Case Study (Diabetes Mellitus)

I. INTRODUCTION Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles. There are 18.2 million people in the United States, or 6.3% of the population, who have diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2 million people (or nearly one-third) are unaware that they have the disease. The primary goals of treatment for patients with diabetes include controlling blood glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for diabetic patients must assist them to develop self-care management skills. I chose the case for my case study. I have taken care of him for 2 consecutive days. Let’s find out more about Diabetes Mellitus! My patient specifically has Type 2 (NonInsulin Dependent Diabetes Mellitus) I hope you will learn many things through my case study.

II. GENERAL DATA Patient’s name: S., B. Z. Address: No. GBA Pitogo Consolacion, Cebu Birthday: October 4, 1952 Age: 54 years old Birthplace: Poro, Camotes Sex: Male Citizenship: Filipino

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Occupation: None Height: 5’ 6” Weight: 140 lbs. Religion: Roman Catholic Status: Married Wife’s name: Diomedes Sotto Occupation: Teacher

III. HISTORY OF PRESENT ILLNESS Twenty days prior to admission, patient noted onset of bullae at left foot dorsum about the size of one peso coin. A days prior to admission, spontaneously ruptured, applied Betadine one a day with no relief. Wound noted to ulcerate spreading over foot dorsum up to proximal tibia. Fever admitted one day PTA at Ormoc Hospital, decided to transfer to VCMC for further management. One day prior to admission, admitted at VCMC for further management. Estimated date of confinement was on November 12, 2006. Vital signs taken: BP – 130/80 mmHg, HR – 117 beats / minute, RR – 19 cycles / minute and temp. – 36.7 0C.

IV. PAST HEALTH HISTORY Diabetic for 14 years with poor compliance to medications for diabetes like humulin and claims no compliance for 5 years. Claim to be an alcoholic beverage and a smoker for 1 year. He was also diagnosed with Hypertension. He has been operated for wound suturing at the left foot

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dorsum last 2001 at CCMC. And on June 2002, he had undergone Below the Knee Amputation at VCMC.

V. NURSING REVIEW OF SYSTEMS 1

General Appearance

Patient is not having fever, conscious, coherent, responsive

when being asked. He has a slender body type; voice is clear when he talks and appears relaxed and comfortable upon my visit. 2

Skin

Patient has cool and has good skin turgor. There are no signs of skin lesions and

sores; there is absence of rashes and itchiness and no change in skin color. 3

Head

Patient is normocephalic, proportion to the body. Sometimes he experienced

headache but was relieved by taking OTC medications. There is even distribution of hair and has slightly dry hair but has no presence of flakes. 4

Eyes

He has pinkish, palpable conjunctiva, does not wear glasses and has clear vision

with absence of eye infection. 5

Ears

Symmetrical, non-tender and smooth texture.

6

Nose

The nose is at the midline of the face, palpable, with no presence of swelling. He

also experienced colds due to weather conditions. 7

Mouth

He does not wear any dentures but experiences toothaches sometimes due to

lack of oral care. 8

Neck

There was no presence of neck stiffness or pain. It can move regularly and there

is no sign of swelling. 9

Upper Extremities

Warm and has good skin turgor, smooth texture, and non-tender.

3

10

Breast

There was absence of lumps, nipple discharge, scales or cracks around the

nipples. 11

Lungs

He has no cough, his not wheezing or having any lung disease.

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Abdomen

13

Lower Extremities

Flabby, soft and non-tender He had undergone Above the Knee Amputation at the left and

Below the Knee Amputation at the right due to Diabetes Mellitus. He has impaired mobility thus he really needs assistance upon movement 14

GENITOURINARY SYSTEM

No presence of sexually transmitted disease. Foreskin

retracts easily. The left sacral sac is lower than the right. Testicles are sensitive to pressure, firm, smooth and equal in size. No swelling, lesions, itching noted in the reproductive area.. 15

NEUROLOGIC SYSTEM

Has clear thinking and has slight changes in emotional

state such as changes in mood and sometimes being irritable because of his health condition. Has a good sense of memory and shows no signs of speech problems. 16

ENDOCRINE SYSTEM

He is able to tolerate cold and hot temperature; he is above

the normal appropriate body mass index and has a history of diabetes.

VI. FAMILY, PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY A. MEMBERS OF IMMEDIATE FAMILY Name

Age

Educational attainment 2nd yr H.S.

