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Holy Angel University

College of Nursing
Angeles City

In Partial Fulfillment of
Requirements in NCM104-RLE

Diabetes Mellitus Type 2


A CASE STUDY

Group 3/ Subgroup 2
N-405
I. INTRODUCTION

1. Description

Diabetes mellitus is a group of metabolic diseases characterized by high blood


sugar (glucose) levels that result from defects in insulin secretion, or action, or both. In
patients with diabetes, the absence or insufficient production of insulin causes
hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be
controlled, it lasts a lifetime.

Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-dependent


diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is characterized by
high blood glucose in the context of insulin resistance and relative insulin deficiency.

Over time, diabetes can lead to blindness, kidney failure, and nerve damage.
These types of damage are the result of damage to small vessels, referred to as
microvascular disease. Diabetes is also an important factor in accelerating the hardening
and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease,
and other large blood vessel diseases.

There are an estimated 23.6 million people in the U.S. (7.8% of the population)
with diabetes with 17.9 million being diagnosed, 90% of whom are type 2. With
prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as
an epidemic.

World

Prevalence of diabetes worldwide

2000 2030
World 171,000,000 366,000,000
Philippines 2,770,000 7,798,000
Chan-Cua said the Philippines is still low on this score compared with
other countries, especially Scandinavian nations like Finland, Sweden, and Norway, but
we are also seeing an increase every year. Moreover, mathematical modeling on
projection yields that 380 million people are expected to develop diabetes by 2025 based
on International Diabetes Federation/World Health Organization data, a good percentage
will be coming from Southeast Asian countries, including the Philippines. This finding
is no longer astonishing considering the latest statistics on Filipinos afflicted with
diabetes and hypertension which continues to increase on the scale of medical records.
This goes to show that statistics on Diabetes Mellitus in the Philippines continues to be
unfavorable to the general population because of the continuous rise in the number of
Filipinos developing diabetes every year which adds to the number of people who
cannot enjoy life and are becoming less productive due to this disease.

Objectives
The researches have the following objectives in this case study:

 Described and explained Diabetes Mellitus together with the risk factors
contributing to the occurrence of the condition.
 Reviewed the anatomy and physiology of the organs involved.
 Interpreted the results in the laboratory and diagnostic procedures done
with the patient including their purposes, and specific nursing
responsibilities before, during and after the procedure.
 Enumerated the different medications administered for the condition, their
indications and specific nursing responsibilities.
 Formulated significant nursing diagnoses, with their significantly related
nursing care plans.
II. NURSING HISTORY

1. PERSONAL HISTORY

a. Demographic data

Mr. Sugar, a 52 years old male who is not married and has no children, was born
on June 27, 1957 at Porac Pamapanga. He is pure Filipino. Mr. Sugar graduated Business
and Accountancy at the college of Holy Angel University. After graduation, he worked
for 16 years at Saver’s Bank Guagua. He presently resides at Baidbid, Porac Pampanga
with his younger brother.

b. Socio-economic and Cultural factors

Mr. Sugar used to work at the bank for 16 years. Due to a confidential incident at
work, Mr. Sugar was asked to leave the company. When he did, he decided to stay with
his brother and help at the bakery. He never smoked and used to drink. When he was
diagnosed, he stopped drinking. He regularly has a walk in the morning as a form of
exercise. He is not choosy in eating foods and loves to eat fruits regularly.

Mr. Sugar is a Roman Catholic. Last 3 years ago he made a habit of going to Apo
to visit the church there but rarely attends mass. Since he grows up at Porac, he usually
speaks the dialect Kapampangan and Tagalog.

When it comes to health practices, he usually practices self medicate when the
sickness isn’t severe and tolerable. Paracetamol is the usual medications they use for
treating colds and colds. He doesn’t use herbs or seek herbalarios or albularyo. If his
condition gets worse, medical attention is sought. He usually goes to Porac District
Hospital for check-ups and emergency cases. Aside from emergencies, he has an annual
check up with his private doctor.
2. FAMILY HEALTH ILLNESS HISTORY

Mr. Sugar is eight child of twelve children. Diabetes Mellitus runs in the family.
His grandfather and father had Diabetes 2 while his mother was diagnosed with
hypertension and died because of a stroke. Among his siblings, one has hypertension and
the two has Diabetes Mellitus while the others are almost at pre-hypertension. His brother
before him is his twin who experiences almost the same as he does.

