University of Saint Anthony

College of Nursing
Iriga City







Diabetes Mellitus Type 2


A term paper submitted to

University of Saint Anthony
School of Graduate Studies and Research
Master of Arts in Nursing



In partial fulfillment of the requirements for the subject

N-246 Advance Medical-Surgical Nursing 1

Second Semester S/Y 2012-2013




Shindy G. Hibaez, RN
Student





Teresita M. Beria, RN, Ph D.
Professor
I. INTRODUCTION

1. Description

Diabetes mellitus is a group of metabolic diseases characterized by high blood
sugar (glucose) levels that result from defects in insulin secretion, or action, or both. In
patients with diabetes, the absence or insufficient production of insulin causes
hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be
controlled, it lasts a lifetime.

Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-dependent
diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is characterized by
high blood glucose in the context of insulin resistance and relative insulin deficiency.

Over time, diabetes can lead to blindness, kidney failure, and nerve damage.
These types of damage are the result of damage to small vessels, referred to as
microvascular disease. Diabetes is also an important factor in accelerating the hardening
and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease,
and other large blood vessel diseases.

There are an estimated 23.6 million people in the U.S. (7.8% of the population)
with diabetes with 17.9 million being diagnosed, 90% of whom are type 2. With
prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as
an epidemic.
World
Prevalence of diabetes worldwide




2000 2030
World 171,000,000 366,000,000
Philippines 2,770,000 7,798,000
Chan-Cua said the Philippines is still low on this score compared with
other countries, especially Scandinavian nations like Finland, Sweden, and Norway, but
we are also seeing an increase every year. Moreover, mathematical modeling on
projection yields that 380 million people are expected to develop diabetes by 2025 based
on International Diabetes Federation/World Health Organization data, a good percentage
will be coming from Southeast Asian countries, including the Philippines. This finding
is no longer astonishing considering the latest statistics on Filipinos afflicted with
diabetes and hypertension which continues to increase on the scale of medical records.
This goes to show that statistics on Diabetes Mellitus in the Philippines continues to be
unfavorable to the general population because of the continuous rise in the number of
Filipinos developing diabetes every year which adds to the number of people who
cannot enjoy life and are becoming less productive due to this disease.

Objectives
The researches have the following objectives in this case study:

Described and explained Diabetes Mellitus together with the risk factors
contributing to the occurrence of the condition.
Reviewed the anatomy and physiology of the organs involved.
Interpreted the results in the laboratory and diagnostic procedures done
with the patient including their purposes, and specific nursing
responsibilities before, during and after the procedure.
Enumerated the different medications administered for the condition, their
indications and specific nursing responsibilities.
Formulated significant nursing diagnoses, with their significantly related
nursing care plans.

II. NURSING HISTORY

1. PERSONAL HISTORY

a. Demographic data

Mr. Sugar, a 52 years old male who is not married and has no children, was born
on June 27, 1957 at Porac Pamapanga. He is pure Filipino. Mr. Sugar graduated Business
and Accountancy at the college of Holy Angel University. After graduation, he worked
for 16 years at Savers Bank Guagua. He presently resides at Baidbid, Porac Pampanga
with his younger brother.

b. Socio-economic and Cultural factors

Mr. Sugar used to work at the bank for 16 years. Due to a confidential incident at
work, Mr. Sugar was asked to leave the company. When he did, he decided to stay with
his brother and help at the bakery. He never smoked and used to drink. When he was
diagnosed, he stopped drinking. He regularly has a walk in the morning as a form of
exercise. He is not choosy in eating foods and loves to eat fruits regularly.

Mr. Sugar is a Roman Catholic. Last 3 years ago he made a habit of going to Apo
to visit the church there but rarely attends mass. Since he grows up at Porac, he usually
speaks the dialect Kapampangan and Tagalog.

When it comes to health practices, he usually practices self medicate when the
sickness isnt severe and tolerable. Paracetamol is the usual medications they use for
treating colds and colds. He doesnt use herbs or seek herbalarios or albularyo. If his
condition gets worse, medical attention is sought. He usually goes to Porac District
Hospital for check-ups and emergency cases. Aside from emergencies, he has an annual
check up with his private doctor.





2. FAMILY HEALTH ILLNESS HISTORY



Mr. Sugar is eight child of twelve children. Diabetes Mellitus runs in the family.
His grandfather and father had Diabetes 2 while his mother was diagnosed with
hypertension and died because of a stroke. Among his siblings, one has hypertension and
the two has Diabetes Mellitus while the others are almost at pre-hypertension. His brother
before him is his twin who experiences almost the same as he does.

3. HISTORY OF PAST ILLNESS
Mr. Sugar was a drinker before. When he is working, he noticed that he got really
weak and easily fatigue, so he decided to get a check up and was diagnosed to have
Diabetes Mellitus type 2 on 1985. Medications were given to control his situation such as
Metformin and a device such as Glucoplus to monitor his blood glucose.

Hypertension arised last 3 months ago and was prescribed a maintenance of Neoblock
one tab every morning and Combizar at night.

