Introduction

Diabetes is a chronic, debilitating and costly disease with severe complications like blindness, heart disease, stroke, kidney failure, and lower limb amputations. It 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. Insulin is a hormone produced by the pancreas to control blood sugar. When someone has the Type-1 diabetes, their bodies do not produce any or do not produce enough of the hormone called insulin to use the energy stored in food. Those with Type-2 or acquired diabetes cannot effectively use the insulin they produce. The causes of diabetes mellitus are unclear; however, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the body's defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a role. Patient Y got Type II Diabetes Mellitus. Type 2 diabetes mellitus usually called NonInsulindependent diabetes mellitus (NIDDM) unlike patients with type 1 diabetes mellitus; patients with type 2 are not absolutely dependent on insulin for life. Adult or maturity- onset diabetes for it usually occurs after age 30yr, but can occur in children. Type II DM consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. For type 2 diabetes mellitus to occur, both insulin resistance and inadequate insulin secretion must exist. For example, all overweight individuals have insulin resistance, but diabetes develops only in those who cannot increase insulin secretion sufficiently to compensate for their insulin resistance. Their insulin concentrations may be high, yet inappropriately low for the level of glycemia.

In the Philippines, one out of every five adult Filipinos are diabetic, according to the latest national survey conducted on the prevalence of diabetes in the country. The survey, conducted in 2007 by the Philippine Cardiovascular Outcome Study on Diabetes Mellitus (PhilCOS-DM). Furthermore, it shows that as many as three out of five adults are already diabetic or on the verge of developing diabetes unless they change their lifestyle. Health authorities and the medical community were alarmed by the "rapid development of diabetes" especially among children, in the last 10 years. In the same instance the presentors of this case study acquire to the statistic of the mortality and morbidity in the case of Diabetes here in the province of Northern Samar explicitly at Northern Samar Provincial Hospital (NSPH) from their record on July to October 2012. From 3976 total number of admission they had with different admitting cases the number of patient admitted with Diabetes is 51. The mortality rate is 10 while the morbidity rate is 41. Our group choose to have Diabetes Mellitus as our case study because most of our group mates relatives acquire the same illness. Therefore as a nursing student and a concern family member, we wanted to expound our knowledge about the said disease and to identify the root causes of acquiring this disease and the detailed process on how diabetes mellitus come about.

Comprehensive Health History

I. Patients Profile
Name Age Birthday Sex Status Occupation Education Attainment Religion Nationality Address Date of Admission Attending Physician Source of Information Date of Interview : : : : : : : : : : : : : : Patient Y 48 years old September 24, 1964 Male Married Maintenance worker High School Born Again Christian Filipino Pambujan, Northern Samar November 16, 2012 Dr. Unay Patient and wife November 17, 2012

Chief Complaint

Diabetic Foot, Left

II.

History of Present Illness

On the month of August 2012 while they were in Cavite his left foot started to become edematous for unknown reason. He decided to wrap the left foot with a garter to put pressure and stop the progression of the edema. After 3 days, the fourth digit on the left foot develops a lesion. He just ignored the lesion because he thought it would heal eventually. It started to get worse so they decided to return to Samar to seek for alternative intervention. They consult a quack doctor about the situation. They placed the

left foot over the smoke of incense because they thought that he was being played by environmental spirits. The patient also drinks a glass of lana every morning given by the quack doctor. But his wound keeps on getting worse. The skin started to slough off and emitted foul odour. He had a hard time sleeping because he always wakes up in the middle of the night because of the pain. He then decided to have another opinion from a doctor in the Health Center of Pambujan. The doctor prescribed Co Amoxiclab and Mefenamic Acid. The patient developed rashes from Co Amoxiclab so the doctor deferred the medication and changed it to Amoxicillin. He always clean the wound and put dressing around it with betadine. On November 16, 2012, they went to the Northern Samar Provincial Hospital (NSPH) to consult a doctor but they were advised that its better to stay in the hospital to have more effective medical management. He was admitted at the Emergency Room with meds prescribed such as Ceftriaxone 1 g vial q8. Ranitidine 50 mg IVTT q12, Clindamycin 150 mg 1 cap TID. He was infused with an IVF Plain LR to run for 10 hours.

