Download Diabetes Type 2

I. Introduction
This case study tackles about the disease, diabetes mellitus type II. I have chosen
this case since this is one of the most common diseases nowadays and many people
from different age groups will be benefited with this case study. Before scanning
through other pages, let me first give you a brief overview of what Diabetes Mellitus
is. I have specifically focused on Type II Diabetes Mellitus since this is the case of
my patient.
Diabetes mellitus is a common disease in which the body cannot use sugar
normally. The body of a diabetic person is slow in using glucose (sugar), and so
glucose builds up in the blood. The kidneys discharge some of the excess glucose
into the urine. In severe cases of diabetes, fats and proteins also cannot be used
normally.
Most physicians once believed that all cases of diabetes were caused by a lack of
the hormone insulin. Insulin, which is produced by the pancreas, enables the body to
use and store glucose quickly. Some diabetics do lack insulin. This form of the
disease is called Type I diabetes (also known as insulin-dependent diabetes or
juvenile-type diabetes). However, many diabetics--especially those who become
diabetic after the age of 40--have normal or even above-normal production of insulin.
Their bodies do not respond efficiently to the insulin. Doctors call this form of the
disease Type II diabetes (also known as non-insulin-dependent diabetes or adult-type
diabetes).
Symptoms of Diabetes include excessive urination, great thirst, hunger, and loss
of weight and strength. These symptoms may appear gradually--and even be
unnoticed--in Type II diabetes, which is most common in overweight individuals over
the age of 40. Many cases of Type II diabetes can be controlled by a diet that is low in
calories. Some Type II diabetics whose condition cannot be controlled by diet alone
use insulin or take oral drugs that reduce the level of glucose in the blood.
Diabetes can lead to serious complications. For example, it may cause changes in
the blood vessels of the retina. This condition is called diabetic retinopathy. In
advanced form, it is a major cause of blindness. Diabetes may cause similar changes
in the blood vessels of the kidneys. This condition, called diabetic nephropathy, may
lead to kidney failure. The nerves may also be affected by diabetes. This
complication, known as diabetic neuropathy, can result in loss of feeling or abnormal
sensations in different parts of the body. Various treatments can control many cases
of diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy. Diabetes can
also lead to atherosclerosis, a form of arteriosclerosis (hardening of the arteries) that
may cause a stroke, heart failure, or gangrene.
Since you already have an idea of what diabetes mellitus is, I hope you’ll be
encouraged to continue reading this case study and be able to implement as well as
impart what you have learned in order to lessen or if possible, eradicate the
occurrence of disease.
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II. Objectives
General Objectives
After 2 days of giving holistic nursing care to the patient who have
Diabetes Mellitus type II, the nurse will be able to gain adequate knowledge, attitude and
skills in taking care of a patient who is suffering from this disease condition.
Specific Objectives
After 8 hours of giving holistic nursing care, the student nurse will be able
to:
1. relate the patients history and level of growth and development
2. explain the significance of the diagnostic results
3. review the anatomy and physiology of the pancreas relating it with insulin
4. explain the disease process and organ involved
5. compare the chart in classical and clinical symptoms of the disease
process
6. formulated appropriate nursing care plan based on identified problem of
patient
7. impart health teachings to the patient and significant others on Diabetes
Mellitus
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After 8 hours of giving holistic nursing care, the patient and significant
others will be able to:
1. gain trust with the nurse
2. verbalize physiologic manifestation as a result of the disease
3. explain the disease process in their own level of understanding
4. relate health history with his present condition.
5. enumerate the different signs and symptoms that needs to be watched for.
6. identify factors that could aggravate his condition.
7. show willingness in the implementation of planned nursing care
8. state some health promotion activities of diabetes mellitus type II.
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III. Nursing Assessment
1. Personal History
1.1Patient’s Profile
Name: Mrs. Soria, Fe F.
Age: 67 years Old
Sex: Female
Civil Status: Married
Religion: Roman Catholic
Date of Admission: January 23, 2006
Room number: 233
Complaints: Frequent Urination, High Blood Sugar and a Lump on her Right
Breast
Impression/Diagnosis: Type II Diabetes Mellitus
Physician: Dr. Armando Tan
Hospital Number: 187908
1.2 Family and Individual Information, Social and Health History
A case of Mrs. Fe F. Soria, 67 year old, female, Filipino and a Roman
Catholic. She is retired government employee from Bacolod City was admitted at
Chong Hua Hospital for the first time.
Three months prior to admission patient suffered Polyuria and Polydipsia
until it progressed into nausea, feeling nervous or jittery; cold, clammy, wet skin;
excessive sweating not caused by exercise, tachycardia, tingling sensation of the
fingertips lips thus patient was hospitalized. Laboratory works done and was
diagnosed with Type II Diabetes Mellitus.
Also one month prior to admission, patient noted 2 cm firm, movable,
circular non tender mass at left upper outer part of her left breast while taking a
bath. Mammography confirmed the mass and biopsy was done. It revealed
calcification at right breast category IV and MRM was advised. She is scheduled
for MRM.
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1.3 Level of Growth and Development
1.3.1 Normal Development of an Older Adult (65 and above)
Physical
Integumentary System
The skin losses resilience and moisture. The epithelial layer thins, and
elastic collagen fibers shrink and become rigid. Wrinkles of the face and neck
reflect lifelong patterns of muscle activity and facial expressions, the pull of
gravity on tissue and diminished elasticity. Skin has spotty pigmentation in
areas exposed to the sun. It is also dry and scaly. There is also decreased fat
distribution on extremities and increase amount on abdomen. There is also
thinning and graying on scalp; often, decreased amount of axillary and pubic
hair and hair in extremities; decreased facial hair in men; possible chin and
upper lip hair in women
Head and Neck
Head is sharp and angular nasal and facial bones; loss of eyebrow hair in
women. Eyes are having decreased visual acuity; decreased accommodation;
