CAS E

STUDY

Mary Bernadette O. Tolentino

Group 20

INTRODUCTION:
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. Symptoms
include frequent urination, lethargy, excessive thirst, and hunger. The
treatment includes changes in diet, oral medications, and in some cases,
daily injections of insulin.
The most common form of diabetes is Type II, It is sometimes called ageonset or adult-onset diabetes, and this form of diabetes occurs most often in
people who are overweight and who do not exercise. Type II is considered a
milder form of diabetes because of its slow onset (sometimes developing
over the course of several years) and because it usually can be controlled
with diet and oral medication. The consequences of uncontrolled and
untreated Type II diabetes, however, are the just as serious as those for Type
I. This form is also called noninsulin-dependent diabetes, a term that is
somewhat misleading. Many people with Type II diabetes can control the
condition with diet and oral medications, however, insulin injections are
sometimes necessary if treatment with diet and oral medication is not
working.
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 bodys
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.
In Type II diabetes, the pancreas may produce enough insulin, however, cells
have become resistant to the insulin produced and it may not work as
effectively. Symptoms of Type II diabetes can begin so gradually that a person

may not know that he or she has it. Early signs are lethargy, extreme thirst,
and frequent urination. Other symptoms may include sudden weight loss,
slow wound healing, urinary tract infections, gum disease, or blurred vision. It
is not unusual for Type II diabetes to be detected while a patient is seeing a
doctor about another health concern that is actually being caused by the yet
undiagnosed diabetes.
Individuals who are at high risk of developing Type II diabetes mellitus include
people who:

are obese (more than 20% above their ideal body weight)

have a relative with diabetes mellitus

belong to a high-risk ethnic population (African-American, Native

American, Hispanic, or Native Hawaiian)

have been diagnosed with gestational diabetes or have delivered a

baby weighing more than 9 lbs (4 kg)

have high blood pressure (140/90 mmHg or above)

have a high density lipoprotein cholesterol level less than or equal to

35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL

have had impaired glucose tolerance or impaired fasting glucose on

previous testing

Diabetes mellitus is a common chronic disease requiring lifelong behavioral

and lifestyle changes. 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 clients
health and well being. Diabetes is a major public health worldwide. Its
complications cause many devastating health problems.

OBJECTIVES:
GENERAL OBJECTIVES:
This case study aims to present accurately the information regarding
Diabetes Mellitus. The study aims to orient the reader with the possible
symptoms and effects, thus, making this study a helpful reference in the
prevention and cure of the disease.
SPECIFIC OBJECTIVES:
At the end of this case study, the students will be able to:
1.

Perform the skills of nursing process effectively (Assessment,

Diagnosis, Planning, Intervention, and Evaluation)
Understand and determine probable and causative factors why
the patient suffered from the disease.
Formulate nursing care plans.
Enumerate ways on how to prevent, cure and teach patients
regarding Diabetes Mellitus.

2.
3.
4.

NURSING HISTORY:
A. Demographic profile

Name: F. A.

Gender: Female

Age: 70 years old

Birth date: September 23, 1939

Birth place: Bulacan, Bulacan

Marital status: Single

Nationality: Filipino

Religion: Born Again- Christian

Address: Bulacan, Bulacan

Educational background: High school graduate

Occupation: none

Usual source of medical care: Doctor/Healthcare

Professional
HISTORY OF PRESENT ILLNESS
Patient is a diagnosed case of DM Type II (2003), with irregular followup. Two weeks PTA, patient noted a wound on the big toe. It was
associated with on-and-off fever. No consultation done. One week PTA,
the signs and symptoms persisted and patient started experiencing
shortness of breath. Few hours PTA, patient was brought to the
attending physician who advised admission.

HISTORY OF PAST ILLNESS

1.
2.
3.
4.
5.

Childhood Illness
bulutong tubig, measles
Immunizations
incomplete
Allergies
None
Accidents
None
Hospitalizations
- 2003, 2005 (Bulacan Provincial
Hospital)

FAMILY HISTORY
Her mother died of diabetes. Her father died of heart attack.
She denies any other heredofamilial disorder such as kidney or liver
problems.
NUTRITIONAL HISTORY
Patient stated that she eats any food, without restrictions at all, even
though shes been advised by her doctor to watch her diet. She loves eating
chicharon and is also fond of sweets such as chocolates and kakanin.
PHYSICAL ASSESSMENT:
General Appearance
1. Posture/Gait

Norms

Actual Findings

Interpretation
and Analysis
Relaxed,
erect Slouched,
Poor posture
posture;
movements are distorts the
coordinated
uncoordinated
bodys proper
movement
vertical
alignment and
the backs
natural curves.
If you have poor

2. Skin Color
Healthy
appearance

3. Personal
Hygiene/Groom
ing

posture, your
bones are not
properly
aligned, and
your muscles,
joints, and
ligaments take
more strain than
nature intended.
Faulty posture
Pallor and weak may cause you
in appearance
fatigue,
muscular strain,
and, in later
stages, pain.