3. HISTORY OF PAST ILLNESS


Mr. Sugar was a drinker before. When he is working, he noticed that he got really
weak and easily fatigue, so he decided to get a check up and was diagnosed to have
Diabetes Mellitus type 2 on 1985. Medications were given to control his situation such as
Metformin and a device such as Glucoplus to monitor his blood glucose.

Hypertension arised last 3 months ago and was prescribed a maintenance of Neoblock
one tab every morning and Combizar at night.
Mr. Sugar thought his medications would maintain his health but one month ago, his eyes
started to swell and the doctor said that it was diabetic retinopathy. Thus, he had
undergone laser therapy to prevent further damage.

4. HISTORY OF PRESENT ILLNESS


On November 13, 2009, Mr. Sugar started to have the feeling of fullness but
didn’t affect his appetite. He also noticed that his bowel pattern started to change because
the urge to defecate is gone.
After 2 days, he started to vomit a lot of times. He mentioned that “parang hindi
nadigest ang mga kinakain ko.” Mr. Sugar was afraid to go to the hospital but his brother
noticed him getting weak and pale. He went to Porac District Hospital on November 17,
2009 at 7:30pm with a chief complaint of body weakness and abdominal pain.
Diagnostics exams were done and his tentative diagnoses were constipation, Diabetes
Mellitus type 2 and Pre-renal disease.
He was then admitted for observation and treatment. A stool softener, Senokot 2
tabs was prescribed so that he can eliminate and to lessen the abdominal pain. On
November 18, 2009 when the student nurses had their nurse-patient interaction, the
patient stated he defecated twice and the pain eased.

5. PHYSICAL EXAMINATION

November 17, 2009 (Admission)


Vital Signs: Bp- 160/110 mmHg; PR- 90bpm; RR- 19bpm; T- 36.4 ºC\
Chief complaint: Constipation and body weakness
General Appearance:

SKIN:
• Pale
• No lesions observed
• Dry skin
HEENT:
Head
• Hair is thin and quite moist, black with minimal white hair strands
• Even distribution of hair
• No dandruff observed
Eyes
• Pale palpebral conjunctiva
• Anicteric sclera
• Patient has blurred vision
Ears
• External canal is clean
• No discharge noted
Nose
• No discharge seen
Tongue and mouth
• Incomplete set teeth
• Pale lips
• Dry lips
• No breath odor
LUNGS:
• Chest expands during inhalation
ABDOMEN:
• Rigid upon palpation
MUSCULOSKELETAL:
• No edema

November 18, 2009


Vital Signs: Bp- 170/90 mmHg; PR- 80bpm; RR- 20bpm; T- 36 ºC

General Appearance:
Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair
disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left
hand.
Assessment:

SKIN:
• No lesions observed
• Skin is moist and warm
HEENT:
Head
• Hair is black with minimal white hair strands
• Even distribution of hair
• No dandruff observed
Eyes
• Pale palpebral conjunctiva
• Anicteric sclera
• Patient has a blurred vision
• Pupils are constrict when in light and dilates when the light is removed
Ears
• External canal is clean
• No discharge noted
• Pinna recoils after it is folded (<2secs)
Nose
• No discharge seen
• Can breath with one nostril occluded
Tongue and mouth
• Dry lips
• Incomplete set of teeth
• No breath odor
NECK:
• Lymph nodes are palpable
LUNGS:
• chest expands during inhalation
ABDOMEN:
• Non-tender upon palpation
• Flabby
• With bowel movement (twice in one day as stated by patient)
GENITO-URINARY:
• With urinary frequency
UPPER AND LOWER EXTREMITIES
• With dry cracking fissures on the soles of the feet.
• With non-pitting edema on both lower extremities
• Capillary refill: 1-2 secs.

6. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostic/ Date Indication or Results Normal Analysis and


Laboratory Ordered Purpose Values Interpretation
Procedures Date results of results
IN
Complete 11/17/09
Blood Count
(CBC)

WBC count -Measures the 11.7 x 5-10 x 10 The result is


number of 10g/L g/L slightly above
WBCs in a cubic the normal
mm of blood. range which
-It is used to may signify
detect infection infection.
or inflammation
and to monitor
client’s response
to or adverse
effects of
chemotherapy or
radiation
therapy.
Lymphocytes -To determine 0.21 0.20 - 0.40 The result is
immune within the
function, normal range.
provides a gross
measure in
nutritional status.
Eosinophils -To fight 0.01 0.01 - 0.06 The result is
infection and within the
control normal range.
mechanism
associated with
allergies and
asthma.
Hemoglobin -To evaluate the 107g/L 140 - 180 The result is
hemoglobin g/L below the
content (iron normal range
status and O2 which
carrying indicates
capacity) of anemia.
erythrocytes by
measuring the
no. of grams of
hemoglobin /dl
of blood.
Hematocrit - Measures the 0.32 0.40 – 0.54 The result is
volume of RBCs below the
in whole blood normal range
expressed as a which
percentage. indicates
- It is also a anemia.
useful in the
diagnosis of
anemia,
polycythemia,
and abnormal
hydration states.
-Value is
roughly three
times the
hemoglobin
concentration.

Nursing Responsibilities:

Prior to the procedure:

• Explain the procedure to the pt. and why it is indicated


• Inform the patient that fluid and food restriction is not required
• Inform the patient that a blood sample will be taken.
• Tell the patient that he may experience transient discomfort from the needle
pincture
• Fill up laboratory request form properly and send it to the laboratory technician
during the collection of sample/specimen.

During the procedure:


• Inform the patient that pain may be felt through prick in the needle
• Instruct the patient to calm down to avoid uneasiness.
After the procedure:
• Apply brief pressure to prevent bleeding
• Apply warm compress if Hematoma will develop at the venipuncture site.

Diagnostic/ Date Indication or Results Normal Analysis and


Laboratory Ordered Purpose Values Interpretation
Procedures Date results of results
IN
Random 11/17/09 To measure 145.3 < 140 The result is
Blood Sugar blood glucose mg/dl mg/dl above the
regardless of normal range
when you last which
ate. indicates too
little insulin/
diabetes
mellitus.

Nursing Responsibilities:
Prior to the procedure:
• Inform patient that there are no food restrictions.
• Wash your hands thoroughly before beginning procedure.
• Ready your meter according to on-screen instructions or owner's manual (every
meter is slightly different).

During the procedure:


• Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry
or dry with gauze.
• Wipe away the first drop of blood
• Squeeze slowly and rhythmically, gripping the digit firmly between the base of
thumb and first finger.

After the procedure:


• Check for sample acceptance and allow time for the machine to work. Apply firm
pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
• Record your glucose level and follow your physician's guidelines pertaining to
necessary actions for low or high glucose levels.

Diagnostic/ Date Indication or Results Normal Analysis and


Laboratory Ordered Purpose Values Interpretation
Procedures Date results of results
IN
Kidney 11/17/09
Function
Test
To monitor renal 3.7 0.4-1.4 Creatinine
Createnine function, mg/dl mg/dl level is above
specifically the the normal
ability of the range which
kidney to indicates
excrete waste kidney
products impairment.

Nursing Responsibilities:

Prior to the procedure:

• Explain to the patient the purpose of the procedure.


• Inform the patient that he need not restrict food or fluids before the test, NPO
post midnight
• Check the patient’s history for use of drugs that may influence test results.
• Inform the patient that the test requires blood sample. Explain whom will perform
the venipuncture and when it will be done
During the procedure:
• Explain to the patient that may experience slight discomfort from the needle
puncture and the tourniquet but that collecting the sample usually takes less than 3
minutes
• Instruct the patient to calm down to avoid uneasiness.

After the procedure:


• Apply warm compress if Hematoma develops at the venipuncture site.
• Apply pressure on the site to avoid bleeding.