reduced adaptation to darkness; and sensitivity to glare. Ears are having
decreased pitch discrimination; diminished light reflex; decreased sense of
smell; mouth and pharynx may use dentures; decreased sense of taste; atrophy
of papillae of lateral edges of tongue. Neck may have nodular thyroid gland;
slight tracheal deviation resulting from muscle atrophy.
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Thorax and Lungs
There is significant increase in systolic pressure with slight increase in
diastolic pressure; usually insignificant changes in heart rate at rest; common
diastolic murmurs; easily palpated peripheral pulses; weakened pedal pulses
and colder lower extremities, especially at night.
Breast
Decreased muscle mass, tone, and elasticity result in smaller breast in
older women. In addition, the breast sag. Atrophy of the glandular tissue,
coupled with more fat deposits, results in a slightly smaller, less dense, and
less nodular breast. Gynecomastia, enlarged breast in men, may be due to
medication side effects, hormonal changes, or obesity. Both men and women
are at risk of breast cancer development.
Gastrointestinal System
Decreased salivary secretions, which may make swallowing more
difficult; decreased peristalsis; decreased production of digestive enzymes,
including hydrochloric acid, pepsin, and pancreatic enzymes; constipation;
reduced motility.
Reproductive System
Changes in the structure and function of the reproductive system occur as
the result of hormonal alterations. Female menopause is related to a reduced
responsiveness of the ovaries to pituitary hormones and a resultant decrease in
estrogen and progesterone levels. In men, there is no definite cessation of
fertility associated with aging. Spermatogenesis begins to decline during the
fourth decade but continues into the ninth. The change in reproductive
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structure and function, however do not affect libido. Less frequent sexual
activity can result from illness, death of a sexual partner, decreased
socialization, or loss of sexual interest.
Urinary System
Decreased renal filtration and renal efficiency; subsequent loss of protein
from kidney; nocturia; decreased bladder capacity; increased incontinence.
Female
Urgency and stress incontinence resulting from decrease in perineal
muscle tone.
Male
Urinary frequency and retention resulting from prostatic enlargement.
Musculoskeletal System
Decreased muscle mass and strength; bone demineralization; shortening of
trunk as result of intervetebral space narrowing; decreased joint mobility;
decreased range of joint motion; enhanced bony prominences.
Neurological System
Decreased rate of voluntary or automatic reflexes, decreased ability to
respond to multiple stimuli; insomnia; shorter sleeping periods.
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Psychosocial Development
According to Erik Erikson, the developmental task at this time is Ego
Integrity vs. Despair. People who attain ego integrity view in life with a
sense of wholeness and derive satisfaction from past accomplishments.
They view death as an acceptable completion of life. According to
Erikson, people who develop integrity accept “one’s one and only life
cycle.” By contrast, people who despair often believe they have made
poor choices during life and wish they could live life over.
Cognitive Development
Piaget’s phases of cognitive development end with Formal Operations
Phase. Changes in cognitive structures occur as a person ages. It is
believed that there is progressive loss of neurons. In addition, blood flow
to the brain decrease, the meninges appear to thicken, and brain
metabolism slows. Older people need additional time for learning,
largely because of the problem of retrieving information.
Moral Development
According to Kohlberg, moral development is completed in the early
adult years. Most old people stay at Kohlberg’s conventional level of
moral development and some are at the preconventional level. An
elderly at the preconvetional level obeys rules to avoid pain and the
displeasure of others. Elderly people at the conventional level follow
society’s rules of conduct in response to the expectation of others.
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Spiritual Development
According to Fowler and Keen, some people enter the sixth stage of
spiritual
development,
Universalizing.
People
whose
spiritual
development reaches their level thinking and act in a way that
exemplifies love and justice.
Sexual Development
Sex drives persist into 70’s, 80’s, and 90’s, provided that health is good
and an interested partner is available. Interest in sexual activity in old
age depends, in large measure, on interest earlier in life. However,
sexual activity does become less frequent. Many factors may play a role
in the ability of an elderly person to engage in sexual activity.
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1.3.2 The Ill Person at a Particular Stage of Patient
The three most common causes of death in older adults are heart
disease, cancer and stroke. Other frequently reported causes of death are
lung disease, accidents/falls, diabetes, kidney disease, and liver disease.
Heart disease is the leading cause of death in older adults. Common
cardiovascular disorders are hypertension and coronary artery disease.
Cancer or malignant neoplasm’s are the second most common cause of
death among older adults. Cerebrovascular accidents, the third leading
cause of death, occurring as brain ischemia or brain hemorrhage.
Cigarette smoking has been recognized as a risk factor in the four most
common cause of death for older adults: heart disease, cancer, stroke and
lung disease. Dental carries, gingivitis, broken or missing teeth and illfitting or missing dentures may affect nutritional adequacy, cause pain,
and lead to infection.
Older adults should be encouraged to maintain physical exercise
and activity. The primary benefits of exercise include maintaining the
strengthening functional ability and promoting a sense of enhanced wellbeing. Arthritis is also a common condition in older adults, especially in
women. The degree to which the mobility of older adults is impaired
depends on the extent of the disease and joint affected. Falls are a safety
concern of many older adults, falls my lead to fear of additional falls,
withdrawal from usual activities and loss of independence.
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2. Diagnostic Results
Diagnostic Test
Hematology
Hemoglobin
Hematocrit
RBC
WBC
Platelets
Segmenters
Eosinophils
Lymphocytes
Urinalysis
Macroscopic
Color
Appearance
Reaction
Specific gravity
Protein
Glucose
Ketones
Blood
Macroscopic
RBC
WBC
Epithelial Cells
Mucus Threads
Bacteria
Leukocytes
Nitrites
Urobilinogen
Bilirubin
Serum
Creatinine
Alt
Capillary Blood Sugar
