Autoimmune Insulin Dependent Diabetes Mellitus (Type 1 Diabetes Mellitus) :
Diadetes Mellitus
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Transcript of Diadetes 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 (Non-
Insulin 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.
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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.
12 Abdomen Flabby, soft and non-tender
13 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
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 Position in the family
Educational attainment
Occupation General Health status
Benito Sotto 54 yrs old Father 2nd yr H.S. None Unhealthy
Diomedes Sotto
66 yrs old Mother College of Educationgraduate
Teacher Healthy
Vincent Sotto 31 yrs old Eldest child 2nd yr College N/A Healthy
Debbie Sotto 30 yrs old 2nd child College of Teacher Healthy
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Education graduate
Larrafe Sotto 27 yrs old 3rd child 2nd yr College N/A Healthy
Disebel Sotto 25 yrs old 4th child 3rd yr College N/A Healthy
Adelfa Sotto 23 yrs old 5th child College of Education graduate
Teacher Healthy
Domagit Sotto
22 yrs old Youngest child
College of Marine Trans. graduate
Seaman 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.
1 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
5 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
6 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 post-
operative pain, has uniform color, not tender and has no lesions, nasal
septum intact and in the midline, breaths freely and regularly
8 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.
9 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.
11 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.
12 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.
13 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
16 MALE GENITALS AND REPRODUCTIVE TRACT Even distribution of pubic hair,
pubic skin intact and has no lesions.
VIII. DEVELOPMENTAL DATA
Age Development Patient’s BehaviorInfancy
(birth to 18 months)
Trust vs. Mistrust Reported that he grew up normally as a young
kid, demonstrated a normal steady growth.
Nourished with breast milk for a year and a half. Toddler
(18 months to 3
years)
Autonomy vs. Shame
and Doubt
Can fully walk alone without holding onto
support bars at the age of 1 year and 8 months.
Was claimed to be very anxious about many
things and enjoys playing alone. Very
negativistic about many things.Preschooler
(4 to 5 years old)
Initiative vs. Guilt Play was the most important activity of the day.
Started to go along with peers and look for
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adventures. At this age, she can manage to wash
himself alone and toilet training was established. School Age
(6 to 12 years old)
Industry vs.
Inferiority
Started grade 1 at the age of 6 years old. He
enjoyed the company of his friends and also
loves to study. Shows interest in studying and
playing.Adolescent
(12 to 18 years old)
Self-Identity vs. Role
confusion
This was marked as the most memorable time of
the patient’s life especially that at this stage, she
had already experienced boy to girl relationship.Early adult
(20 to 40 years old)
Intimacy vs. Isolation Already go married at the age of 22 years old.
And he had 6 children; some were already
professional and some got married and have
children too.At Present 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.
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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 → acetoneosmolarity protein and fat stores breathdue to glucose ↓
↓ Wasting of lean body mass → fatigue ↓ ↓ ↓ ↓Polydipsia Polyuria Polyphagia Weight loss
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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 RESULT UNIT REFERENCEWBC 25.8 10^3/ul 4.8-10.8NEU 23.2LYM 1.65MONO .857EOS .020BASO .083
RBC 3.99 10^6/ul M 4.7-6.1; F 4.2-5.4HGB 11.7 g/dl M 14.0-18.0; F 12.0-16.0HCT 33.6 % M 42.0-52.0; F 37.0-47.0MCV 84.2 Fl M 80-94; F 81-99MCH 29.4 Pg 27.0-31.0MCHC 34.9 g/dl 33.0-37.0Platelet 612 10^3/ul 130-400
Fasting Blood Glucose 252 Mg/dlTotal Cholesterol 186 Mg/dlHDL Cholesterol 10 Mg/dlTriglycerides 120 Mg/dlVLDL Cholesterol 24 Mg/dlLDL Cholesterol 152 Mg/dlGlycosylated Hemoglobin 12.50 %
DATA RESULT RANGE UNIT
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Creatinine
Sodium
Potassium
0.48
130
3.80
0.6-1.5
134-148
3.3-5.3
Mg/dl
mmol/L
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
MICROSCOPE (per test)
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
D. DIET
Breakfast: Full Diabetic Diet
Lunch: Full Diabetic Diet
Dinner: Full Diabetic Diet
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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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