Unkempt
Clean, neat

Excessively thin
4. Nutritional
Status

Proportionate,
varies
with
lifestyle
Adult
age
years old

71

5. Age
Appropriatenes
s

Understandable,
exhibits thought
associations

Many
individuals with
chronic back
pain can trace
their problems
to years of
faulty postural
habits. In
addition, poor
posture can
affect the
position and
function of your
vital organs,
particularly
those in the
abdominal
region.
Due to patients
present health
condition he is
experiencing
weakness and
this is one of the
signs and
symptoms of
diabetes
mellitus II.

6. Verbal
Behavior

7. Non-verbal
Behavior

Understandable,
moderate pace;
Personal
exhibits thought
grooming
associations
Cooperative, no includes
distress noted
activities such
as showering,
dressing,
Cooperative, no
toileting and
distress noted
attention to
personal
presentation,
such as
brushing hair,
applying
makeup etc.
due to his
present
condition the
patient is
unable to
undertake
personal
grooming
because of
underlying
causes of
diabetes, like
muscle
weakness, easy
fatigability.
Due to his
diabetes the
patient
experiences
polyphagia,
polydipsia, and
polyuria,
because of this
there is
variation to his
nutritional
status.
Genetic makeup
influences
biologic
characteristics,
innate
temperament,

activity level,
and intellectual
potential. It has
been related to
susceptibility to
specific disease,
such as
diabetes. The
distribution of
disease. Certain
acquired and
genetic diseases
are common in
middle-aged
males.
No
abnormalities
found

No
abnormalities
noted
Measurements
1. Temperature
2. Pulse Rate
3. Respiratory
Rate
4. Blood
Pressure
5. Weight
6. Height
Body Part
Hair
Face

36.5 37.5
60 120 bpm
14 24 bpm
120/70 mmHg

Norms

37.1 C
118 bpm
30 bpm
140/90 mmHg
72 kg
153 cm
Actual Findings
White, fine,
Oval in shape,
symmetrical,
facial expression
is dependent on
the mood or true
feelings, uneven
with wrinkles, no
involuntary
muscle

Normal
Normal
Normal
Abormal

Interpretation
and Analysis

movements
Eyes

Eyebrows

Eyelashes

Eyelids

Lid Margins

Sclera
Iris

Parallel and
evenly placed,
symmetrical,
non-protruding,
with scant
amount of
secretions, both
eyes black but
patient does not
have clear vision,
slowed blink
reflex
Black
symmetrical,
parallel to each
other
Black evenly
distributed and
turned outward
Upper eyelids
cover a small
portion of the iris
and the cornea
and the sclera
when the eyes
are open. When
the eyes are
closed, the lids
meet completely.
Symmetrical in
color is the same
as the
surrounding skin.
Looseness of the
eyelids.
No palpable
mass
Clear without
scalings, lacrimal
duct are evident
at the nasal ends
of the upper and
lower lids
White but not
that clear
Proportional to
the size of the
eyes, round,

Eye Movement

Ears

Ear Canal

Hearing Acuity

Nose
Mouth (lips)

Gums

Teeth
Tongue

Neck

black and
symmetrical
Not able to move
eyes in full range
of motion and
not able to move
in all directions
Parallel,
symmetrical,
proportional to
the size of the
head, beanshaped, is in line
with the outer
canthus of the
eye, skin is same
in color as the
surrounding area
Firm cartilage
Pinkish, with
scant amount of
cerumen and few
cilia
Not able to hear
spoken words,
you need to
louder you voice
and repeat it
again
Midline,
symmetrical,
Pinkish,
symmetrical, lip
margin well
defined, uneven
and dry
Pinkish, smooth,
moist no
swelling, no
discharge
Has denture and
1 tooth
Medium, pink,
slight rough on
top, smooth
along lateral
margins, moist
but not freely
movable
Proportional to