Occupation

54 yrs old

Position in the family Father

None

General Health status Unhealthy

Benito Sotto Diomedes Sotto

66 yrs old

Mother

Teacher

Healthy

Vincent Sotto

31 yrs old

Eldest child

College of Education graduate 2nd yr College

N/A

Healthy

Debbie Sotto

30 yrs old

2nd child

College of

Teacher

Healthy

4

Larrafe Sotto

27 yrs old

3rd child

Education graduate 2nd yr College

Disebel Sotto

25 yrs old

4th child

3rd yr College

Adelfa Sotto

23 yrs old

5th child

Domagit Sotto

22 yrs old

Youngest child

College of Teacher Education graduate College of Seaman Marine Trans. graduate

N/A

Healthy

N/A

Healthy Healthy Healthy

B. PERSONAL AND SOCIAL HISTORY Date of birth: October 04, 1952 Place of Birth: Poro, Camotes Nationality: Filipino Civil Status: Married Home address: GBA Pitogo Consolacion, Cebu Name of Father: Bienvinido Sotto Name of Mother: Julia Sotto Personal Habits: Driving Dialects Spoken: Cebuano, Tagalog, English

C. ENVIRONMENTAL HISTORY They once lived in Poro, Camotes where the patient’s parents lived but transferred in Consolacion, Cebu together with his eldest son and family. He described his neighborhood as a clean place and peaceful. Garbage disposal are properly taken cared of by government garbage collectors. They secure water by means of the faucet from MCWD

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D. HEREDO-FAMILIAL HISTORY He verbalized that his father is diagnosed with mild hypertension. And his mother is also a diabetic. She has no food and drug allergies.

VII. PHYSICAL ASSESSMENT The patient was observed lying on bed, able to tolerate light movements, afebrile, comfortable and no headache. Vital signs were noted to be; BP – 130/90 mmHg, HR – 96 bpm, RR – 25 cpm and temp. – 35.90C.

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SKIN Shows no signs of erythema, jaundice or cyanosis. Generally has uniform pigmentation except in areas around the neck and areas exposed to the sun. No signs of skin interruptions. Have warm and good skin turgor.

2

HAIR Variable, no infestation, slightly dry hair, evenly distributed hair.

3

NAILS Has smooth texture, highly vascular and pink in color, and intact epidermis

4

HEAD Normocephalic and smooth skull contour, absence of nodules, symmetric facial features, symmetric facial movements

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EYES Eyebrows symmetrically aligned and equal movement, skin intact, no discharge, no discoloration, lids closed symmetrically, approximately 15 to 20 involuntary blinks per minute, sclera appears white, shiny, smooth and pink conjunctiva, pupils black in color, equal in size, positive reaction to light and accommodation able to read at a regular distance

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EARS Color is same as facial skin, symmetric position, mobile, firm and not tender, able to hear ticking sounds on both ears, has smooth texture and no signs of

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discharges 7

NOSE Symmetric and straight, no discharge but manifests slight flaring due to postoperative pain, has uniform color, not tender and has no lesions, nasal septum intact and in the midline, breaths freely and regularly

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MOUTH AND BUCCAL CAVITY Uniform pink color, ability to purse lips, no retraction of gums, pink gums, smooth, white, shiny tooth enamel, lips were red, soft and symmetrical in shape, no lesions, no bleeding noted on gums, tongue is in central position, pink color, smooth lateral margins, moves freely and has no lesions.

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NECK Muscles equal in size, head centered, coordinated, smooth movements with no discomfort, has equal strength, lymph nodes not palpable.

10

LUNGS AND THORAX Chest is symmetrical, skin intact, uniform temperature, full symmetric chest expansion, clear breath sounds, respiratory rate is 25 cycles/min.

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PERIPHERAL VASCULAR SYSTEM Full pulsations, symmetric pulse volumes, blood pressure is noted to be 140/80; extremities show no sign of redness, tenderness and edema.

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BREAST AND AXILLAE Skin is uniform in color, it is also smooth and intact, no lesions and absence of discharges. No presence of tenderness and masses on the axillae.

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ABDOMEN Unblemished skin, uniform in color, symmetric contour, flabby and soft, no rashes or skin lesions, no appearance of bulges.

