Mg/dl
Glycosylated Hemoglobin 12.50 %

DATA RESULT RANGE UNIT

19
Creatinine 0.48 0.6-1.5 Mg/dl

Sodium 130 134-148 mmol/L

Potassium 3.80 3.3-5.3 mmol/L

URINALYSIS

MACROSCOPIC

Color = amber - within the normal range

Character = cloudy - within the normal range

pH = 6.0 - within the normal range

Sp Gravity = 1.020 - within the normal range

Albumin = 2.51 - not normal

Glucose = +2 - not normal

Protein = +1 - not normal

MICROSCOPE (per test)

WBC = 0-2/hpf - within the normal range

RBC = 1-3/hpf - within the normal range

Epithelial cells = moderate - within the normal range

Bacteria = few - not normal

D. DIET

Breakfast: Full Diabetic Diet

Lunch: Full Diabetic Diet

Dinner: Full Diabetic Diet

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XI. NURSING CARE MANAGEMENT

A. ACTUAL CARE GIVEN

Vital signs were taken and recorded in the patient’s chart. Input and output were

measured and noted to determine and evaluate patient’s fluid balance. Medications were given as

ordered by the physician. Pillows were placed on patients leg for support because patient

undergone surgery in his knee. Massaging of both legs and feet of the patient was done. Patient

was assisted to when getting up in the bed. I encouraged the patient to follow diet plan to prevent

complications of Diabetes Mellitus. Advise patient to have regular exercise as to benefit from

advantages of exercise. I taught the patient daily self-care skills to prevent acute fluctuations in

blood glucose. Discuss with the patient the mechanism of action of his drugs and its side effects

in order for the patient to know the benefits he could get if he complies with his medication

regimen. I encouraged the patient to discuss feelings and fears related to complications. Support

and encouragement was offered to the patient.

B. PROBLEMS ENCOUNTERED DURING MY NURSING CARE

There were no problems encountered during the implementation of nursing care. The

patient was very accommodating and was so easy to deal with. He answers questions asked by

his student nurse. Also, his brother and children were hospitable that I felt I am part of their

family. The patient is cooperative during nurse care like, taking vital signs, measuring I & O,

administering medications and interviewing for assessment purposes.

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C. RESTORATIVE MEASURES USED

In consonance of the very heart of nursing care, I have engaged a dozen of nursing

measures. I had attended to his needs and talk to his about his health concerns; I helped him ease

his anxiety. I encouraged him to sit up to his bed and assisted him as he gets up on bed. This is

to hasten return of normal body circulation and peristaltic movement. I had also done measuring

her intake and output of fluids as well as monitoring his vital signs. I also administered

prescribed medications by the physician to aid him in his recovery.

As a student nurse, I did health teaching on particular pharmacologic regimen and

procedures to be done to the client to facilitate her well being and continue therapy. I also

established rapport to the client and to his family to improve communication and nursing care to

the patient.

D. EVALUATION

After rendering my interventions to my patient, he stressed his gratitude which clearly

showed a positive response to all the measures of treatment employed to him. He manifests

efficient recovery and a good sense of well- being. He, and his significant others showed positive

attitude.

E. PATIENT TEACHING

Health Teaching is important for patients having Diabetes Mellitus. Patient should be

taught on the importance of exercise, dietary changes, lifestyle, and medication regimen. Patient

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should be discussed thoroughly about the disease condition. Simple pathophysiology will do to

increase patient’s knowledge about the disease condition.

XII.

A. CONCLUSION

In making this care study, I really appreciate how vital our organs are, that we should be

very careful in doing things, in every action we take, because it may result to damage of such

organ. Diabetes Mellitus is a very complex disease process if not treated appropriately. Patients

with such condition should know how to control his lifestyle, diet, and avoid factors that could

worsen the condition. Through this case study we learned many things that are necessary and

have relevance to our future career.

B. RECOMMENDATION

This study aims to recommend a continued teaching to enhance skills and abilities of

concerned people, and to develop a good quality loaded with knowledge. This is also to eradicate

complications patients with Diabetes Mellitus

XIII. IMPLICATION OF THE STUDY TO

A. NURSING EDUCATION

The care study provides the academe of nursing education the opportunity to focus on

how to engage in care management of Diabetes Mellitus. And to renew the idea of dealing

patients easily, instead we must set much more effort in dealing with them because this is the

times when they need more support.

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B. NURSING PRACTICE

The care study provides a wider venue for nursing students to develop and enrich their

skills and knowledge in rendering efficient and effective care. It sharpens our abilities in

performing nursing measures to be rendered to our respective clients. Thus, provides us

satisfactory exposure that can’t be paid by any means.

C. NURSING RESEARCH

The care study helps in further investigation and research to optimize nursing care and

expand the scope of nursing practice. Thus, continued investigation is further encouraged on the

ultimate predisposing factor of having Diabetes Mellitus.

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