You are on page 1of 16

NURSING PROCESS FORMAT

Introduction to diabetes

Diabetes is the inability of the body to control the blood sugar level. High blood sugar levels are known as hyperglycemia this is
controlled by the hormone insulin. So having diabetes means there is interference with the creation and secretion of insulin. There
three types of diabetes

Type 1 diabetes

This first type of diabetes is known as Type 1 diabetes, what it means is that the person
with it is insulin dependent mellitus or has juvenile diabetes. It can be called juvenile
because of the age it is often acquired. It is not common to get Type 1 diabetes when
you have past your mid 20's.

This type of diabetes is also known as autoimmune disorder. That means the body
destroys cells that produce the insulin the reason for this is that it thinks that it is
harmful to the body. The cells are called the beta cells that are found in the islet cells
and are found in the pancreas. When the insulin producing cells get destroyed blood
sugar levels are not able to be regulated by the body so insulin has to be injected into
the body to perform this function.

Type 2 diabetes

The second type of diabetes or Type 2 diabetes, which is sometimes also known as
adult onset diabetes, this is because it was commonly found to occur in later life. It is
caused by insulin resistance. Beta cells in the pancreas continue to produce insulin but
the body needs more insulin than secreted to process the glucose or the insulin is less
effective in converting glucose into glycogen and thus reducing the blood sugar level.

It is not completely verified why Type 2 diabetes happens, being overweight seems to be
a common condition of most people that have Type 2 diabetes. There is a theory that a
lifestyle of eating unhealthy foods with out taking regular or adequate exercise could
contribute to causing this disease. it is also believed that type 2 diabetes can be hereditary, although the most documented advice on avoiding
type 2 diabetes is to lose weight, eat healthily and do more exercise.
Symptoms for diabetes Type 2

It is important to be aware that you could have diabetes and diabetes related problems without symptoms.

Type 3 diabetes

Third type of diabetes is Gestational diabetes this is acquired during pregnancy and is the product of hormonal changes in the body during the
pregnancy stage and also hereditary genes. this type 3 diabetes usually stops after childbirth.

CONCLUSION

The most common type of diabetes is type 2 diabetes it is estimated that 90% of diabetics suffer the type 2 diabetes ailment. There is also more
information on how to avoid and prevent type 2 diabetes than any of the others. Exercising more regularly and eating a healthy, balanced diet can
help considerably reduce the chances of getting diabetes. And if you have diabetes, exercise and healthy eating can make it less intrusive to your
lifestyle.
I. Biographic Data

Name: E.R.
Address: Tatalon, Quezon City
Gender: Male
Religious Affiliation: Roman Catholic
Marital Status: Married
Room and Bed #: 216A Occupation: none
Chief Complaint: Wound in the right foot
Provisional Diagnosis: Gangrene of the big toe and distal plantar area ®
Attending Physician: Dr. Nelson Dy / Emil dela Rosa

II. Nursing History


A. Past Health History
1. Childhood Illness – None
2. Immunizations - None
3. Allergies - None
4. Accidents - None
5. Hospitalizations
6. Medications used or currently taken
Motillium tablet TID 8-1-6
FeSO4 capsule TID 8-1-6
Cefuroxime 500 g / tab BID 8-6
Aminobrane 1 capsule BID 8-6
7. Foreign Travel ( when, length of stay) – None
B. History of Present Illness
Patient is a diagnosed case of DM Type II (2003), with irregular follow-up. Two weeks PTA, patient noted a
wound on the ® big toe. It was associated with on-and-off fever. No consultation done. One week PTA, the
signs and symptoms persisted. Few hours PTA, patient was brought to the attending physician who advised
admission.
C. Family History

D . 1987 D . 1983

f a the r m o the r
he a rt o ld
a tta c k age

D . 1997 1937 1939 1940 1944 19 4 7


68
71 67 63 60
e ld e s t ET w ife s is te r s is te r b ro the r
b ro the r D ia b e te s HTN/ HTN/ HTN/ TB/
kid ne y f a ilure a liv e a liv e aliv e a live

e ld e s t d a ug the r so n
so n a s thm a / w e ll/
w e ll/a liv e a liv e a liv e
V. Physical Assessment

General Appearance Norms Actual Findings Interpretation and Analysis


1. Posture/Gait Relaxed, erect posture; Slouched, and in bent posture. Poor posture distorts the body’s
coordinated movement proper vertical alignment and the
back’s natural curves. If you have
poor posture, your bones are not
properly aligned, and your
muscles, joints, and ligaments
take more strain than nature
intended. Faulty posture may
cause you fatigue, muscular
strain, and, in later stages, pain.
Many individuals with chronic back
pain can trace their problems to
years of faulty postural habits. In
addition, poor posture can affect
the position and function of your
vital organs, particularly those in
the abdominal region.