14 MUSCOSKELETEL SYSTEM

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UPPER EXTREMITIES Has an equal size on both sides of the body, no contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body’s side. LOWER EXTREMITIES He had undergone Above the Knee Amputation at the left and Below the Knee Amputation at the right due to Diabetes Mellitus. He has impaired mobility thus he really needs assistance upon movement. 15

NEUROLOGIC SYSTEM Conscious and coherent, no language deficiency, well oriented to time and place, coordinated body movements, smooth and steady

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MALE GENITALS AND REPRODUCTIVE TRACT Even distribution of pubic hair, pubic skin intact and has no lesions.

VIII. DEVELOPMENTAL DATA Age Infancy

Development Trust vs. Mistrust

Patient’s Behavior Reported that he grew up normally as a young

(birth to 18 months)

kid, demonstrated a normal steady growth.

Toddler

Autonomy vs. Shame

Nourished with breast milk for a year and a half. Can fully walk alone without holding onto

(18 months to 3

and Doubt

support bars at the age of 1 year and 8 months.

years)

Was claimed to be very anxious about many things and enjoys playing alone. Very

Preschooler (4 to 5 years old)

Initiative vs. Guilt

negativistic about many things. Play was the most important activity of the day. Started to go along with peers and look for 8

adventures. At this age, she can manage to wash School Age

Industry vs.

himself alone and toilet training was established. Started grade 1 at the age of 6 years old. He

(6 to 12 years old)

Inferiority

enjoyed the company of his friends and also loves to study. Shows interest in studying and

Adolescent

Self-Identity vs. Role

playing. This was marked as the most memorable time of

(12 to 18 years old)

confusion

the patient’s life especially that at this stage, she

Intimacy vs. Isolation

had already experienced boy to girl relationship. Already go married at the age of 22 years old.

Early adult (20 to 40 years old)

And he had 6 children; some were already professional and some got married and have

At Present

children too. Now, it’s his concern to have more grandchildren and his children would raise them properly. He is ever glad that his family has been very supportive in these times.

IX. A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED PANCREAS Glandular organ are organs that secretes digestive enzymes and hormones. In humans, the pancreas is a yellowish organ about 7 in. (17.8cm) long and 1.5 in., 1.5 in.(3.8cm) wide. It lies beneath the stomach and is connected to the small intestine at the duodenum. Most of the pancreatic tissue consists of grapelike clusters of cells that produce a clear fluid (pancreatic juice) that flows into the duodenum through a common duct along with bile from the liver. 9

Pancreatic juice contains three digestive enzymes: tryptase, amylase, and lipase that, along with intestinal enzymes, complete the digestion of proteins, carbohydrates, and fats, respectively. Scattered among the enzyme producing cells of the pancreas are small groups of endocrine cells, called the islets of langerhans that secrete two hormones, insulin and glucagons. The pancreatic islets contain several types of cells: alpha-2 cells, which produce the hormone glucagons; beta cells, which manufacture the hormone insulin; and alpha-1 cells, which produce the regulatory agent glucagons has the opposite action. Failure of the insulin-secreting cells to function properly results in which can occur in two major forms, the division being between juvenile onset and onset in maturity.

B. CONCEPTUAL FRAMEWORK ON THE PATHOPHYSIOLOGY OF DIABETES MELLITUS TYPE 2

Destruction of alpha and beta cells of the pancreas ↓ ↓ ↓ Ineffecient to produce insulin Production of excess glucagons ↓ ↓ Increased ← elevated blood glucose Production of glucose → acidosis → acetone osmolarity protein and fat stores breath due to glucose ↓ ↓ Wasting of lean body mass → fatigue ↓ ↓ ↓ ↓ Polydipsia Polyuria Polyphagia Weight loss 10