III.

Past Health History

In his childhood, he experienced symptoms like cough, cold, fever and other common ailments which have been remedied by using over-the-counter drugs such as Paracetamol and Neozep. When the patient was still in his 20s, he accidentally fall from a cliff while he was working as a construction worker. There was a fracture on his 7th rib viewed from the x-ray result. He already suffered transient ischemic attack three times. The first attack was when he was working at the construction site when he was 33 year old. He was immediately brought to the hospital by his co-workers. On his second attack, he was only prayed over by their pastor. According to the patient mayda kakaiba na energy na nagdaloy sak lawas san ginpray over ak san amun pastor.

Hes been diabetic for almost 12 years for he was diagnosed to have Diabetes Mellitus Type II, in Tarlac, Manila in the year 2000. He is taking diabet as his maintenance before. It was prescribed by his physician in Tarlac when he was diagnosed with diabetes. He has an unhealthy lifestyle before he had diabetes. Hes a smoker and a heavy drinker. He can consume 2 packs of cigarette per day. Nakakaubos ak bug-os na crispy pata pati 1.5 na coke. Sayo ka bandihado na luto ak nauubos pagnangangaon kami. But when he was diagnosed with diabetes, he changed hes lifestyle and he also changed religion into Born Again upon his diagnosis on year 2000. He started to change his diet, stop smoking and drinking liquor. He also lose weight. He started to smoke again when he had his wound because of the foul smell and the pain.

IV.

Family Health History

The family has no known history of diabetes. His father is hypertensive.

Functional Health Pattern

Health Perception/Health Management
Prior to Admission The patient is concern with his condition. He went to a quack doctor to seek alternative intervention and he also consulted a physician in Pambujan for medical intervention. He stopped his vices when he was diagnosed with diabetes. He always does exercise to keep his body healthy. During Admission The patient perceives his present health status as 4 out of the scale of 110, 10 being the state of positive regard for health and 1 as the state of negative regard to his health. Even though he knows he is diabetic, he can eat 2-4 plates of rice every meal and he is fund of drinking soft drinks. In his situation now, hes still hoping to have other option aside from debridement of his fourth digit in his left foot.

Nutrition/Metabolic
Prior to Admission The patient eats 3 meals a day with snacks in between. He usually eats meat and fish with two plates of rice. Hes also fund of drinking soft drinks. He eats 1-2 plates of rice per meal. During Admission On the stay in the hospital, he is in a diabetic diet. He eats foods in moderation.

Elimination/Pattern
Prior to Admission The patient usually urinates more than 10 times a day. He defecates every morning. During Admission: The patient urinates more than 10 times a day. He defecates in the morning.

Activity/Exercise
Prior to Admission He can perform his ADL without assistance such as eating, bathing. He lifts weights to maintain body exercise because he cant play basketball. He takes a walk at their neighbourhood and visit his friends in his barangay. During Admission: The patient can perform his ADL with some assistance from his wife like bathing and changing clothes. He can ambulate without assistance from other people.

Sleep/Rest Pattern
Prior to Admission The patient usually has a hard time sleeping because of the pain on his left foot. He also wakes up in the middle of the night just to urinate. He cant have a continuous sleep because of these interruptions. He then gets at least 4-5 hours of sleeps during night time.

During Admission: The patient dont have problem in sleeping. He sleeps around 8 pm and wake up around 6 am.

Cognitive/Perceptual Pattern
The patient has no sensory deficits. He is oriented to time, place and person. He responds to verbal and physical stimuli appropriately.

Role Relationship Pattern

The patient lives with his wife in a small kubo in Pambujan. His first and third son already has a family. The eldest is living in Manila while the youngest prefers to stay here in Samar. The second child is still single and working in Manila. His family always consider his decision as the head of the family.

Value/Belief
The patient is a born again Christian. Before having an injury to his foot, hes very active in the church. He also preaches in their church and does bible sharing. After his injury to his foot, he refrained from attending to church because he was ashamed of the foul smell of his left foot.