Diagnostic/ Date Indication or Results Normal Analysis and


Laboratory Ordered Purpose Values Interpretation
Procedures Date results of results
IN
Serum 11/17/09
Electrolytes

Sodium (Na) To reflect 135.2 137 – 145 The result is


water balance. mmol/L mmol/L below the
normal range
which
indicates that
there is a
relative
increase in the
amount of
body water
relative to
sodium.
Potassium To evaluate 3.6 3.6 – 5.0 The result is
(K) fluid and mmol/L mmol/L within the
electrolyte normal level
balances and which
identify renal indicates
dysfunction. normal
Potassium is osmotic
critical to pressure and
neuromuscular cardiac and
function, neuromuscular
specifically electrical
skeletal and conduction.
cardiac muscle
activity.
Chloride (Cl) It reflects a 97 96 – 110 The result is
change in the mmol/L mmol/L within the
dilution or normal range
concentration which
of the ECF and indicates
does so in normal
direct balance of
proportion to fluids.
sodium
concentration.
Before the procedure:
• Explain to the patient that the test is used to evaluate the electrolytes content of
blood.
• Inform the patient that he need not restrict food or fluids before the test, NPO
post midnight
• Check the patient’s history for use of drugs that may influence test results.
• Inform the patient that the test requires blood sample. Explain whom will perform
the venipuncture and when

During the procedure:


• Explain to the patient that may experience slight discomfort from the needle
puncture and the tourniquet but that collecting the sample usually takes less than 3
minutes
• Instruct the patient to calm down to avoid uneasiness.

After the procedure:


• Apply warm compress if Hematoma develops at the venipuncture site.
• Apply pressure on the site to avoid bleeding.

Diagnostic/ Date Indication or Results Normal Analysis and


Laboratory Ordered Purpose Values Interpretation
Procedures Date results of results
IN
Fasting 11/18/09 To measure 146 70 – 110 The result is
Blood Sugar blood glucose mg/dl mg/dl above normal
(FBS) after you have range which
not eaten for at indicates too
least 8 hours. It little insulin/
often is the first diabetes
test done to mellitus.
check and
monitor
treatment of
diabetes.

Nursing Responsibilities:
Prior to the procedure:
• Ask patient if he/she had not eaten at least 8 hours.
• Wash your hands thoroughly before beginning procedure.
• Ready your meter according to on-screen instructions or owner's manual (every
meter is slightly different).

During the procedure:


• Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry
or dry with gauze.
• Wipe away the first drop of blood
• Squeeze slowly and rhythmically, gripping the digit firmly between the base of
thumb and first finger.

After the procedure:


• Check for sample acceptance and allow time for the machine to work. Apply firm
pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.

• Record your glucose level and follow your physician's guidelines pertaining to
necessary actions for low or high glucose levels.
III. ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The body’s
primary energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food circulates
in the blood as a ready energy source for any cells that need it. Insulin is a hormone or
chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin
bonds to a receptor site on the outside of cell and acts like a key to open a doorway into
the cell through which glucose can enter. Some of the glucose can be converted to
concentrated energy sources like glycogen or fatty acids and saved for later use. When
there is not enough insulin produced or when the doorway no longer recognizes the
insulin key, glucose stays in the blood rather entering the cells.

Anatomy of the pancreas:


The pancreas is an elongated, tapered organ located across the back of the
abdomen, behind the stomach. The right side of the organ (called the head) is the widest
part of the organ and lies in the curve of the duodenum (the first section of the small
intestine). The tapered left side extends slightly upward (called the body of the pancreas)
and ends near the spleen (called the tail).
The pancreas is made up of two types of tissue:
• Exocrine tissue
The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a
network of ducts that join the main pancreatic duct, which runs the length of the
pancreas.
• Endocrine tissue
The endocrine tissue, which consists of the islets of Langerhans, secretes
hormones into the bloodstream.

Functions of the pancreas:


The pancreas has digestive and hormonal functions:
• The enzymes secreted by the exocrine tissue in the pancreas help break down
carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel
down the pancreatic duct into the bile duct in an inactive form. When they enter
the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate
to neutralize stomach acid in the duodenum.
• The hormones secreted by the endocrine tissue in the pancreas are insulin and
glucagon (which regulate the level of glucose in the blood), and somatostatin
(which prevents the release of the other two hormones.

Anatomy of kidney

The kidneys play key roles in body function, not


only by filtering the blood and getting rid of waste
products, but also by balancing levels of electrolytes in the
body, controlling blood pressure, and stimulating the
production of red blood cells.
The kidneys are located in the abdomen toward the back, normally one of each
side of the spine. They get their blood supply through the renal arteries directly from the
aorta and send blood back to the heart via the renal veins to the vena cava. (The term
"renal" is derived from the Latin name for kidney.)

