INTRODUCTION A.

OVERVIEW 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 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 1

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, have been diagnosed with gestational diabetes or have delivered a baby have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 have had impaired glucose tolerance or impaired fasting glucose on

Hispanic, or Native Hawaiian)

weighing more than 9 lbs (4 kg)

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

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 problem B. OBJECTIVE AND PURPOSE OF THE STUDY This study generally aims to investigate the condition of a client and further understand the extent of the case. Specifically the student nurse sought to: Perform Physical Assessment, Data Base and History Taking that solidifies the present diagnosis of the client. Identify Signs and Symptoms associated with the disorder. 2

Identify priority nursing problems which will be the basis of the care plan. Develop Plan of Care and Implement nursing interventions relevant and suitable to the case. Evaluate the effectiveness of the interventions and detect any progress or regression of the clients disease condition.

The purpose of the study is to gather significant data to broaden our knowledge of the disease process and to improve my abilities as future healthcare provider. This is done to be able to aid in the recovery process of the client. Moreover this case study will enable me to apply the acquired skills we have obtained in the classroom set-up. C. SCOPE AND LIMITATION OF THE STUDY The scope of the study consists of one Medical ward client of Camp Evangelista Station Hospital. The time period for which the study was conducted and completed, was constrained and limited to a span of 1 week. The first assessment done was last February 10, 2011, at around 8:00 am. Then continuous assessment was done in the span of my duty in the said ward from February 10 & 11 2011. The said assessment dates were maximized to gather of information including profile, data base, and history of present illness, chart data and many others.

II. HEALTH HISTORY A. Patients Profile Name of Patient: FM Sex: MALE Age: 54 years old Birthday: July 15, 2009 Birthplace: Religion: Butuan City Civil Status: Married Educational Attainment: High Sch Mother: EM Father: PM Nationality: Filipino Date Admitted: February, 2010 Time Admitted: 12:15 am Informant: Mother Temperature: 36.0 C Pulse Rate: 74 bpm Respiration: 23 cpm Blood Pressure: 130/ 80 mmHg Diagnosis: Diabetes Mellitus, Type 2 Attending Physician: Dr. Jolo B. Past Health History Diabetic for 14 years with poor compliance to medications for diabetes claims no compliance for 5 years. Claim to be an alcoholic beverage and a smoker for 1 year. He was also diagnosed with Hypertension. C. Chief Complains and History of Present Illness He had been in good health until about two months ago when he started to feel weak and tired more rapidly than usual. On questioning, he 4

admitted to getting up two or three times a night to urinate. He also is often thirsty at those times and drinks a glass of water each time. His weight had been average. His appetite remained excellent but he now was losing weight and becoming weak. The pain in his feet was worse at night and sometimes kept him awake. It was burning in character and sometimes his toes felt numb. And he had a small non healing - wound on his feet. His vision was blurry at times, especially in the afternoon. III. DEVELOPMENT DATA A. Erik Eriksons Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favourable outcome and by an important event that this conflict resolves itself around. In the Eriksons 8th stage of psychosocial Development theory which is Senior: Integrity vs. Despair (65 years onwards). Integrity means moral soundness, whole or completeness of a person, Despair means being hopeless. When it comes to my patient he was loosing hope that his illness will be cure, it is because he feels that he was really old and he dont have the capabilities of living the way it should be. But still, because of the support of the family little by little he was trying to understand his situation tried to think on positive side and for him to live longer for his family that still need him as a father, as a grandfather and as a husband. B. Sigmund Freuds Psychosexual Development Theory According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people seek pleasure through from a series of 5

erogenous zones. These erogenous zones are only part of the story, as the social relations learned when focused on each of the zones are also important. Freud's theory of development has 2 primary ideas: One, everything you become is determined by your first few years - indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially acceptable ways.My patient belongs to the genital stage which begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that.

C. Robert J. Havighursts Developmental Task Theory

Havighurst categorized the tasks, in first category are the tasks, which has to be completed in certain period, and the second are the tasks that continue for a long, sometimes for a lifetime. So what happens if the task is not completed in that stage or completed in a later date? Havighurst reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result will be the failure to achieve success in future tasks. D. Jean Piagets Theory of Development According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation (i.e., people transform incoming information so that it fits within their existing schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming information). My patient belongs to the formal operational stage. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information

available, as well as apply all these processes to hypothetical situations. The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem.