Review of System
Date of Examination Time of Examination Name of Patient : November 17, 2012 : 3:30 pm : Patient Y

General Appearance: Patient Y is wearing a white t-shirt, well-groomed, can ambulate on his own. Presence of gangrenous wound in his left foot, 4th digit. Vital Signs: Temp. RR PR BP Integumentary Skin: Color : brown complexion Presence of scars in upper and lower extremities because of the rashes he developed while taking amoxiclab - (result of his extensively scratched because of severe itchiness) Presence of gangrenous wound in the left foot, fourth digit : : : : 37c 23 88 130/90

Hair:

Hair evenly distributed on scalp. Thick and short Presence of white hair

Nails Head Eyes Ears Color same as facial sinuses Auricle aligned with outer canthus of eye No lesion No discharge Thin eyebrows evenly distributed No discharge Pupil in central position Constricts when exposed to light Rounded skull with prominent frontal area Presence of scars developed from taking amoxiclab Convex curvature Angle of nail plate about 160 degrees trimmed nails

Nose and Sinuses Mouth Respiratory Thorax and Lungs Cardiovascular Heartbeat is in normal range (88bpm) Capillary refill is 2 sec. Pale lips 23 bpm No tenderness or masses on the chest wall Pale lips Tounge is in central position Pink gums Nasal septum intact No discharge No lesion

Suffered from stroke 4 times

Gastrointestinal Normal abdominal sound Positive bowel movement No abdominal distention

Musculoskeletal Needs no assistance when moving No musculoskeletal impairment

Neurologic Assessment Glasgow Coma Scale Eye opening 4 Motor Response 6 Verbal Response 5 Language Able to name common objects Able to respond simple verbal commands Orientation Oriented to time and place as well as the person around him

Cranial Nerves I

Names

Findings

Implication

Olfactory

Identified scent(body spray) correctly with each nostril

Normal

II

Optic

Can read newsprint 1 foot away Pupils constrict when looking at

Normal

III

Oculomotor

near objects and dilates when looking at far objects.

Normal

IV

Trochlear

Both eyes are coordinated while assessing the six ocular

Normal

movement

Trigeminal: Opthalmic branch Blinks when the sclera is touched with a wisp of cotton. Can feel light touch to ear and reacts to blunt objects Mandibular branch able to clenched teeth.

Normal

Maxillary branch

VI VII

Abducens Facial

Can move eyes laterally Can smile and raise eyebrows -frowns -blowed out cheeks Closed eyes tightly as instructed Facial movements are symmetrical

Normal Normal

VIII

Acoustic: Vestibular Branch Cochlear Branch Able to stand without assistance Able to hear normal voice tone

Normal

IX

Glossopharyngeal

Can move tongue from side to side, up and down Presence of gag reflex

Normal

Vagus

Presence of gag reflex Able to talk without any pain on the muscle used

Normal

XI

Spinal Accesory

Symmetrical, strong contraction of the trapezius muscle

Normal

XII

Hypoglossal

Able to protrude tongue on the midline Symmetrical tongue with smooth outward movement and bilateral strenght

Normal

Prognosis:
The prognosis is poor because patient who acquires Type II Diabetes Mellitus needs extensive life style modification that should be strictly followed. Also Type II DM is a disease which is to be carried by the patient through his entire life and any negligence to treat and support the primary management for the said disease may worsen the patients condition.

Republic of the Philippines University of Eastern Philippines University Town, Northern Samar College of Nursing

Case Presentation In Surgery Ward

Prepared By:
Abran, Jocelyn V. Adriatic, Jenelyn P. Aguilando, Honeyca Esperanza T. Asinas Abegiel P. Aquino, Justine B. Balan, Aleli T. Balanza, Leovieh E Basiloy, Perlyn Mac E. Bernabe, Princess Diana Mae I. Berso, Jaine ANgelica O. Bianes, Laizza Zherramae E. Caadan, Christian James P. Cabagsang, Desiree P. Capetillo, Clarizza Faye C.
BSN-4