CASE 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 age-
onset 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 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.

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 client’s
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)
2. Understand and determine probable and causative factors why
the patient suffered from the disease.
3. Formulate nursing care plans.
4. Enumerate ways on how to prevent, cure and teach patients
regarding Diabetes Mellitus.

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 follow-

up. 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. Childhood Illness – bulutong tubig, measles

2. Immunizations - incomplete
3. Allergies - None
4. Accidents - None
5. 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 she’s 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 Norms Actual Findings

Interpretation
Appearance and Analysis
1. Posture/Gait Relaxed, erect Slouched, Poor posture
posture; movements are distorts the
coordinated uncoordinated body’s proper
movement vertical
alignment and
the back’s
natural curves.
If you have poor
 posture, your
bones are not
properly
aligned, and
your muscles,
joints, and
ligaments take
more strain than
nature intended.
Faulty posture
2. Skin Color Pallor and weak may cause you
Healthy in appearance fatigue,
appearance muscular strain,
and, in later
stages, pain.

3. Personal Unkempt Many individuals

Hygiene/Groo with chronic
ming Clean, neat back pain can
trace their
problems to
years of faulty
postural habits.
In addition, poor
posture can
affect the
position and
function of your
Excessively thin vital organs,
4. Nutritional particularly
Status Proportionate, those in the
varies with abdominal
lifestyle region.

Adult age 71 Due to patient’s

years old present health
5. Age condition he is
Appropriatene experiencing
ss weakness and
this is one of the
signs and
symptoms of
diabetes
mellitus II.

Understandable,
exhibits thought
associations
Personal
6. Verbal Understandable,
Behavior moderate pace; grooming
exhibits thought includes
associations Cooperative, no activities such
distress noted as showering,
dressing,
7. Non-verbal toileting and
Behavior Cooperative, no attention to
distress noted 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 36.5 – 37.5 37.1 C Normal
2. Pulse Rate 60 – 120 bpm 118 bpm Normal
3. Respiratory 14 – 24 bpm 30 bpm Normal
Rate 120/70 mmHg 140/90 mmHg Abormal
4. Blood 72 kg
Pressure 153 cm
5. Weight
6. Height
Body Part Norms Actual Findings Interpretation
and Analysis
Hair White, fine,
Oval in shape,
Face symmetrical,
facial expression
is dependent on
the mood or true
feelings, uneven
with wrinkles, no
involuntary
muscle
movements

Eyes 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
Eyebrows Black
symmetrical,
parallel to each
other
Eyelashes Black evenly
distributed and
turned outward
Upper eyelids
cover a small
Eyelids 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
Lid Margins scalings, lacrimal
duct are evident
at the nasal ends
of the upper and
lower lids
Sclera White but not
that clear
Iris Proportional to
the size of the
eyes, round,
black and
symmetrical
Eye Movement Not able to move
 eyes in full range
of motion and
not able to move
in all directions
Parallel,
Ears symmetrical,
proportional to
the size of the
head, bean-
shaped, is in line
with the outer
canthus of the
eye, skin is same
in color as the
surrounding area
Firm cartilage
Ear Canal Pinkish, with
scant amount of
cerumen and few
cilia
Hearing Acuity Not able to hear
spoken words,
you need to
louder you voice
and repeat it
again
Nose Midline,
symmetrical,
Mouth (lips) Pinkish,
symmetrical, lip
margin well
defined, uneven
and dry
Gums Pinkish, smooth,
moist no
swelling, no
discharge
Teeth Has denture and
1 tooth
Tongue Medium, pink,
slight rough on
top, smooth
along lateral
margins, moist
but not freely
movable
Neck Proportional to
the size of the
head,
symmetrical
 Presence of
internal jugular
vascular
access(temporari
ly used for
hemodialysis),
presence of
blister
Neck (ROM) Not freely
movable
Thorax and Lungs No lumps,
masses, areas of
tenderness
Has difficulty in
breathing
Heart The heart sounds
are audible at
apical area,
cardiac rate is 72
Blemished skin,
flat, symmetrical
Abdomen 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
Upper Extremities Dark skin,
Arms symmetrical, fine
hair evenly
distributed,
presence of
visible veins,
presence of
vascular access
for hemodialysis
on the left arm.
 Warm, dry, non-
elastic, no areas
of tenderness,
poor muscle tone
Palms and Dorsal Non-elastic, dry
Surfaces and saggy
Nails Five fingers in
each hand,
brittle
Shoulders Has slight
difficulty raising
arms to vertical
position
Arms Has slight
difficulty to
abduct, adduct,
and rotate
arms(internal
and external)
Elbows Bend and
straighten
elbows with
slight difficulty
Hands and Wrists Extend and
spread fingers
Lower Extremities Fine hair evenly
Legs distributed,
presence of
varicose veins,
presence of
edema
Poor muscle tone
ROM Difficulty in
performing ROM

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.

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 Addison’s 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 system’s 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 membrane-
bound 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 Intravascular: increase glucose

enter in ICS in blood

Hypergylcemia Systemic blood

Viscosity

ECF/ICF Cell Starvation

dehydration
Sluggish circulation
Polydipsia Polyphagia

Increase Osmotic
Poor oxygen delivery
pressure in renal
to peripheral area
tubules

Proliferation of
Polyuria
microorganism
Poor
wound
healing

Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation

and Analysis
11/22/09 Capillary Blood 80.00 – 128.00 High
7:30am Glucose 110.00 mg/dl
mg/dl
11/22/09 Capillary Blood 80.00 – 150.00 High
Glucose 110.00 mg/dl
mg/dl
11/23/09 Capillary Blood 80.00 – 442.00 High
Glucose 110.00 mg/dl
mg/dl
11/23/09 AST/RBS/CBG 80.00- 423.00 High
110.00 mg/dl
mg/dl
11/23/09 AST/RBS/CBG 80.00- 335.00 High
110.00 mg/dl
mg/dl
11/23/09 AST/RBS/CBG 80.00- 196.00 High
110.00 mg/dl
mg/dl
11/23/09 RBS/CBG 80-120.00 162 mg/dl High
mg/dl
11/23/09 RBS/CBG 80-120.00 123 mg/dl High
mg/dl

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 self-
injection. 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.