IV. MEDICAL MANAGEMENT

A. DOCTORS ORDER DATE February 6, 2011 ORDER Please admit to medical ward Secure Consent TPR q 4 IMPLICATION - For individualized care and monitoring - For legal and documentation purposes - For closer monitoring of the patients vital signs - For blood glucose monitoring HGT Monitoring Medicines: - Metformin - Clindamycin - Amlodipine Laboratory Test: - Fecalysis -To identify presence of microorganisms in the feces -To check presence of microorganisms in the urine

Urinalysis

B. LABORATORY RESULTS FECALYSIS Date: February 6, 2011 Macroscopic appearance: Color: yellow Microscopic appearance: Pus cells: few RBC: none seen /hpf Fat globules: none seen / hpf URINALYSIS Date: February 6, 2011 Color: Yellow Appearance: Clear Specific gravity: 1.025 Protein (Albumin): Negative Glucose: Negative Bacteria: Few

Consistency: Soft

V. PATHOPHYSIOLOGY & ANATOMY AND PHYSIOLOGY A. PATHOPHYSIOLOGY OF DIABETES MELLITUS

B. 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.

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VI. NURSING REVIEW CHART IV. PHYSICAL ASSESSMENT

NURSING SYSTEM REVIEW CHART Name: FM Date:February 10,2011 Vital Signs: Pulse:138 bpm BP: N/a

Temp: 36.0

Respi: 40 cpm

EENT [] impaired vision [] blind [] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth [] asses eyes, ears, nose [] throat for abnormality [X] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [x] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, []no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [] grip [] assess motor function, sensation, LOC, strength [] grip, gait, coordination, speech, [X]no problem 2 MUSCULOSKELETAL and SKIN [] appliance [] stiffness [] itching [] petechiae [] hot [] drainage [] prosthesis [] swelling [] lesion [] poor turgor [] cool [] deformity [] atrophy [x] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [] skin color, texture, turgor, integrity [] no problem

Decreased appetite

polyuria

Blurry vision

Numbness and pain

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VII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT NURSING INTERVENTIONS: CUES SO: ga ngot ngot akong tiil day kong ilihok as verblized by the pt. Objective: Pain scale of 6/10 Facial grimace NURSING DX Pain related to disease process OBJECTIVES At the end of 30 mins the patient reported pain will be relieved/controlled. INTERVENTIONS
> Document location and intensity of pain (0 10)

RATIONALE
- aids in evaluating need for effectiveness of intervention. -lessens edema formation by enhancing venous return: reduces muscle fatigue and skin/ tissue pressure - refocuses attention, promotes relaxation, may enhance coping abilities - to reduce pain and muscle spasms.

EVALUATION Goal partially met, the patient reported pain is somehow relieved/controlled.

> elevate affected part by raising foot of bed slightly or use of pillow/sling for upper-limb amputation.

> encourage deep breathing exercise, visualization, and guided imagery

>administer medications, as indicated (mefenamic acid)

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CUES SO: dili kayo ko ganahan mo kaon day, bawal Objectives: Lack interest in food Recent weight loss weakness

NURSING DX Imbalanced nutrition: less than body requirements decrease oral intake

OBJECTIVES At the end of 30 mins patient will be able to display usual energy level

INTERVENTIONS
> weigh daily as indicated

RATIONALE
-assess adequacy of nutritional intake

EVALUATION Goal partially met, patient display usual energy levels.

> provide liquids containing nutrients and electrolytes as soon as client can tolerate oral fluids

- oral route is preferred when client is alert and bowel function is restored

daghan man gud related to

>Auscultate bowel sounds.

- hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/function.

> provide diet approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals/ snacks.

- Complex Carbohydrates decrease glucose levels/ Insulin needs reduce serum cholesterol levels and promote satiation.

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CUES SO: gamay ra gani kayo ni akong samad, dli pa gyud gaka ayo as verblized by the pt. Objective: Presence of non healing wound

NURSING DX Risk for infection related to high glucose levels and decrease leukocyte function

OBJECTIVES At the end of 30 mins, patient will be able patient prevent/reduce risk for infection

INTERVENTIONS
> Observe for signs of infection and inflammation

RATIONALE
-client maybe admitted with infection, may develop a nosocomial infection

EVALUATION Goal partially met, patient able to prevent/ reduce risk of infection

> promote good hand washing by student nurse/ staff and client > provide conscientious skin care, gently massage bony areas, keep the skin dry, keep linens dry and wrinkle free

- reduces risk of cross contamination

-peripheral circulation maybe impaired, placing client at risk for skin irritation/breakdown and infection

>Administer antibiotics as appropriate

- early treatment may help prevent sepsis

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B. ACTUAL NURSING MANAGEMENT

S O A P I

Not applicable

Pain scale of 6/10 Facial grimace Pain related to disease process

At the end of 30 mins the patient reported pain will be relieved/controlled.