The kidneys have the ability to monitor the amount of body fluid, the
concentrations of electrolytes like sodium and potassium, and the acid-base balance of
the body. They filter waste products of body metabolism, like urea from protein
metabolism and uric acid from DNA breakdown. Two waste products in the blood can be
measured: blood urea nitrogen (BUN) and creatinine (Cr).

Kidneys are also the source of erythropoietin in the body, a hormone that
stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor
the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the
body starts to manufacture more red blood cells.
IV. THE PATIENT AND HIS ILLNESS
a. Schematic diagram

Pathophysiology (book–based)
b.1. Definition of the disease
Diabetes Mellitus
Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly
known as adult-onset diabetes, it usually affects people aged over 40 and
progresses gradually. In this type the pancreas has not ceased to produce insulin,
but the quantity is insufficient, or the hormone is not stimulating the glucose
uptake in muscles and tissues required for energy. The result is a build-up of
glucose in blood and urine.
Although the cause of this malfunctioning is unclear, non-insulin
dependent diabetes mellitus tends to run in families. Other risk factors, such as
increasing age, obesity, and a sedentary lifestyle, probably contribute to its
increased incidence in developed countries.
Non-insulin dependent diabetes mellitus can often be controlled initially
by diet alone, or in combination with tablets that reduce the amount of blood
glucose. There are two main types of blood glucose-reducing drugs:
sulphonylureas work mainly by stimulating the pancreas’s islet cells (known as
the islets of Langerhans) to produce more insulin and biguanides increase the
effectiveness of insulin on cells. Eventually, however, patients may need insulin
injections.

Prerenal Acute Renal Failure


It is categorized as an acute renal failure which is characterized by inadequate
blood circulation (perfusion) to the kidneys, which leaves them unable to clean
the blood properly. Many patients with prerenal ARF are critically ill and
experience shock (very low blood pressure).There often is poor perfusion within
many organs, which may lead to multiple organ failure.

Prerenal ARF is associated with a number of preexisting medical


conditions, such as atherosclerosis ("hardening" of the arteries with fatty
deposits), which reduces blood flow. Dehydration caused by drastically reduced
fluid intake or excessive use of diuretics (water pills) is a major cause of prerenal
ARF. Many people with severe heart conditions are kept slightly dehydrated by
the diuretics they take to prevent fluid buildup in their lungs, and they often have
reduced blood flow (underperfusion) to the kidneys

b.2. Predisposing Factors


• Age - Type 2 DM usually occurs at the age 40 years old and above. Type 2 DM
occurs most commonly in people older than 30 years who are obese.
• Family history of DM - Type 2 DM has a strong genetic component. Although the
major gene that places the patient at risk is not yet identified, it is clear that the
disease is polygenic and multifactorial. Individuals with a parent with type 2 DM
have an increased risk for diabetes. Genetic factors are thought to play a role in
insulin résistance and impaired insulin secretion in type 2 DM.
• Race (African-Americans, Hispanic-Americans) - The risk for type 2 diabetes
varies among population groups. Diabetes also seems to pose higher or lower
risks for specific complications among racial groups.

Precipitating Factors
• Obesity - Elevated levels of free fatty acids, a common feature of obesity, may
contribute to the pathogenesis of type 2 DM. It can impair glucose utilization in
skeletal muscles, promote glucose production by the liver and impair beta cell
function.
• Environmental Factors/Stress – An increase in stress hormone triggers the release
of epinephrine and norepinephrine which will promote the secretion of glucose
leading to hyperglycemia.
• Inactive Lifestyle – A risk factor that had contributed in the occurrence of DM
due to the fact that lack of muscle activities decreases the need for the body to
utilize glucose as a form of energy.
• Diet – Foods rich in carbohydrates can easily promote the increasing level of
glucose along the bloodstream.
Prerenal Risk Factors

• Atherosclerosis cause obstruction to the flow of blood reaching the kidneys


• Blood loss can lead to the constriction of the arteries carrying blood throughout
the body, reducing the volume of blood reaching various organs including the
kidney
• Heart disease can lead to a reduction in the pumping effect of the heart, reducing
the amount of blood reaching the kidneys and other organs.

b.3. Signs and Symptoms with Rationale


Diabetes Mellitus
HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)
• May be due to lack of physiologically active insulin that transports
glucose from extracellular to intracellular leading to accumulation of
glucose in the intravascular space. The glucose is not utilized by the body
and it remains in the blood streams.
POLYURIA
• Increased frequency of urination. This may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.
POLYDIPSIA
• Increased thirst and fluid intake. This may be due to the activation of the
thirst center in the hypothalamus resulting form the intracellular
dehydration or volume depletion.
POLYPHAGIA
• Increased hunger and food intake. This may be due to the decrease glucose
uptake by the cells leading the stimulation of the satiety center in the
hypothalamus resulting to the ‘hunger sensation.”