C. DISCUSSION OF THE PATHOPHYSIOLOGY Regardless of the cause, insulin deficiency produces generally predictable consequences. In the normal state, insulin (formed by the beta cells of the pancreas by the precursor proinsulin) acts to facilitate transport of glucose, some amino acids, and some fatty acids across cell membranes of tissue that are insulin sensitive, namely, liver, skeletal muscle and adipose tissue. In the liver, glucose is used as glucose or stored as glycogen. In the absence of sufficient insulin, excess glucose accumulates and circulates in the bloodstream (hyperglycemia) and spills into the urine (glucosuria). Muscle cells require insulin to incorporate amino acids into muscle protein. Insulin deficiencies cause withdrawal of amino acids and subsequent increases in serum amino acid levels. Finally, insulin is needed to facilitate transport of glucose into the cells to maintain a balance of lipolysis between stored triglycerides and esterification of fatty acids to triglycerides. In insulin, deprived states there is an increase in release of fatty acids and glycerol. The interference with glucose transported to the liver, muscle and adipose tissue, and resulting serum elevations of glucose, amino acids, fatty acids, and glycerol, precipitate further metabolic changes. There is hypertonic dehydration as water leaves the cells, osmotic diuresis brought about by glucosuria, and limited tubular re-absorption, causing polyuria and loss of electrolytes, notably sodium and potassium. Finally, fatty acids breakdown into ketone bodies, acetoacetic acid, beta hydrobutyric acid, and acetone, causing a state of ketoacidosis. DIABETES MELLITUS Somatostatins are hormones secreted directly into the bloodstream, and together, they regulate the level of glucose in the blood. Insulin lowers the blood sugar level and increases the

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amount of glycogen (stored carbohydrate) in the liver; Diabetes mellitus is a metabolic disorder, specifically affecting carbohydrate metabolism. It is a disease characterized by persistent hyperglycemia (high glucose blood sugar). It is a metabolic disease that requires medical diagnosis, treatment and lifestyle changes. The World Health Organization recognizes three main forms of diabetes: type 1, type 2 and gestational diabetes (or type 3, occurring during pregnancy), although these three "types" of diabetes are more accurately considered patterns of pancreatic failure rather than single diseases. Type 1 is generally due to autoimmune destruction of the insulin-producing cells, while type 2 and gestational diabetes are due to insulin resistance by tissues. Type 2 may progress to destruction of the insulin-producing cells of the pancreas, but is still considered Type 2, even though insulin administration may be required. Since the first therapeutic use of insulin (1921) diabetes has been a treatable but chronic condition, and the main risks to health are its characteristic long-term complications. These include cardiovascular disease (doubled risk), chronic renal failure (it is the main cause for dialysis in developed world adults), retinal damage which can lead to blindness and is the most significant cause of adult blindness in the non-elderly in the developed world, nerve damage, erectile dysfunction (impotence) and gangrene with risk of amputation of toes, feet, and even legs. TYPE 1 DIABETES MELIITUS Type 1 diabetes mellitus formerly known as insulin-dependent diabetes (IDDM), childhood diabetes, or juvenile-onset diabetes - is characterized by loss of the insulin-producing beta cells of the islets of Langerhans of the pancreas leading to a deficiency of insulin. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. This type comprises up to 10% of total cases in North America and Europe, though this varies by

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geographical location. This type of diabetes can affect children or adults, but has traditionally been termed "juvenile diabetes" because it represents a majority of cases of diabetes affecting children. The most common cause of beta cell loss leading to type 1 diabetes is autoimmune destruction, accompanied by antibodies directed against insulin and islet cell proteins. The principal treatment of type 1 diabetes, even from the earliest stages, is replacement of insulin. Without insulin, ketosis and diabetic ketoacidosis can develop and coma or death will result. Currently, type 1 diabetes can be treated only with insulin, with careful monitoring of blood glucose levels using blood testing monitors. Emphasis is also placed on lifestyle adjustments (diet and exercise). Apart from the common subcutaneous injections, it is also possible to deliver insulin via a pump, which allows infusion of insulin 24 hours a day at preset levels, and the ability to program a push dose (a bolus) of insulin as needed at meal times. This is at the expense of an indwelling subcutaneous catheter. It is also possible to deliver insulin via an inhaled powder. Type 1 treatment must be continued indefinitely at present. Treatment does not impair normal activities, if sufficient awareness, appropriate care, and discipline in testing and medication. The average glucose level for the type 1 patient should be as close to normal (80– 120 mg/dl, 4–6 mmol/l) as possible. Some physicians suggest up to 140–150 mg/dl (7-7.5 mmol/l) for those having trouble with lower values, such as frequent hypoglycemic events. Values above 200 mg/dl (10 mmol/l) are often accompanied by discomfort and frequent urination leading to dehydration. Values above 300 mg/dl (15 mmol/l) usually require immediate treatment and may lead to ketoacidosis. Low levels of blood glucose, called hypoglycemia, may lead to seizures or episodes of unconsciousness. TYPE 2 DIABETES MELLITUS