> Document location and intensity of pain (0 10) - aids in evaluating need for effectiveness of intervention. > elevate affected part by raising foot of bed slightly or use of pillow/sling for upper-limb amputation. -lessens edema formation by enhancing venous return: reduces muscle fatigue and skin/ tissue pressure > encourage deep breathing exercise, visualization, and guided imagery - refocuses attention, promotes relaxation, may enhance coping abilities >administer medications, as indicated (mefenamic acid) - to reduce pain and muscle spasms.

Goal partially met, the patient reported pain is somehow relieved/controlled.

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S O A P I

Not applicable

Lack interest in food Recent weight loss weakness Imbalanced nutrition: less than body

requirements related to decrease oral intake

At the end of 30 mins patient will be able to display usual energy level
> weigh daily as indicated -assess adequacy of nutritional intake > provide liquids containing nutrients and electrolytes as soon as client can tolerate oral fluids - oral route is preferred when client is alert and bowel function is restored >Auscultate bowel sounds. - hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/function. > provide diet approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals/ snacks. - Complex Carbohydrates decrease glucose levels/ Insulin needs reduce serum cholesterol levels and promote satiation.

Goal partially met, patient display usual energy levels.

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S O A P I

Not applicable

presence of no healing wound

Risk for infection related to high glucose levels and decrease leukocyte function

At the end of 30 mins, patient will be able tp prevent/reduce risk for infection
> Observe for signs of infection and inflammation -client maybe admitted with infection, may develop a nosocomial infection > promote good hand washing by student nurse/ staff and client - reduces risk of cross contamination > provide conscientious skin care, gently massage bony areas, keep the skin dry, keep linens dry and wrinkle free -peripheral circulation maybe impaired, placing client at risk for skin irritation/breakdown and infection >Administer antibiotics as appropriate - early treatment may help prevent sepsis

Goal partially met, patient able to prevent/ reduce risk of infection

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C. DRUG STUDY
NAME OF DRUG DATE ORDER ED CLASSIFICAT ION DOSE/ FREQUENC Y/ ROUTE MECHANISM OF ACTION SPECIFIC INDICATION
CONTRAINDICATION

SIDE EFFECTS

NURSING PRECAUTION

Amlodipine

Feb. 6, 2011

1 tab, OD, Calcium channeloral blocker Antianginal drug Antihypert

ensive

Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells,

Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina) Chronic stable angina, alone or in combination with other drugs Essential hypertension, alone or in combination with other antihypertensives

Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), lactation. Use cautiously with CHF, pregnancy.

CNS: Drowsiness, sedation, dizziness, headache, fatigue that tend to diminish within 46 wk, dreams, nightmares, insomnia, hallucinations, delirium, nervousness, restlessness, anxiety,

NAME OF

DATE

CLASSIFICAT

DOSE/

MECHANISM OF

SPECIFIC INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING

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DRUG

ORDER ED

ION

FREQUENC Y/ ROUTE

ACTION

PRECAUTION

Clidamycin

Feb. 6, 2011

antibiotic

1 tab, BID, Oral

Inhibits cell walls synthesis; causing cell death

Treatment of more than 18 years of age with mild, moderate and severe infection caused by susceptible strains of microorganisms

Diarrhea, abdominal discomfort, nausea, anorexi, vomiting, stomatitis, and heart burns; insomia, headache and dizziness; rash, pruritis, and aczema; muscles and joints pain; bone marrow depression,

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VIII. REFERRAL AND FOLLOW UP Once the client will be discharged, I encouraged my client to drink his home medications religiously to prevent further infection. Health Teaching is important for patients having Diabetes Mellitus. Patient should be taught on the importance of exercise, dietary changes, lifestyle, and medication regimen. Patient should be discussed thoroughly about the disease condition. Simple pathophysiology will do to increase patients knowledge about the disease condition. IX. EVALUATION AND IMPLICATION After rendering my interventions to my patient, he stressed his gratitude which clearly showed a positive response to all the measures of treatment employed to him. He manifests efficient recovery and a good sense of well- being. The case study provides the academe of nursing education the opportunity to focus on how to engage in care management of Diabetes Mellitus. And to renew the idea of dealing patients easily, instead we must set much more effort in dealing with them because this is the times when they need more support. X. DOCUMENTATION - (None, I have no written consent that will allow me to take a photo of the said client.)

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