Neck (ROM)
Thorax and Lungs

Heart

Abdomen

Upper Extremities
Arms

the size of the

head,
symmetrical
Presence of
internal jugular
vascular
access(temporari
ly used for
hemodialysis),
presence of
blister
Not freely
movable
No lumps,
masses, areas of
tenderness
Has difficulty in
breathing
The heart sounds
are audible at
apical area,
cardiac rate is 72
Blemished skin,
flat, symmetrical
movements
caused by
respiration,
umbilicus is flat
and positioned
midway between
the xiphoid
process and the
symphisis pubis,
color is the same
as the
surrounding skin
Borborygmi
sounds,
stomach
growling heard
No tenderness,
no lumps or
masses
Dark skin,
symmetrical, fine
hair evenly
distributed,
presence of
visible veins,
presence of

Palms and Dorsal

Surfaces
Nails
Shoulders

Arms

Elbows

Hands and Wrists

Lower Extremities
Legs

ROM

vascular access
for hemodialysis
on the left arm.
Warm, dry, nonelastic, no areas
of tenderness,
poor muscle tone
Non-elastic, dry
and saggy
Five fingers in
each hand,
brittle
Has slight
difficulty raising
arms to vertical
position
Has slight
difficulty to
abduct, adduct,
and rotate
arms(internal
and external)
Bend and
straighten
elbows with
slight difficulty
Extend and
spread fingers
Fine hair evenly
distributed,
presence of
varicose veins,
presence of
edema
Poor muscle tone
Difficulty in
performing ROM

ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The bodys
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.

ENDOCRINE SYSTEM
Homeostasis depends on the precise regulation of the organ and organ
systems of the body. The nervous and endocrine system are two major
systems responsible for that regulation. Together they regulate and
coordinate the activity of nearly all other body structures. When these system
fail to function properly, homeostasis is not maintained. Failure ofsome
component of the endocrine system to function can result in disease such as
Diabetes Mellitus or Addisons disease.
The regulatory function of the nervous system and endocrine systems are
similar in some respects, but they differ in other important ways. The nervous
system controls the activity of tissues by sending action potentials along
axons, which release chemical signals at their ends, near the cell they

control. The endocrine system releases chemical signals into the circulatory
sytem, whichh carries to all parts of the body. The cell that can detect those
chemical signal produce reponses.
The nervous system usually acts quickly and has short term effects, whereas
the endocrine system usually response more slowly and has longer-lasting
effects. In general, each nervous stimulus controls a specific tissue or organ,
whereas each endocrine stimulus controls several tissues or organ.
FUNCTIONS:

It regulates water balance by controlling the solute concentratiuon of

the blood.

It regulates uterine contractions during delivery of the newborn and

stimulates milk release from the breast in lactating females.

It regulates the growth of many tissues, such as bone and muslces,

and the rate of the metabolism of many tissues, which helps maintain
a normal body temperature and normal mental function. Maturation of
tissues, which result in the development of adult features and adult
behavior, are also influence by the endocrine system.

It regulaytes sodium, potassium and calcium concentrations in the

blood.

It regulates the heart rate and blood pressure and helps prepare the
body for physical activity.

It regulates blood glucoce levels and other nutrient levels in the blood

It helps control the production and function of immune cells.

It controls the development and the function of the reproductive

systems in males and females.

Pancreas
an elongated gland extending from the duodenum to the spleen;
consist of a head, body, and the tail. There is an exocrine portion,

which secretes digestive enzymes that are carried by the pancreatic

duct to the duodenum, and pancreatic islet, which secrete insulin and
glucagon.
The endocrine part of the pancreas consists of pancreatic islets (small
islands; islet of Langerhans) dispersed among the exocrine portion of
the pancreas. The islets secrete two hormones insulin and glucagon
which function to help regulate blood nutrient levels, especially blood
glucose.
Alpha cells of the pancreatic islets secrete glucagon.
Beta cells of the pancreatic islet secrete insulin.
It is very important to maintain blood glucose levels within a normal
range of values. A decline in the blood glucose levels within a normal
range causes the nervous system to malfunction because glucose is
the nervous systems main source of energy. When blood glucose
decreases, other tissues to provide an alternative energy source break
fats and proteins rapidly. As fats are broken down, the liver to acidic
ketones, which are release into the circulatory system, converts some
of the fatty acids. When blood glucose level are very low, the break
down of fats can cause the release of enough fatty acid and ketones to
cause the pH of the fluids to decrease below normal, a condition called
acidosis. The amino acids of proteins are broken down and used to
synthesize glucose by the liver.
If blood glucose levels are too high, the kidneys produce large volumes
of urine containing substantial amounts of glucose because of the
rapid loss of water in the form of urine, dehydration result.
Insulin is released from the beta cells primarily response to the
elevated blood glucose levels and increased parasympathetic
stimulation that is associated with digestion of a meal. Increase blood
levels of certain amino acids also stimulates insulin secretion.
Decreased result from decreasing blood glucose levels and from

stimulation by the sympathetic of the nervous system. Sympathetic

stimulation of the pancreas occurs during physical activity. Decreased
insulin levels allow blood glucose to be conserved to provide the brain
with adequate glucose and to allow other tissues to metabolize fatty
acids and glycogen stored in the cell.