ECG Report
Normal Values
Patient’s
Result
11.5-16 g/dl
35-49 vol %
4.5-5.3x10^6/dl
4.5-15.0x10^3/dl
12.3 g/dl
36.6 vol %
3.98x10^6/dl
5.41x10^3/dl
150,000-450,000 cu/mm
54-62%
1-3%
25-33%
267,000 cu/mm
36%
02%
54%
Normal
Normal
Normal
Elevated following surgery
Source:Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., 1954
Yellow
clear
5.5-7.5
1.001-1.045
Negative
Negative
Negative
Negative
Yellow
Slightly cloudy
6.0
1.045
Negative
Negative
Negative
Negative
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
<3 RBC’s/HFF
0-5 WBC/ HPF
Rare
Rare
None
Negative
Negative
Trace
Negative
0-1
0-1
Rare
Rare
Negative
Negative
Negative
Trace
Negative
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
.7-1.5
11.-66.
62-117 mg/dl
.8
36
196 mg/dl
Normal
Normal
Elevated in Diabetes Mellitus
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G.
Aortic Sclerosis
Sinus rhythm with non-specific ST – T
wave changes
Significance
Normal
Normal
Normal
Normal
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3. Present Profile of Functional Health Patterns
3.1 Health perceptions/ Health management
Mrs Soria describes her health as fair even though she knows she has
diabetes she wants to learn more about this disease. In their home she usually do
walking in their farm at the back of their house. Do gardening occasionally.
She verbalized that she has complete immunizations. She does Self-breast
examination every twice a month thus when she realized that she has a mass on
her right breast. Thinks of her hospital experience as a positive one inorder to
improve her health level. She is on oral hypoglycemic and on a diabetic diet but
she is usually tempted with sweets.
3.2 Nutritional/Metabolic pattern
Prior to admission, patient usually eats 3 meals a day with occasional
snacks in between meals. She has no allergies to foods. She eats almost
anything, but usually her diet is composed of fish and meat. She drinks more
than 8 glasses of water a day. She is taking glucophage as maintenance
medication. Currently, she is on a diabetic diet carefully balanced by the dietary
department to fit her daily caloric needs. Her diet now composed of 60%
carbohydrate, 30% protein, and 10% fat with less than 300 mg cholesterol a
day, no simple sugar and high fiber diet
3.3 Elimination Patterns
Mrs. Soria can void and defecate independently but she complains of this
occasional frequent urination and it makes her uncomfortable. She defecates
about once a day with formed stools without and mucus or blood but sometimes
defecates with slightly loose stools.
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3.4 Activity/ Exercise Pattern
The patient verbalized that after her retirement her daily activities are
gardening and early in the morning walking around at the farm at the back of
her house. She can independently ambulate with perfect balance, bathe, dress,
groom, and perform general hygiene by herself. But she complains of easily
getting tired, sometimes she loses drive in performing activities, getting
disinterested and sometimes becomes irritable.
3.5 Cognitive/Perceptual Pattern
She uses reading glasses as her vision is not to good because of advancing
age. She doesn’t have any complaints regarding occurrence or vertigo and
insensitivity to cold/ heat/pain. As she is a college level graduate, she can
perfectly read and legibly write.
3.6 Rest/ Sleep Pattern
She usually sleeps at around 10 pm and wakes up at around 6 am. She
sleeps for about 8 hours. She doesn’t use any medication to induce sleep but she
sometimes take snacks before sleeping. She verbalized that she usually takes a
bath before sleeping. She does not have problems sleeping.
3.7 Self- Perception Pattern
She is concern about her diagnosis on whether it could have a huge impact
on her life. Her present health goal is to keep on visiting her doctor for her
disease condition. She describes herself doing fine. Having this disease make
her a stronger person as verbalized and will seek treatments in order to manage
her condition.
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3.8 Roles- Relationship Pattern
Mrs. Soria speaks fluent English and Bisaya. Her speech is very coherent
and clear. She usually expresses herself by speaking and sometimes making
gestures, forming faces to express her emotions.
She lives with her husband in their farm, who she been married for quite
sometime now, and she verbalized than when theirs a need for help she turn to
her husband or call her daughter who is working abroad.
3.10 Coping- Stress Management Pattern
She makes decisions together with her husband. When in stress she
usually gets some sleep and rest and hope that waking up will calm things
down.
3.11 Values- Belief System
She finds her source of strength to God and her Family who is always with
her. She is a devout Roman Catholic and a very active church goer. She
verbalized that religion is very important to her for spiritual growth
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4. Pathophysiology and Rationale
4.1 Normal Anatomy and Physiology of Organ System Affected
The pancreas is located deep in the abdomen, sandwiched between the stomach and the
spine. It lies partially behind the stomach. The other part is nestled in the curve of the
duodenum (small intestine). To visualize the position of the pancreas, try this: Touch the
thumb and "pinkie" finger of your right hand together, keeping the other three fingers
together and straight. Then, place your hand in the center of your belly just below your
lower ribs with your fingers pointing to the left. Your hand will be at the approximate
level of your pancreas.
Because of the pancreas' deep location, tumors are rarely palpable (able to be felt by
pressing on the abdomen.) It also explains why many symptoms of pancreatic cancer
often do not appear until the tumor grows large enough to interfere with the function of
nearby structures such as the stomach, duodenum, liver, or gallbladder.
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The pancreas is made up of glandular tissue and a system of ducts. The main duct is the
pancreatic duct which runs the length of the pancreas. It drains the pancreatic fluid from
the gland and carries it to the duodenum. The main duct is about one-sixteenth of an inch
in diameter and has many small side branches. The pancreatic duct merges with the bile
duct to form the ampulla of Vater (a widening of the duct just before it enters the
duodenum.)
Your doctor will probably refer to different parts of the pancreas when discussing your
situation. The part of the pancreas that a tumor arises in will effect how it is treated. For
descriptive purposes, there are two ways the pancreas is divided into parts: by parts of the
overall shape and by the function of its cells.
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SHAPE
The five parts of the pancreas are:

uncinate process
The part of the gland that bends backwards and underneath the body of the
pancreas. Two very important blood vessels, the superior mesenteric artery and vein
cross in front of the uncinate process.

head
The widest part of the gland. It is found in the right part of abdomen, nestled in
the curve of the duodenum which forms an impression in the side of the gland.

neck
The thin section between the head and the body of the gland

body
The middle part of gland between the neck and the tail. The superior mesenteric
blood vessels run behind this part of the gland.

tail
The thin tip of gland in the left part of abdomen in close proximity with the spleen
FUNCTION
The pancreas can also be thought of as having different functional components, the
endocrine and exocrine parts. Tumors can arise in either part. However, the vast majority
arise in the exocrine (also called non-endocrine) part. Since the parts have different
normal functions, when tumors interfere with these functions, different kinds of
symptoms will occur.
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
Islets of Langerhans
These are the endocrine (endo= within) cells of the pancreas that produce and
secrete hormones into the bloodstream. The pancreatic hormones, insulin and
glucagon, work together to maintain the proper level of sugar in the blood. The sugar,
glucose, is used by the body for energy.

Acinar cells
These are the exocrine (exo= outward) cells of the pancreas that produce and
transport chemicals that will exit the body through the digestive system. The
chemicals that the exocrine cells produce are called enzymes. They are secreted in the
duodenum where they assist in the digestion of food.
The pancreas is an integral part of the digestive system. The flow of the digestive system
is often altered during the surgical treatment of pancreatic cancer. Therefore it is helpful
to review the normal flow of food before reading about surgical treatment.
Food is carried from the mouth to the stomach by the esophagus. This tube descends from
the mouth and through an opening in the diaphragm. (The diaphragm is a dome shaped
muscle that separates the lungs and heart from the abdomen and assists in breathing.)
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Immediately after passing through the diaphragm's opening, the esophagus empties into
the stomach where acids that break down the food are produced. From the stomach, the
food flows directly into the first part of the small intestine, called the duodenum. It is here
in the duodenum that bile and pancreatic fluids enter the digestive system.
Bile
Bile is a greenish-yellow fluid that aids in the digestion of fats. After being produced by
cells in the liver, the bile travels down through the bile ducts which merge with the cystic
duct to form the common bile duct. The cystic duct runs to the gallbladder, a small pouch
nestled underneath the liver. The gallbladder stores extra bile until needed. The common
bile duct actually enters the head of the pancreas and joins the pancreatic duct to form the
ampulla of Vater which then empties into the duodenum.
Flow of bile indicated by green arrows
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Pancreatic fluid
Instead of carrying bile, the pancreatic duct carries the pancreatic fluid produced by the
acinar cells (exocrine) of the pancreas. The pancreatic duct runs the length of the
pancreas and joins the common bile duct in the head of the pancreas. These ducts join to
form the ampulla of Vater which then empties into the duodenum.
Flow of pancreatic fluid indicated by dark yellow arrow.
The food, bile and pancreatic fluid travels through many more feet of continuous intestine
including the rest of the duodenum, jejunum and ileum which comprise the small
intestine, then through the cecum, large intestine, rectum, and anal canal.
20
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4.3 Disease process and Effects on Different Organ System
Genetic factors, usually polygenic, form disease background in a prevailing
number of patients. Environmental factors like obesity, lack of exercise and sedentary
lifestyle sometimes lead to insulin resistance. Insulin resistance means that body cells do
not respond appropriately when insulin is present.
Other important contributing factors:



increased hepatic glucose production (eg, from protein degradation)
decreased insulin-mediated glucose transport in muscle and adipose tissues
(receptor and post-receptor defects)
impaired beta-cell function - loss of early phase of insulin release in response to
hyperglycemic stimuli
This is a more complex problem than type 1, but is sometimes easier to treat especially in
the initial years, when insulin is often still produced. Type 2 may go unnoticed for years
in a patient before diagnosis, since the symptoms are typically milder (no ketoacidosis)
and can be sporadic. However, severe complications can result from unnoticed type 2
diabetes, including renal failure, blindness, wounds that fail to heal, and coronary artery
disease. The onset of the disease is most common in middle age and later life.
Diabetes mellitus type 2 is presently of unknown etiology or cause. Diabetes mellitus that
has a known etiology, such as secondary to other diseases, known gene defects, or effects
of drugs, is more appropriately called secondary diabetes mellitus. Examples include
diabetes mellitus caused by hemochromatosis, pancreatic insufficiency, or certain types
of medications (e.g. long-term steroid use).
About 90-95% of all North American cases of diabetes are type 2, and about 20% of the
population over the age of 65 has diabetes mellitus type 2. The fraction of type 2
diabetics in other parts of the world varies substantially, almost certainly for
environmental and lifestyle reasons. There is also a strong inheritable genetic connection
in type 2 diabetes: having relatives (especially first degree) with type 2 is a considerable
risk factor for developing type 2 diabetes. The majority of patients with type 2 diabetes
mellitus are obese - chronic obesity leads to increased insulin resistance that can develop
into diabetes, most likely because adipose tissue is a (recently identified) source of
chemical signals (hormones and cytokines). Other research shows that type 2 diabetes
causes obesity.1
Diabetes mellitus type 2 is often associated with obesity and hypertension and elevated
cholesterol (combined hyperlipidemia), and with the condition Metabolic syndrome (also
known as Syndrome X). It is also associated with acromegaly, Cushing's syndrome and a
number of other endocrinological disorders
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4.4 Comparative Chart
Classical Symptom
Clinical Symptom
Rationale
Polyuria
Manifested
- Patient verbalized frequent
urinations a day
Glucose attracts water, and an
osmotic
diuresis
occurs,
resulting in polyuria.
Source: Medical – Surgical
Nursing, Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition, p. 934
Polydipsia
Manifested
- Patient also verbalized
episodes of thirst when ever
her blood sugar is high
The loss of water and results in
thirst and increases fluid intake.
Losses of electrolytes such as
potassium, magnesium, and
phosphorus occur with the
osmotic diuretic effect of
glucosuria.
Source: Medical – Surgical
Nursing, Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition, p. 934
Blurred Vision
Not Manifested
Changes in the retinal capillaries
cause decreased blood flow to
the retina, leading to retinal
ischemia and possible retinal
hemorrhage or detachment.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p.382
23
Recurrent Infection
Not Manifested
Glucose accumulates in the
epidermal layer of the skin.
Moisture tends to collect under
the armpits, breasts, groin, or
genitalia. The higher the normal
concentration of glucose in the
skin coupled with moisture
creates a perfect breeding area
for microorganisms.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p.382-383
Paresthesias
Not Manifested
Diabetic peripheral neupathies
are bilateral sensory disorders.
The manifestations appear first
in the toes and feet and then
eventually progress upward to
involve the fingers and hands.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p.382
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IV. Nursing Interventions
Care Guide of Patient with Disease Condition
The nurse reinforces teaching and skills for clients with DM. The content of a teaching
plan includes the following points:

Information about normal glucose metabolism and how diabetes changes
metabolism

Dietary plan: How diet helps keep blood glucose in normal range; number pf kcal
required and why; why they should eat complex carbohydrate and foods high in
fiber but limit the intake of sugar, fat, sodium, and alcohol; concerns regarding
meal preparation; how to read food label for sugar, fat, and protein; integrating
personal food preferences; eating meals away from home; relationships between
diet, exercise, and medication. Fluid intake should be encountered, because the
thirst mechanism may be impaired.

Exercise: How it helps lower blood glucose; the importance of regular exercise
program; types of exercise; and integrating personal exercise choices

Glucose levels: Self-monitoring of blood glucose; how to perform the test
accurately; how to care for equipment; what to do for high or low blood glucose.

Medications:
o Insulin type, dosage, mixing instructions (if necessary); times of onset
and peak actions; how to get and care for equipment; how to give
injections; timing of insulin injections and mealtimes
o Oral agents: Type, dosage, side effects, interaction with other drugs

Complications:
o Factors that cause diabetic ketoacidosis or HHNS;
o Manifestations of each; what to do when they occur.
o Factors that cause hypoglycemia; manifestations; what to do when they occur
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
Safety precautions: Identify family to contract in an emergency; carrying ID card
and tag; carrying rapid-acting glucose; carrying insulin and glucagons kit

Hygiene: Skin, dental, foot care

Vision: Yearly exam, sources for vision aids such as magnifying sleeve for
insulin syringe or large-print instructions