2. Skin Color Healthy appearance Pallor and weak in appearance Due to patient’s present health
condition he is experiencing
weakness and this is one of the
signs and symptoms of diabetes
mellitus II.

Personal grooming includes


3. Personal Hygiene/Grooming Clean, neat Unkempt activities such as showering,
dressing, toileting and attention to
personal presentation, such as
brushing hair, applying makeup
etc. due to his present condition
the patient is unable to undertake
personal grooming because of
underlying causes of diabetes, like
muscle weakness, easy
4. Nutritional Status fatigability.
Proportionate, varies with lifestyle Excessively thin
Due to his diabetes the patient
experiences polyphagia,
polydipsia, and polyuria, because
of this there is variation to his
5. Age Appropriateness nutritional status.
Adult age 71 years old
Genetic makeup influences
biologic characteristics, innate
temperament, activity level, and
intellectual potential. It has been
related to susceptibility to specific
disease, such as diabetes. The
distribution of disease. Certain
6. Verbal Behavior acquired and genetic diseases are
Understandable, moderate pace; Understandable, exhibits thought common in middle-aged males.
exhibits thought associations associations
No abnormalities found

7. Non-verbal Behavior
Cooperative, no distress noted Cooperative, no distress noted

No abnormalities noted

Measurements
1. Temperature 36.5 – 37.5 37.1 C Normal
2. Pulse Rate 60 – 120 bpm 73 bpm Normal
3. Respiratory Rate 14 – 24 bpm 23 bpm Normal
4. Blood Pressure 120/70 mmHg 110/70 mmHg Normal
5. Weight 45 kg
6. Height 153 cm

Body Part Norms Actual Findings Interpretation and Analysis


Hair White, fine,
Oval in shape, symmetrical, facial
Face expression is dependent on the
mood or true feelings, uneven with
wrinkles, no involuntary muscle
movements

Eyes Parallel and evenly placed,


symmetrical, non-protruding, with
scant amount of secretions, both
eyes black but patient does not
have clear vision, slowed blink
reflex
Eyebrows Black symmetrical, parallel to
each other
Eyelashes Black evenly distributed and
turned outward
Upper eyelids cover a small
portion of the iris and the cornea
Eyelids and the sclera when the eyes are
open. When the eyes are closed,
the lids meet completely.
Symmetrical in color is the same
as the surrounding skin.
Looseness of the eyelids.
No palpable mass
Clear without scalings, lacrimal
Lid Margins duct are evident at the nasal ends
of the upper and lower lids
Sclera White but not that clear
Iris Proportional to the size of the
eyes, round, black and
symmetrical
Eye Movement Not able to move eyes in full
range of motion and not able to
move in all directions
Parallel, symmetrical, proportional
Ears to the size of the head, bean-
shaped, is in line with the outer
canthus of the eye, skin is same in
color as the surrounding area
Firm cartilage
Ear Canal Pinkish, with scant amount of
cerumen and few cilia
Hearing Acuity Not able to hear spoken words,
you need to louder you voice and
repeat it again
Nose Midline, symmetrical,
Mouth (lips) Pinkish, symmetrical, lip margin
well defined, uneven and dry
Gums Pinkish, smooth, moist no
swelling, no discharge
Teeth Has denture and 1 tooth
Tongue Medium, pink, slight rough on top,
smooth along lateral margins,
moist but not freely movable
Neck Proportional to the size of the
head, symmetrical
Presence of internal jugular
vascular access(temporarily used
for hemodialysis), presence of
blister
Neck (ROM) Not freely movable
Thorax and Lungs No lumps, masses, areas of
tenderness
Has difficulty in breathing
Heart The heart sounds are audible at
apical area, cardiac rate is 72
Blemished skin, flat, symmetrical
movements caused by respiration,
Abdomen umbilicus is flat and positioned
midway between the xiphoid
process and the symphisis pubis,
color is the same as the
surrounding skin
Borborygmi sounds, “stomach
growling” heard
No tenderness, no lumps or
masses
Upper Extremities Dark skin, symmetrical, fine hair
Arms evenly distributed, presence of
visible veins, presence of vascular
access for hemodialysis on the
left arm.
Warm, dry, non-elastic, no areas
of tenderness, poor muscle tone
Palms and Dorsal Surfaces Non-elastic, dry and saggy
Nails Five fingers in each hand, brittle
Shoulders Has slight difficulty raising arms to
vertical position
Arms Has slight difficulty to abduct,
adduct, and rotate arms(internal
and external)
Elbows Bend and straighten elbows with
slight difficulty
Hands and Wrists Extend and spread fingers
Lower Extremities Fine hair evenly distributed,
Legs presence of varicose veins,
presence of edema
Poor muscle tone
ROM Difficulty in performing ROM