The major target tissues for insulin are the liver, adipose tissue,
muscles, and the area of the hypothalamus that controls appetite,
called satiety center (fulfillment of hunger). Insulin binds to membranebound receptor and, either directly or indirectly, increases the rate of
glucose and amino acid uptake in these tissues. Glucose is converted
to glycogen or fat, and the amino acids used to synthesize protein.

Glucagon is released from the alpha cell when blood glucose level is
low. Glucagon binds to membrane-bound receptors primarily in the
liver and caused the conversion of glycogen storage in the liver to
glucose. The glucose is then released into the blood to increase blood
glucose level. After a meal, when blood glucose levels are elevated a
glucagon secretion is reduced.
Insulin and glucagon function together to regulate blood glucose
levels. When blood glucose increase, insulin secretion increases, and
glucagon secretion decreases. When blood glucose levels decrease,
the rate of insulin secretion declines and the rate of glucagon secretion
increase. Other hormones, such as epinephrine, cortisol, and growth
hormones, also function to maintain blood levels of nutrients. When
blood glucose level decrease, these hormones are secreted at a
greater rate. Epinephrine and cortisol caused the breakdown of protein
and fat and the synthesis of glucose to help increase blood levels of
nutrients. Growth hormone slows protein breakdown and favors fat
breakdown.

PATHOPHYSIOLOGY:

Modifiable

Non-modifiable

Diet

Hereditary

Stress

Age

Poor production of Beta

cells
Insulin Deficiency

Intracellular: failure of glucose to

enter in ICS

Intravascular: increase glucose

in blood

Hypergylcemia

ECF/ICF
dehydration

Systemic blood
Viscosity
Cell Starvation
Sluggish circulation

Polydipsia

Polyphagia

Poor oxygen delivery

to peripheral area

Proliferation of
microorganism
Poor wound
healing

Increase Osmotic
pressure in renal
tubules

Polyuria

Laboratory and Diagnostic Examination Results

Date

Procedure

Norms

Result

Interpretation
and Analysis

11/22/09
7:30am

Capillary Blood
Glucose

11/22/09

Capillary Blood
Glucose

11/23/09

Capillary Blood
Glucose

11/23/09

AST/RBS/CBG

11/23/09

AST/RBS/CBG

11/23/09

AST/RBS/CBG

11/23/09

RBS/CBG

11/23/09

RBS/CBG

80.00
128.00
110.00
mg/dl
mg/dl
80.00
150.00
110.00
mg/dl
mg/dl
80.00
442.00
110.00
mg/dl
mg/dl
80.00423.00
110.00
mg/dl
mg/dl
80.00335.00
110.00
mg/dl
mg/dl
80.00196.00
110.00
mg/dl
mg/dl
80-120.00
162 mg/dl
mg/dl
80-120.00
123 mg/dl
mg/dl

High
High
High
High
High
High
High
High

HEALTH TEACHINGS:
Advice patient about the importance of an individualized meal plan in
meeting weekly weight loss goals and assist with compliance.
Assess patients for cognitive or sensory impairments, which may
interfere with the ability to accurately administer insulin.
Demonstrate and explain thoroughly the procedure for insulin selfinjection. Help patient to achieve mastery of technique by taking step
by step approach.
Review dosage and time of injections in relation to meals, activity, and
bedtime based on patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation
and meal timing to avoid hypoglycemia.
Explain the importance of exercise in maintaining or reducing weight.
Advise patient to assess blood glucose level before strenuous activity
and to eat carbohydrate snack before exercising to avoid
hypoglycemia.
Assess feet and legs for skin temperature, sensation, soft tissues
injuries, corns, calluses, dryness, hair distribution, pulses and deep
tendon reflexes.
Maintain skin integrity by protecting feet from breakdown.
Advice patient who smokes to stop smoking or reduce if possible, to
reduce vasoconstriction and enhance peripheral flow.

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