WEAKNESS/ FATIGUE

• This is due to the decreased glucose uptake by the cells leading to


decreased energy production.
GLYCOSURIA
• The kidney filters the blood, making it to its normal state. Glucose was
filtered out and excreted in the urine.
• Due to the excess glucose ad compared to the kidney threshold, which
results to the excretion of glucose in the urine.

GASTROPARESIS (Stomach fullness) ,CONSTIPATION and BLOATING

• This is due to changes in nerves and damages the blood vessels


that carry oxygen and nutrients to the nerves. Over time, high blood
glucose can damage the vagus nerve. The stomach fails to empty properly
and is likely due to the generalized neuropathy.

NAUSEA/ VOMITING

• Due to stomach fullness, there will be an involuntary emptying of


stomach contents that are forcefully expelled by the mouth.
• A compensatory mechanism due to acidity of body because of decrease
excretion of metabolic waste.

PALE

• Due to decreased production of erythropoietin.


Schematic diagram of the disease
PATHOPHYSIOLOGY(client-centered)
b.1. Predisposing/ Precipitating Factors
Predisposing Factors
• Age- 52 years old.
• Heredity- patient’s grandfather and father has DM
Precipitating Factors
• Sedentary lifestyle

b.2. Signs and Symptoms

• Gastroparesis( Stomach fullness) and Constipation


o November 13, 2009
o This is due to changes in nerves and damages the blood vessels
that carry oxygen and nutrients to the nerves. Over time, high
blood glucose can damage the vagus nerve. The stomach fails to
empty properly and is likely due to the generalized neuropathy.
• Nausea/vomiting
o November 15, 2009
o Due to stomach fullness, there is a involuntary emptying of
stomach contents that are forcefully expelled by the mouth.
o A compensatory mechanism due to acidity of body because of
decrease excretion of metabolic waste.
• Hyperglycemia
o November 17, 2009
o Due to lack of physiologically active insulin that transports
glucose from extracellular to intracellular will lead to
accumulation of glucose in the intravascular space. The glucose is
not utilized by the body and it remains in the blood streams.
• Hypertension
o November 17, 2009 160/110 mmHg
o Due to increase in osmotic pressure, fluid goes to the vascular
space increasing the blood volume.

• Weakness/fatigue
o November 17, 2009

o Due to decreased glucose uptake by the cells leading to decreased


energy production.
• Pale
o November 17, 2009
o Due to decreased production of erythropoietin.
V. PATIENT AND HIS CARE
1. Medical Management
a. IVF
Date Ordered/
Date
Medical Client’s
Performed/ General Indication or
Management response to the
Date Description Purpose
Treatment treatment
Changed/
D/C
Plain Normal 11/17/09 An aqueous It can be used for The drug was
Saline solution of 0.9 hydration, and, administered
Solution percent sodium as a solvent for properly, with
(PNSS) chloride, drugs that are to expected effects
1L x isotonic with the be administered achieved, and
40gtts/min. blood and tissue parenterally. the patient did
fluid, used in not experience
medicine chiefly dehydration.
for bathing
tissue and, in
sterile form.

Nursing Responsibilities:
Prior the procedure:
• Read the doctor’s order
• Check IV label
During the procedure:
• Check for patency of tubing
• Regulate as ordered
After the procedure:
• Check IV infusion and amount every 2 hours

b. Drugs
Date
Route of
Ordered/ General Action,
administration, Client’s
Date Taken/ Classification
Name of Drug Dosage and response to the
Date Mechanism of
Frequency of medication
Changed/ Action
administration
D/C

Generic Name: 11/17/09 1 amp, IV An anti-emetic The patient did


metoclopramide STAT then q 8 drug that blocks not vomit the
dopamine, but also day after the
Brand Name: stimulates medication was
Plasil acetylcholine to given and has
increase gastric bowel
emptying. It movement.
increases the force
of gastric
contraction, relaxes
pyloric sphincter,
and increases
peristalsis in the
duodenum and
jejunum without
affecting the
motility of the
large intestine.