VI. Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation and


Analysis
04/15/08 Capillary Blood 80.00 – 110.00 mg/dl 128.00 mg/dl High
7:30am Glucose
04/14/08 Capillary Blood 80.00 – 110.00 mg/dl 150.00 mg/dl High
Glucose
04/13/08 Capillary Blood 80.00 – 110.00 mg/dl 442.00 mg/dl High
Glucose
04/14/08 AST/RBS/CBG 80.00-110.00 mg/dl 423.00 mg/dl High
04/13/08 AST/RBS/CBG 80.00-110.00 mg/dl 335.00 mg/dl High
04/12/08 AST/RBS/CBG 80.00-110.00 mg/dl 196.00 mg/dl High
04/03/08 RBS/CBG 80-120.00 mg/dl 162 mg/dl High
04/02/08 RBS/CBG 80-120.00 mg/dl 123 mg/dl High
Generic/ Dosage/Freque Classification Indication Contarindication Side Effects Nursing
trade ncy Responsibility
name
Humulin-N 10 units 6am, AC Hormonal drug Control  contraindicat GI: dry mouth  Don’t use insulin
Isophane 5 units 6pm PC hyperglycemia in ed during Metabolic: that changes
insulin patients with type II episodes of hyperglycemia color or becomes
suspension diabetes hypoglycemia clumped or
granular in
appearance
 Make sure that
the pt knows that
the drug relieves
symptoms but
doesn’t cure
disease
 Instruct pt about
the dse. and
importance of
following
therapeutic
regimen,
adhering to
specific diet,
losing weight,
getting exercise,
following
personal hygiene
program, and
avoiding
infection.
 Teach pt that
glucose level and
urine ketone test
provide essential
guides to dosage
and success of
the therapy. It’s
impt to pt to
recognize
symptoms of high
and low glucose
levels.
 Advise pt not to
smoke within 30
minutes after
insulin injection
bec. Smoking
decreases
amount of insulin
absorbed by
subcutaneous
route.
VIII. Anatomy and Physiology

Pancreas

The islets of Langerhans are destroyed in type I diabetes mellitus. This occurs probably as a consequence of a genetic susceptibility,
followed by the onset of autoimmune destruction triggered by some environmental factor such as a viral infection. Heavy lymphocytic
infiltrates appear in and around islets. The number and size of islets are eventually reduced, leading to decreased insulin production
and glucose intolerance.

The islets of Langerhans are normal in number or somewhat reduced with type II diabetes mellitus. Fibrosis and deposition of amylin
polypeptide within islets are most characteristic of the chronic states of type II diabetes.
XI. Prioritized List Nursing Problem

Date Nursing Problems Identified Cues Justification


April 16, 2008 Altered Nutrition less than body  verbalized dietary The state in which an individual
requirements related to concern experiences an intake of
insufficient intake to meet  weight under normal nutrients insufficient to meet
metabolic demands as  loss of weight with metabolic needs. As a
manifested by verbalized adequate food intake physiologic need an adequate
dietary concern  poor muscle tone intake of balance nutrients:
water, carbohydrates, proteins,
fats, vitamins, and minerals.
Nutrients have 3 major
functions: providing energy for
body processes and
movement, providing structural
material for body tissues, and
regulating body processes.
April 16, 2008 High risk for infection related to  Poor wound healing Clients with diabetes are
poor wound healing as susceptible to infections of
manifested by gangrenous foot many types. Once infection
occur, it is difficult to treat.
Because diabetes mellitus is
chronic, nursing intervention
focuses on teaching the client
and family how to manage the
disorder on a day-to-day basis
and how to assess
complications.
April 17, 2008 Knowledge deficit regarding  Lack of exposure This is a state where an
disease process related to  Unfamiliarity of individual lacks specific
development of preventable information resources information necessary to make
complications  Cognitive limitation choices regarding
condition/therapies/treatment.

XII. Nursing Care Plan

Nursing Problem Analysis Goal/Objectives Nursing Rationale Evaluation


Cues Interventions