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Type 2 diabetes mellitus is previously known as adult-onset diabetes, maturity-onset diabetes, or non-insulin dependent diabetes mellitus (NIDDM) - is due to a combination of defective insulin secretion and defective responsiveness to insulin (often termed insulin resistance or reduced insulin sensitivity), almost certainly involving the insulin receptor in cell membranes. In early stages, the predominant abnormality is reduced insulin sensitivity, characterized by elevated levels of insulin in the blood. In the early stages, hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver, but as the disease progresses the impairment of insulin secretion worsens and therapeutic replacement of insulin often becomes necessary. There are numerous theories as to the exact cause and mechanism for this resistance, but central obesity (fat concentrated around the waist in relation to abdominal organs, not it seems, subcutaneous fat) is known to predispose for insulin resistance, possibly due to its secretion of adipokines (a group of hormones) that impair glucose tolerance. Abdominal fat is especially active hormonally. Obesity is found in approximately 90% of Developed world patients diagnosed with type 2 diabetes. Other factors may include aging and family history, although in the last decade it has increasingly begun to affect children and adolescents. Type 2 diabetes may go unnoticed for years in a patient before diagnosis, since the symptoms are typically milder (e.g. lack of ketoacidotic episodes) and can be sporadic. However, severe complications can result from unnoticed type 2 diabetes, including renal failure, vascular disease (including coronary artery disease), vision damage, etc. Type 2 diabetes is usually first treated by changes in physical activity (usually increase), diet (generally decrease carbohydrate intake, especially glucose generating carbohydrates), and through weight loss. These can restore insulin sensitivity, even when the weight loss is modest,

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for example, around 5 kg (10 to 15 lb), most especially when it is in abdominal fat deposits. The next step, if necessary, is treatment with oral antidiabetic drugs. As insulin production is initially unimpaired, oral medication (often used in combination) can still be used that improves insulin production (eg, sulfonylureas) and regulate inappropriate release of glucose by the liver (and attenuate insulin resistance to some extent (eg, metformin), and substantially attenuate insulin resistance (eg, thiazolidinediones). If these fail, insulin therapy will be necessary to maintain normal or near normal glucose levels. A disciplined regimen of blood glucose checks is recommended in most cases, most particularly and necessarily when taking most of these medications. GESTATIONAL DIABETES Gestational diabetes, Type 3, also involves a combination of inadequate insulin secretion and responsiveness, resembling type 2 diabetes in several respects. It develops during pregnancy and may improve or disappear after delivery. Even though it may be transient, gestational diabetes may damage the health of the fetus or mother, and about 20%–50% of women with gestational diabetes develop type 2 diabetes later in life. Gestational diabetes mellitus occurs in about 2%–5% of all pregnancies. It is temporary, and fully treatable, but, if untreated, may cause problems with the pregnancy, including macrosomia (high birth weight) of the child. It requires careful medical supervision during the pregnancy.

D. SYMPTOMATOLOGY SIGNS AND SYMPTOMS OF DIABETES MELLITUS

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Type 2 diabetes almost always has a slow onset (often years), but in Type 1, particularly in children, onset may be quite fast (weeks or months). Early symptoms of Type 1 diabetes are often polyuria (frequent urination) and polydipsia (increased thirst and consequent increased fluid intake). There may also be weight loss (despite normal or increased eating), increased appetite, and unreduceable fatigue. These symptoms may also manifest in Type 2 diabetes, though this seldom happens for some years, and sometimes not at all. Clincally, it is most common in Type 2 patients who appear at the doctor with frank poorly controlled diabetes. Another common presenting symptom is altered vision. Prolonged high blood glucose causes changes in the shape of the lens in the eye, leading to blurred vision and, perhaps. All unexplained quick changes in eyesight should force a fasting blood glucose test. Especially dangerous symptoms in diabetics include the smell of acetone on the patient's breath (a sign of ketoacidosis), Kussmaul breathing (a rapid, deep breathing), and any altered state of consciousness or arousal (hostility and mania are both possible, as is confusion and lethargy). The most dangerous form of altered consciousness is the so-called "diabetic coma" which produces unconsciousness. Early symptoms of impending diabetic coma include polyuria, nausea, vomiting and abdominal pain, with lethargy and somnolence a later development, progressing to unconsciousness and death if untreated. Signs and symptoms of diabetes mellitus are due to the high amounts of sugar in the body. The signs and symptoms of Type 1 diabetes develop quicker and become more severe than those of Type 2 diabetes. However, the symptoms of Type 2 diabetes may not be noticed until a regular medical checkup. The more severe the diabetes is, the more sugar is in the blood and the longer high blood sugar levels last. The high amount of sugar in the blood means that more urine is needed to carry it out of the body. As a result, people with diabetes usually experience a strong