Nursing Responsibilities:
Prior to Administration
-Check patient’s name before administration
-Check the doctor’s order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.
After Administration
-Monitor bowel movement.
-Instruct patient not to drink alcohol during therapy.
Date
Route of
Ordered/ General Action,
administration, Client’s
Name of Date Taken/ Classification
Dosage and response to the
Drug Date Mechanism of
Frequency of medication
Changed/ Action
administration
D/C

Generic 11/17/09 2 tabs, It is laxative that is The patient had


Name: used as a short-term defecated.
Senna treatment of
constipation and to
evacuate the colon
Brand Name: for bowel or rectal
Senokot examinations.

Prior to Administration
-Check patient’s name before administration
-Check the doctor’s order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.
After Administration
-Monitor bowel movement.
-Instruct patient not to drink alcohol during therapy.
Date
Route of
Ordered/ General Action,
administration, Client’s
Date Taken/ Classification
Name of Drug Dosage and response to the
Date Mechanism of
Frequency of medication
Changed/ Action
administration
D/C

Generic 11/17/09 1 tab, PO, OD Metoprolol is in a Patient’s blood


Name: group of drugs pressure is still
metoprolol called beta- high. From
blockers. It is a 160/110 mmHg
selective inhibitor upon admission
Brand Name: of beta1-adrenergic rises to 170/ 90
Neobloc receptors affecting mmHg.
the heart and
circulation. It is
used to treat angina
and hypertension.
Nursing Responsibilities:
Prior to Administration
-Check patient’s name before administration
-Check the doctor’s order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.

After Administration
-Monitor for signs of tachycardia, palpitations and especially blood pressure
-Instruct patient to sit before standing

Name of Date Route of General Action, Client’s


Drug Ordered/ administration, Classification response to the
Date Taken/ Dosage and Mechanism of medication
Date Frequency of Action
Changed/ administration
D/C

Generic 11/17/09 1 tab, PO, OD Losartan is in a Patient’s blood


Name: group of drugs pressure is still
losartan called angiotensin II high. From
receptor 160/110 mmHg
antagonists. upon admission
Brand Name: Losartan keeps rises to 170/ 90
Combizar blood vessels from mmHg.
narrowing, which
lowers blood
pressure and
improves blood
flow. It is also used
to slow long-term
kidney damage in
people with type 2
diabetes who also
have high blood
pressure

Nursing Responsibilities:
Prior to Administration
-Check patient’s name before administration
-Check the doctor’s order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.

After Administration
-Monitor for signs of tachycardia, palpitations and especially blood pressure
-Instruct patient to sit before standing
Date
Route of
Ordered/ General Action,
administration, Client’s
Date Taken/ Classification
Name of Drug Dosage and response to the
Date Mechanism of
Frequency of medication
Changed/ Action
administration
D/C

Generic 11/17/09 1 tab, PO, OD It decreases hepatic Glucose level of


Name: glucose production, the patient may
metformin decreasing decrease. ( No
intestinal absorption available data)
of glucose and
Brand Name: improves insulin
Glucophage sensitivity

Nursing Responsibilities:
Prior to Administration
-Check patient’s name before administration
-Check the doctor’s order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.

During Administration
-Instruct the patient to calm down to avoid uneasiness.

After Administration
-Monitor glucose level closely in this patient because severe hypoglycemia may result
before the patient develops symptoms.
-Advice patient to avoid vigorous exercise immediately after dose.
-Inform patient to avoid alcohol, which lowers glucose level.
c. Diet
Client’s
Date started/ General Indication or response and/or
Type of diet
Date changed description purpose. reaction to the
diet
Nothing per 11/17/19 It is a type of Indicated for Since the patient
patients unable
orem (NPO) diet that was oriented and
to consume a
withholds oral regular diet and understands
patients wild
fluids and needed
mild G.I.
foods. problems. interventions, he
followed with
the doctors
prescriptions.
Nursing Responsibilities
Prior
• Verify doctor’s order.
• Explain the diet prescribed to the patient.
• Instruct patient to withhold oral fluids and foods.
During
• Ensure that the patient strictly follow the diet.
After
• Assess for patient’s condition; how he responds to the diet.

d. Exercise/ Activity

Date
Ordered,
Date Client’s Response
Type of General Indication or
Started, and/or reaction to
exercise description Purpose
Date activity
Changed or
D/C
Keep rested An activity Indicated to 11/17/09 Patient responded
where strenuous avoid fatigue. to doctor’s order
activities should and stated
be avoided. Bed decreased body
rest should be weakness.
implemented
but with
assisted
bathroom
privilege to
avoid further
aggravation of
the gangrene
and to reduce
pain as well.