Sick days: What to do about food, fluids, and medications

Communication and Follow-up:
o What signs and symptoms to report; whom to contact; when to report
o Importance of keeping follow-up appointments
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2. Actual Patient Care
2.1.1 Nursing Assessment
Name of Patient: Mrs. Fe F. Soria
Impression/Diagnosis: Type II Diabetes Mellitus
Attending Physician: Dr. Armando Tan
Body Part
Head
Face
Eyes
I
P
Rounded,
(normocephalic)
with frontal ,
parietal and
occipital
prominences/
smooth skull
contour
Smooth, uniform
in consistency,
absence of
nodules and
masses.
Symmetrical
facial features,
palpebral fissures
equal in size,
symmetric
nasolabial folds
and symmetrical
facial
movements
P
A
Temporal pulse:
78 bpm
Smooth, no
deformities,
absence of
nodules or
masses. No
tenderness over
lacrimal gland
Resonant sound
found upon
percussion
Eyebrows
symmetrically
aligned equal
movement.
Eyelashes
equally
distributed and
curled slightly
upward, skin
intact, n
discharges and
no discoloration.
Lids close
symmetrically.
27
Sclera is white,
palpebral
conjunctiva is
shiny, smooth
and pink. Eyes
are black with
pupils equally
round and
reactive to light
and
accommodation
Ears
Auricle in line
with the outer
canthus of the
eyes, absence of
lesions,
discharges and
swelling
Nose
No discharges
and swelling
Mouth and lips
Dark pink and
moist, slightly
cracked, pinkish
gums
Neck
Muscles equal in
size, head
centered,
coordinated
smooth
movements with
no discomfort
Trachea
Thyroid gland
Lymph nodes not
palpable
Central
placement in
midline of neck,
spaces are equal
in both sides
Not visible,
gland ascends
Palpable right
lobe of the
thyroid moves
28
during
swallowing
Breast
No observable
lesions on front,
no discharges, no
retractions, right
breast remove
through MRM
procedure
when
swallowing, nontender
No palpable
mass
Absence of
crackles and
rhales
Clear breath
sounds,
distinctive heart
sounds, regular
rhythm, systolic
murmurs present
Heart
82bpm
Abdomen
Rounded,
globular, brown
in color,
Smooth and
rounded, no
masses nontender
Kidney
Not painful upon
palpation
Spleen
Not enlarged
Upper
Extremities
No IVF, uniform
in color and
texture, muscles
have equal size
and strength has
no deformities,
joints move
smoothly, no
tenderness.
Complete set of
fingers. Visible
veins on hands
and skin, dry,
thin skin with
reduced turgor
Muscles are firm
with smooth
coordinated
movement. No
palpable mass.
Absence of
tenderness and
swelling. Good
capillary refill
11 bowel sounds
per min.
BP
Radial pulse-66
29
Lower
Extremities
Muscles have
equal size and
strength has no
deformities,
uniform in color
and texture,
joints move
smoothly, no
tenderness.
Complete set of
toes. Visible
veins on feet and
skin. Abrasions
noted on upper
left leg
Bilaterally even
pulse rate,
rhythm and skin
temperature,
muscles are firm
with smooth
coordinated
movement. No
palpable mass.
Absence of
tenderness and
swelling. Good
capillary refill
Popliteal pulse65
30
2.1.2 Nursing Care Plan
Name of Patient: Mrs. Soria, Fe. F
Age: 67 y. o.
Room/Ward: 233
Sex: female
Chief Complaints: Frequent urination, High Blood Sugar, and a Lump on her
Breast
Needs/
Problems/
Nursing
Diagnosis
Scientific
Basis
Objectives
of Care
Altered
nutrition,
more the
body
requirement
s: high
blood sugar
levels
related to
- patient
insufficient
verbalized insulin
“ lami kayo production
ika.on sad
ug mga
tam.is”
The
pancreas
produces
either
normal or
excessive
amounts
of insulin,
but the
body is
unable to
use it
effectively
, and
glucose
levels
remain
elevated.
This
defect is
known as
insulin
resistance
and is seen
I type II
DM.
Fundamen
After 8
hours of
holistic
nursing
care the
patient will
be able to
verbalized
optimal
individual
diet and
health
maintenan
ce
programs
Cues
Nursing
Intervention
Rationale
I. physiologic
1. Altered
Nutrition,
More than
Body
Requiremen
ts: High
Blood
Sugar levels
- capillary
blood
sugar is
elevated at
about 196
mg/dl
- patients
weight is
above
normal
Measures to:
- optimize health
1. monitor blood
glucose levels
regularly and
report values
below 60 mg/dl
or above 200
mg/dl.
- clients with diabetes
are at risk for
hypoglycemia or
hyperglycemia
Source: Medical –
Surgical
2. identify food
preferences,
including
ethnic/cultural
needs.
- clients are more
likely to eat food they
like and that meets
their ethnic/ cultural
requirements.
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition. p. 384
Source: Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
31
- triceps
skin fold is
30mm
tally, it is
the failure
of the
pancreas
to produce
enough
insulin to
overcome
this insulin
resistance
that
precipitate
s clinical
type II
DM in
predispose
d
individuals
Source:
Medical
Surgical
Nursing
Health and
Illness
Perspectiv
es
Phipps,
Wilma, et.
al. 7th
edition
p. 930
3. encourage
client to eat all
of the prescribe
diet
- anorexia, gastric
fullness, and
abdominal pain can
reduce oral intake. To
prevent hypoglycemia,
the client must
consume the amount
of food included in the
diet plan.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
4. encourage
patient to
become involved
in setting goals
for dietary
changes,
documenting
food intake,
planning meals.
- there is a greater
probability that
changes will be made
when the patient is
involved in planning
those changes.
Patients know their
own likes and dislikes,
financial resources
and ability to make
dietary changes.
Participation allows
the patient greater
control over the
situation.
Source: : Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 954
5. monitor
percentage of
meals and snaks
that client eats.
- monitoring of
nutritional intake
helps to determine the
need for a dietary
consult.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
32
1st Edition., p. 384
6. provide meals
and snacks on
time
- glucose and insulin
control is more
effective when meals
are eaten on time.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
7. include a
high-fiber, high
carbohydrate
diet
- it has been shown to
decrease insulin
requirements and
cholesterol. It has
been shown to
increase satiety, which
might help with
weight reduction.
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 949
8. teach or
- knowledge increases
reinforce earlier the likelihood of
teaching about
compliance
the selected
Source: Medical Surgical
Nursing Health and
system of dietary
Illness Perspectives
management
Phipps, Wilma, et. al.
7th edition. p. 955
9. teach client
the sign and
symptoms of
hypoglycemia
and how to treat
it.
- patient receiving oral
hypoglycemic agents
must be concerned
about hypoglycemia ;
they need to know
how to identify and
handle it.
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 955
33
10. give oral
hypoglycemic
agents as
ordered
- to prevent
hyperglycemia, oral