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urge to pee, high amounts of urination (peeing), and constant thirst. The strong urge to pee can occur at night and lead to low amounts of sleep. A high amount of peeing also leads to high amounts of water and electrolyte loss. Electrolytes are chemical substances that are able to conduct electricity after they are melted or dissolved in water. For people with diabetes mellitus, the urine smells sweet because the extra sugar comes out in the urine flow. Weakness and tiredness occur because the cells in the body are not able to store or use the sugar that they need for energy. Thus, the body is being starved of one its main energy sources. The body still gets some energy, however, from breaking down stored fat. The breaking down of stored fat, in turn, leads to weight loss. Although people with diabetes mellitus can break down stored fat for energy, the body has a difficult time doing so. People with diabetes mellitus also have a difficult time breaking down proteins. The difficulty in breaking down fats, especially when the body does not produce insulin, can lead to the production of acids and poisonous chemical substances called ketones. This condition is known as ketoacidosis. Ketoacidosis is a medical emergency because it can cause coma, severe loss of body fluids, and even death. A coma is a state of deep unconsciousness in which there are no voluntary movements, no responses to pain, and no verbal speech. The signs and symptoms of ketoacidosis are nausea, vomiting, abdominal pain, confusion, deep breathing, and foul-smelling breath. The foul-smelling breath smells like nail polish remover. Emergency treatment for ketoacidosis includes giving the person fluids to correct for fluid loss and to bring back a normal chemical balance in the blood. Insulin injections are also given to allow cells to better absorb glucose from the blood. Ketoacidosis can occur in people with Type 1 and Type 2 diabetes. The difficulty with breaking down fats is especially true for

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people with Type 1 diabetes (see two sections down for a description) if they miss several doses of insulin or develop another disease. The reason for this is that developing another disease increases the body's use of insulin. Other symptoms of diabetes mellitus are blurry vision, increased hunger, boils, as well as tingling and loss of sensation in the feet and hands. Boils are inflamed, pus-filled areas of the skin. Pus is a yellow or green creamy substance sometimes found at the site of infections.

X. MEDICAL MANAGEMENT A. TREATMENT AND PROCEDURES Name: Sotto Benito Z., 54 years old, Filipino Hospital no: N98361 Date: 11 – 12 – 06 Ward: Surgical Ward, MS-04 Preoperative diagnosis: Diabetic Foot Gangrene at the left Operation: Below the Knee Amputation Post-operative diagnosis: Diabetic Foot Gangrene at the left Anesthetic: Spinal/ Saddle Analgesia Anesthetic started: 1:15 pm Operation started: 1:40 pm

Ended: 3:08 pm

B. MEDICATIONS Atenolol 50mg/tab 1 tab OD q 8am Tramadol 50mg/amp 1 amp IVTT q 6 hrs RTC

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Clindamycin 300mg/cap 1 cap q 6 hrs Humulin 70/30 35 ‘u’ SQ ACBF 15’u’ SQ AC supper Cataflam 50mg/tab 1 tab BID

C. DIAGNOSTIC PROCEDURES HEMATOLOGY Patient: Benito Z. Sotto

Room: MS-04

Physician: Dr. Luis Carlos Fanlo

November 12, 2006 LABORATORY RESULTS

TEST WBC NEU LYM MONO EOS BASO

RESULT 25.8 23.2 1.65 .857 .020 .083

UNIT 10^3/ul

REFERENCE 4.8-10.8

RBC HGB HCT MCV MCH MCHC Platelet

3.99 11.7 33.6 84.2 29.4 34.9 612

10^6/ul g/dl % Fl Pg g/dl 10^3/ul

M 4.7-6.1; F 4.2-5.4 M 14.0-18.0; F 12.0-16.0 M 42.0-52.0; F 37.0-47.0 M 80-94; F 81-99 27.0-31.0 33.0-37.0 130-400

Fasting Blood Glucose Total Cholesterol HDL Cholesterol Triglycerides VLDL Cholesterol LDL Cholesterol Glycosylated Hemoglobin