Nursing Responsibilities
Prior
• Check doctor’s order for any other considerations needed.
• Explain the activity to the patient.
• Explain why it is important and what it could improve in her condition.
During
• Assess patient’s present condition.
• Reinforce information as appropriate.
After
• Note patient’s response to activity.
VI. NURSING CARE PLAN
VII. DISCHARGE PLANNING
1. General Condition of the Client

Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair
disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left
hand. He reported that he had already two bowel movements.

2. METHODS

M-edication

Metoprolol 1tab PO,OD


Losartan 1tab PO,OD
Metformin 1tab PO,OD

E-xercise

• Instruct to exercise at least 3 days a week and avoid strenuous activity.

>Regular exercise, even of moderate intensity (such as brisk walking),

improves insulin sensitivity and may play a significant role in preventing

type 2 diabetes

T-reatment

• Follow-up check up on his private doctor.

H-

• Instruct pt. to comply with the given diet.

• Explain the importance of exercise in maintaining or losing weight.

• Advise patient to check blood glucose level before doing any activities and to eat

carbohydrate snack before exercising to avoid hypoglycemia.


>Blood glucose levels should be monitored before and after exercise to

establish blood glucose response patterns to the exercise regimen. If blood

glucose is >250 mg/dl, the patient should delay the exercise session.

O-PD follow-up

D-iet

• Diabetic Diet

>Carbohydrates should provide 45 - 65% of total daily calories. Best choices are

vegetables, fruits, beans, and whole grains. These foods are also high in fiber.

Carbohydrate counting or meal planning exchange lists.

>Fats should provide 25 - 35% of daily calories. Limit saturated fat.

>Protein should provide 12 - 20% of daily calories, although this may vary
depending on a patient individual health requirements

• Avoid eating too much sweet foods.

• Eat foods rich in fiber such as banana.


VIII. CONCLUSION

In this study, the student nurses’ aim is to understand the disease more,
manifestations, risk factors and complications. Diabetes mellitus is a condition in which
the pancreas no longer produces enough insulin or cells stop responding to the insulin
that is produced, so that glucose in the blood cannot be absorbed into the cells of the
body.
Mr. Sugar’s diabetes mellitus was caused mainly by his sedentary lifestyle, his
food preference and due to hereditary factor since his grandfather and his father both had
diabetes. Diabetic retinopathy, a complication of diabetes mellitus, also occurred and Mr.
Sugar opted to undergo laser therapy a month ago.

It is best managed with a team approach to empower the client to successfully


manage the disease. As part of the team the, the nurse plans, organizes, and coordinates
care among the various health disciplines involved; provides care and education and
promotes the client’s health and well being. Diabetes is a major public health worldwide.
Its complications cause many devastating health problems.

Through this case study, we should be able to learn and understand the disease
Diabetes Mellitus type 2 and therefore give us knowledge in proper management,
prevention and treatment. As a student nurse, it is very important to know many things
including the said disease condition. After the hardships of completing our case study, a
reward of self-fulfillment and credential to our knowledge and skills has been added to us
being student nurses as well as professionals in the near future.
IX. RECOMMENDATION
The researchers would recommend the further study of this case as this is a
disease that is interesting. It would be better if another causative factor would be studied
to be able to provide diverse information about this disease and to be able to compare to
spot similarities and differences in the manifestations of this disease if there is a different
causative factor. To be able to appreciate the physical manifestations of this disease, we
advise future researchers to investigate this case on the onset of the disease to be able to
assess and note more overt manifestations both for educational and documentation
purposes.
X. BIBLIOGRAPHY
http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes
http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm
http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-
philippines-and-worldwide/
http://nursingcrib.com/diabetes-mellitus-case-study/
Brunner&Suddarth.Textbook of medical-surgical nursing.2008.Lippincott Williams
& Wilkins.