hypoglycemic agents
must be given on time.
Altered times might
be necessary when
food is delayed or
diagnostic procedures
are being done.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
2. Activity
Intolerance
: Fatigue
- patient
verbalized
“ kapoy
man cge
ako lawas”
- disinterest
in
surroundin
gs
- decreased
drive in
performing
activities
- sometimes
irritable
Activity
intolerance:
fatigue
related to
poor
utilization
of glucose
Fatigue is
a common
symptom
of diabetes
and also
related to
increased
age or
anemia.
Diabetes
leads to
loss of fat
deposits
under the
skin, loss
of
glycogen,
and
catabolism
of body
proteins
Source: :
Medical –
Surgical
Nursing
Care
Burke,
Karen,
LeMone,
Priscilla ,
- state that
fatigue is
reduced
and energy
is
returning
to normal
-measures to
reduce fatigue
1. teach patient
that
improvement in
metabolic
control will
decrease fatigue.
-understanding the
relationship between
metabolic
abnormalities and
fatigue increases the
likelihood of
compliance with the
prescribed treatment
regimen.
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 955
2. monitor
severity of
patients fatigue
- a baseline
assessment is
necessary for later
comparisons and to
determine treatment
effectiveness
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 955
3. encourage
patient to
prioritize daily
- fatigue compromises
one’s ability to
participate in daily
34
and
MohnBrown,
Elaine,1st
Edition., p.
368
activities when
feeling fatigued
and to let go of
unessential
tasks.
activities. It is
important that the
patient’s available
energy be used to
complete priority
activities until blood
glucose are regulated.
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 955
4. explore
strategies to
modify existing
activities,
conserving
energy when
possible; seek
assistance and
delegate
activities; and
pace activities
through the day
to allow a
balance between
activity and rest.
5. encourage
patient to obtain
at least 8 hours
of uninterrupted
sleep at night.
- many daily activities
can be modified to
consume less energy,
but this requires the
patient’s willingness
to think about routine
activities in a different
way. It may not be
possible for the patient
to perform all desired
activities until she is
metabolically stable.
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 955
- effective nighttime
sleep patterns help
decrease daytime
fatigue
Source: Medical Surgical
Nursing Health and
Illness Perspectives
Phipps, Wilma, et. al.
7th edition. p. 955
35
3. Risk for
Infection:
Left Leg
Abrasions
- scratch
marks on
her left leg
- the
patients
disease
condition
could
further
worsen the
would
especially
when body
defenses
cannot fight
thoroughly
because
altered
inflammator
y process
and
impaired
would
healing.
Risk for
infection:
left leg
abrasions
related to
ineffective
body
defenses
Persons
with
diabetes
are at
increased
risk of
infection.
The
effectivene
ss of the
skin as a
first line of
defense
can be
diminished
.
Hyperglyc
emia can
hamper
the
inflammat
ory
response
and wound
healing
and impair
leukocyte
function,
migration
of
leukocytes
to the site
of
infection,
phagocyto
sis, and
bacterial
killing, al
of which
are
involved
in
combating
infection.
- prevent
occurrence
of
infection
- identify
manageme
nt to avoid
complicati
ons.
- measures to
avoid infection
1. monitor
manifestations
of infection:
fever, chills;
tachycardia;
abnormal breath
sounds; cloudy,
foul smelling
urine; redness,
pain swelling, or
discharge at
injury site.
- early diagnosis and
treatment of infections
can control their
severity and decrease
possible
complications.
2. use and teach
meticulous
handwashing
- handwashing is the
best method for
preventing the spread
of infection.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
3. keep skin
clean and dry,
using mild soap
and lukewarm
water.
- clean intact mucous
membranes are the
first line of defense
against infection.
4. maintain
meticulous
sterile technique
when
performing
wound care or
- these prevent
infection in existing
wounds or
introduction of
bacteria into the body.
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
Source: Medical – Surgical
Nursing Care
36
Sources:
Medical
Surgical
Nursing
Health and
Illness
Perspectiv
es
Phipps,
Wilma, et.
al. 7th
edition
p. 967
any invasive
procedure.
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
5. turn client and
encourage
coughing, deep
breathing, and
activity as
tolerated.
- sedentary clients are
prone to developing
atelectasis and/or
pneumonia
6. encourage
adequate
nutrition and
fluid intake
- maintaining
satisfactory food and
fluid intake reduces
susceptibility to
infection
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
Source: Medical – Surgical
Nursing Care
Burke, Karen ,
LeMone, Priscilla ,
and Mohn-Brown,
Elaine
1st Edition., p. 384
37
2.1.3 Drug Therapy Record
Hospital No.: 187908
Physician: Dr. Armando Tan
Drug/
Route/
Frequency/
Route
1. Unasyn
750 mg 1
tab BID
P.O.
8 AM
Service: Medical
Impression: Type II Diabetes Mellitus
Classification/
Indications/
Mechanism of Contraindications/
Action
Side Effects
Antibacterial
Indications;
Bind bacteria
cell wall,
resulting in
cell death.
-Upper and lower
respiratory tract
infection
- UTI and
pyelonephritis
- Skin and soft
tissue infections
- gonoccocal
infections
Contraindications;
- History of allergic
reaction to any
penicillin.
Adverse effects;
GI: GI disturbances
Derm: Skin raches,
itching
CV: Phlebitis,
boold disorders,
anaphylaxis and
superinfection
Principles of
Care
1. Asses
patient for
infections
2. Monitor
vital signs
3. Monitor
intake and
output of the
patient.
4. Before
initiating
therapy, obtain
a history to
determine
previous use of
and reactions
to penicillin or
cephalosporins.
Treatment
1. Provide
safety
2. inform the
patient of the
possible side
effects of the
drug
Evaluation
The patient
WBC is in
normal
range and
did not
experience
any side
effects
3. Tell patient
to notify
physician if
diarrhea and
fever occurs.
4. Advise
patient to
report signs
of
superinfection
and allergy.
5. Observe
patient for
signs and
symptoms of
anaphylaxis.
38
2.
Glucophage
(Metformin)
500 mg BID
1 TAB P.O.
give with
meals.
Oral
hypoglycemic
agents
Decreases
hepatic
production of
glucose,
decreases
intestinal
absorption of
glucose,
increases
sensitivity to
insulin
Indications:
- Type II Diabetes
Mellitus,
monotherapy or in
combination with
other oral
antidiabetics
Contraindication:
- Diabetic coma
- Ketoacidosis
- renal impairment
- chronic liver
disease
- cardiac failure
and recent MI
- alcoholism
- hypoxemia
- shock
- pregnancy
1. Administer
metformin with
meals to
minimize side
effects
1. Observe
patient for
signs of
hypoglycemic
reactions
2. Patients
stabilized on a
diabetic
regimen who
are exposed to
stress, fever
trauma,
infection, or