252 186 10 120 24 152 12.50

Mg/dl Mg/dl Mg/dl Mg/dl Mg/dl Mg/dl %

DATA

RESULT

RANGE 19

UNIT

Creatinine

0.48

0.6-1.5

Mg/dl

Sodium

130

134-148

mmol/L

Potassium

3.80

3.3-5.3

mmol/L

URINALYSIS MACROSCOPIC Color

=

amber

- within the normal range

Character

=

cloudy

- within the normal range

pH

=

6.0

- within the normal range

Sp Gravity

=

1.020

- within the normal range

Albumin

=

2.51

- not normal

Glucose

=

+2

- not normal

Protein

=

+1

- not normal

WBC

=

0-2/hpf

- within the normal range

RBC

=

1-3/hpf

- within the normal range

Epithelial cells

=

moderate

- within the normal range

Bacteria

=

few

- not normal

MICROSCOPE (per test)

D. DIET Breakfast: Full Diabetic Diet Lunch: Full Diabetic Diet Dinner: Full Diabetic Diet 20

XI. NURSING CARE MANAGEMENT A. ACTUAL CARE GIVEN Vital signs were taken and recorded in the patient’s chart. Input and output were measured and noted to determine and evaluate patient’s fluid balance. Medications were given as ordered by the physician. Pillows were placed on patients leg for support because patient undergone surgery in his knee. Massaging of both legs and feet of the patient was done. Patient was assisted to when getting up in the bed. I encouraged the patient to follow diet plan to prevent complications of Diabetes Mellitus. Advise patient to have regular exercise as to benefit from advantages of exercise. I taught the patient daily self-care skills to prevent acute fluctuations in blood glucose. Discuss with the patient the mechanism of action of his drugs and its side effects in order for the patient to know the benefits he could get if he complies with his medication regimen. I encouraged the patient to discuss feelings and fears related to complications. Support and encouragement was offered to the patient.

B. PROBLEMS ENCOUNTERED DURING MY NURSING CARE There were no problems encountered during the implementation of nursing care. The patient was very accommodating and was so easy to deal with. He answers questions asked by his student nurse. Also, his brother and children were hospitable that I felt I am part of their family. The patient is cooperative during nurse care like, taking vital signs, measuring I & O, administering medications and interviewing for assessment purposes.

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C. RESTORATIVE MEASURES USED In consonance of the very heart of nursing care, I have engaged a dozen of nursing measures. I had attended to his needs and talk to his about his health concerns; I helped him ease his anxiety. I encouraged him to sit up to his bed and assisted him as he gets up on bed. This is to hasten return of normal body circulation and peristaltic movement. I had also done measuring her intake and output of fluids as well as monitoring his vital signs. I also administered prescribed medications by the physician to aid him in his recovery. As a student nurse, I did health teaching on particular pharmacologic regimen and procedures to be done to the client to facilitate her well being and continue therapy. I also established rapport to the client and to his family to improve communication and nursing care to the patient.

D. EVALUATION 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. He, and his significant others showed positive attitude.

E. PATIENT TEACHING 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

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should be discussed thoroughly about the disease condition. Simple pathophysiology will do to increase patient’s knowledge about the disease condition. XII. A. CONCLUSION In making this care study, I really appreciate how vital our organs are, that we should be very careful in doing things, in every action we take, because it may result to damage of such organ. Diabetes Mellitus is a very complex disease process if not treated appropriately. Patients with such condition should know how to control his lifestyle, diet, and avoid factors that could worsen the condition. Through this case study we learned many things that are necessary and have relevance to our future career.

B. RECOMMENDATION This study aims to recommend a continued teaching to enhance skills and abilities of concerned people, and to develop a good quality loaded with knowledge. This is also to eradicate complications patients with Diabetes Mellitus

XIII. IMPLICATION OF THE STUDY TO A. NURSING EDUCATION The care 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.

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B. NURSING PRACTICE The care study provides a wider venue for nursing students to develop and enrich their skills and knowledge in rendering efficient and effective care. It sharpens our abilities in performing nursing measures to be rendered to our respective clients. Thus, provides us satisfactory exposure that can’t be paid by any means.

C. NURSING RESEARCH The care study helps in further investigation and research to optimize nursing care and expand the scope of nursing practice. Thus, continued investigation is further encouraged on the ultimate predisposing factor of having Diabetes Mellitus.

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