surgery may
require
administration
of insulin.
Withhold
metformin and
reinstitute after
resolution of
acute episode
2.Monitor
CBC prior to
and at least
annually
throughout
therapy
Patient
serum
glucose
remained
in normal
level
through the
course of
the
therapy.
3. Monitor
serum
glucose and
glycosylated
hemoglobin
to evaluate
effectiveness
of therapy
Adverse Effects:
GI: nausea,
vomiting, diarrhea,
abdominal bloating,
unpleasant metallic
taste
Endo:
hypoglycemia
F and E: Lactic
ascidosis
Misc: decreased
vit. B12 levels
3. Withhold
metformin
during studies
requiring IV
administration
of iodinated
contrast media.
39
2.1.4 Health Teaching Plan
Patient’s Name: Mrs. Fe F. Soria
Impression: Type II Diabetes
Mellitus
Complaints: Frequent urination
Physician: Dr. Armando Tan
High Blood Sugar and a Lump on her Breast
Objectives
General
After 8 hours of
teaching – learning
activities the patient
and significant others
will be able to have a
clear picture about her
present condition
Content
Methodology
Evaluation
Specific
After 45 mins. of
varied teaching –
learning activities the
patient and significant
other will able to:
1. define and
identify fact
about Type II
Diabetes
Mellitus
Definition of Type II Diabetes
Lecture –
Mellitus
Discussion
- is characterized by insufficient
insulin production or resistance.
Sufficient insulin is produced to
prevent the breakdown of fats;
therefore, ketosis does not
occur. However, the amount of
available insulin is inadequate to
lower blood glucose levels
through the uptake of glucose by
muscle and fat cells. While it
can occur at any age, Type II
DM is usually seen older people.
Heredity plays an important role
in its transmission.
The patient
was able
verbalize and
demonstrate
necessary
knowledge,
attitude and
skills in
managing this
disease
condition like
stating the
necessary
information
needed in
type II
diabetes
mellitus,
managing
40
2. identify the risk Risk Factors of Type II Diabetes
factors for this Mellitus
disease
condition.
- obesity
- increasing age
- belonging to high-risk ethnic
group
3. enumerate
possible
complication
that may arise
in Type II
Diabetes
Mellitus
Lecture –
Discussion
hypoglycemia
and
demonstrating
how to
perform
wound care.
Complications of Type II
Lecture –
Diabetes Mellitus
Discussion
- Hyperglycemic Hyperosmolar
Nonketotic Syndrome
 characterized by severely
elevated blood glucose
levels, extreme
dehydration, and an
altered level of
consciousness. Infection,
surgery, and dialysis are
a few factors that can
trigger HHNS
- Hypoglycemia
 cause by too much
insulin, overdose of oral
antidiabetic agents, a
little food , or excess
physical activity. The
onset is sudden, and
blood glucose is usually
les than 50 mg/dL.
4. state the
management of
hypoglycemia
Management of Hypoglycemia
- people with hypoglycemia
should take about 15 g of rapid
acting sugar. Examples of fastacting glucose are:
 3 glucose tablets
 ½ cup of fruit juice or
regular soda
 6 oz of skim milk
 6 to 8 Life Savers
candies
 2 to 3 tsp of sugar or
honey
Lecture –
Discussion
41
5. demonstrate
proper wound
care
6. appreciate the
importance of
the
management of
Type II
Diabetes
Mellitus to
prevent further
complications.
Wound Care
 Prepare the and assemble
all needed the equipment
 Remove binders or
adhesive tapes if used
 Remove and dispose of
soiled dressings
appropriately
 Clean the wound with
gauze swabs moistened
with cleaning solution
 Use a separate swab for
each stroke , and discard
each swab after use
 Dry the surrounding skin
with dry gauze swabs as
required. Do not dry the
incision or wound itself.
 Apply the ordered
powder or equipment
 Apply dressings to the
drain site or incision.
The patient will be able to
verbalize the importance of the
management of this disease
condition to prevent further
complications.
Discussion –
Demonstration
– Return
Demonstration
Sharing Discussion
42
V. Evaluation and Recommendation
After rendering holistic care, the patient and the nurse were able to achieve the
specific objectives. The patient went home with an improved condition as evidenced by
having the sufficient knowledge, attitude and skill in managing her disease condition;
increased energy levels as evidenced by performance of activities of daily living and a
wound that steadily healing and free from any signs of infection. She was given discharge
health teaching about her diet, management of complications, and importance of wound
care. Discharge medications instruction was also given.
VI. Evaluation and Implication of This Case Study To:
Nursing Practice
This case study provides information about Type II Diabetes Mellitus and
nursing interventions and therapeutic techniques used with patients who have this
disease. It also provides information about the plan of care for patients who have
this disease condition for efficient nursing care.
Nursing Education
To nursing education, this case study would help by providing information
about the disease condition Type II Diabetes Mellitus. The student nurses, as
well as the teachers could gain additional information about this disease that is
common in children, so that it could better equip them for efficient nursing care
in the future.
Nursing Research
To the research team, that they will be able to come up with a new and
better interventions, whether medical or nursing, to treat the disease at an early
duration as well as knowing the latest facts to prevent the occurrence of the
disease, diabetes mellitus.
43
VII.
The Referral and Follow-up
The patient was asked to visit her doctor, Dr. Armando Tan, one week after
discharge for a follow-up check up. She was also advice to have a strict
compliance on her medications and refer for any signs of complications.
44
VIII. Bibliography
Burke, Karen , LeMone, Priscilla ,and Mohn-Brown, Elaine. Medical – Surgical Nursing
Care. 1st Edition. Upper Saddle River, New Jersey: Pearson Education, Inc., 2003.
Deglin, Judith and Vallerand, April. Davis’s Drug Guide for Nurses. 5th Edition.
Philadelphia, Pennsylvania: 1997
Kozier, Barbara, ET. Al. Fundamentals of Nursing: Concept, Process and Practice. 5th
Edition. USA: Addison-Wesley Longman, Inc., 1998.
Martini, Frederic. Fundamentals of Anatomy and Physiology 6th Edition. USA: Pearson
Education, Inc., 2004.
Phipps, Wilma, ET. Al. Medical – surgical Nursing, Health and Illness Perspectives. 7th
Edition. St. Louis, Missouri: Mosby, Inc. 2003
Potter, Patricia and Perry, Anne Griffin. Fundamentals of Nursing: Concept, Process and
Pracitce. 3rd Edition. St. Louis, Missouri: Mosby, Inc., 1993
Smeltzer, Suzanne and Brenda Bare. Textbook of Medical Surgical Nursing. 9th Edition.
Philadelphia, PA: Lippincott Williams and Williams, 2000.
Thibodeau, Gary and Patton, Kevin. Anatomy and Physiology 5th Edition. USA:
Mosby, Inc., 2003.
45