Mr. Sugar thought his medications would maintain his health but one month ago, his eyes
started to swell and the doctor said that it was diabetic retinopathy. Thus, he had
undergone laser therapy to prevent further damage.

4. HISTORY OF PRESENT ILLNESS
On November 13, 2009, Mr. Sugar started to have the feeling of fullness but
didnt affect his appetite. He also noticed that his bowel pattern started to change because
the urge to defecate is gone.
After 2 days, he started to vomit a lot of times. He mentioned that parang hindi
nadigest ang mga kinakain ko. Mr. Sugar was afraid to go to the hospital but his brother
noticed him getting weak and pale. He went to Porac District Hospital on November 17,
2009 at 7:30pm with a chief complaint of body weakness and abdominal pain.
Diagnostics exams were done and his tentative diagnoses were constipation, Diabetes
Mellitus type 2 and Pre-renal disease.
He was then admitted for observation and treatment. A stool softener, Senokot 2
tabs was prescribed so that he can eliminate and to lessen the abdominal pain. On
November 18, 2009 when the student nurses had their nurse-patient interaction, the
patient stated he defecated twice and the pain eased.

5. PHYSICAL EXAMINATION

November 17, 2009 (Admission)
Vital Signs: Bp- 160/110 mmHg; PR- 90bpm; RR- 19bpm; T- 36.4 C\
Chief complaint: Constipation and body weakness
General Appearance:

SKIN:
Pale
No lesions observed
Dry skin
HEENT:
Head
Hair is thin and quite moist, black with minimal white hair strands
Even distribution of hair
No dandruff observed
Eyes
Pale palpebral conjunctiva
Anicteric sclera
Patient has blurred vision
Ears
External canal is clean
No discharge noted
Nose
No discharge seen
Tongue and mouth
Incomplete set teeth
Pale lips
Dry lips
No breath odor
LUNGS:
Chest expands during inhalation
ABDOMEN:
Rigid upon palpation
MUSCULOSKELETAL:
No edema

November 18, 2009
Vital Signs: Bp- 170/90 mmHg; PR- 80bpm; RR- 20bpm; T- 36 C

General Appearance:
Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair
disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left
hand.
Assessment:

SKIN:
No lesions observed
Skin is moist and warm
HEENT:
Head
Hair is black with minimal white hair strands
Even distribution of hair
No dandruff observed
Eyes
Pale palpebral conjunctiva
Anicteric sclera
Patient has a blurred vision
Pupils are constrict when in light and dilates when the light is removed
Ears
External canal is clean
No discharge noted
Pinna recoils after it is folded (<2secs)
Nose
No discharge seen
Can breath with one nostril occluded
Tongue and mouth
Dry lips
Incomplete set of teeth
No breath odor
NECK:
Lymph nodes are palpable
LUNGS:
chest expands during inhalation
ABDOMEN:
Non-tender upon palpation
Flabby
With bowel movement (twice in one day as stated by patient)
GENITO-URINARY:
With urinary frequency
UPPER AND LOWER EXTREMITIES
With dry cracking fissures on the soles of the feet.
With non-pitting edema on both lower extremities
Capillary refill: 1-2 secs.


6. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostic/
Laboratory
Procedures
Date
Ordered
Date results
IN
Indication or
Purpose
Results Normal
Values
Analysis and
Interpretation
of results
Complete
Blood Count
(CBC)

WBC count







11/17/09









-Measures the
number of
WBCs in a cubic
mm of blood.
-It is used to
detect infection
or inflammation
and to monitor
clients response
to or adverse
effects of
chemotherapy or
radiation
therapy.




11.7 x
10g/L










5-10 x 10
g/L












The result is
slightly above
the normal
range which
may signify
infection.
Lymphocytes

-To determine
immune
function,
provides a gross
measure in
nutritional status.
0.21

0.20 - 0.40

The result is
within the
normal range.
Eosinophils

-To fight
infection and
control
mechanism
associated with
allergies and
asthma.
0.01

0.01 - 0.06

The result is
within the
normal range.
Hemoglobin

-To evaluate the
hemoglobin
content (iron
status and O2
carrying
capacity) of
erythrocytes by
measuring the
107g/L

140 - 180
g/L
The result is
below the
normal range
which
indicates
anemia.
no. of grams of
hemoglobin /dl
of blood.
Hematocrit - Measures the
volume of RBCs
in whole blood
expressed as a
percentage.
- It is also a
useful in the
diagnosis of
anemia,
polycythemia,
and abnormal
hydration states.
-Value is
roughly three
times the
hemoglobin
concentration.
0.32 0.40 0.54 The result is
below the
normal range
which
indicates
anemia.


Nursing Responsibilities:

Prior to the procedure:

Explain the procedure to the pt. and why it is indicated
Inform the patient that fluid and food restriction is not required
Inform the patient that a blood sample will be taken.
Tell the patient that he may experience transient discomfort from the needle
pincture
Fill up laboratory request form properly and send it to the laboratory technician
during the collection of sample/specimen.

During the procedure:
Inform the patient that pain may be felt through prick in the needle
Instruct the patient to calm down to avoid uneasiness.

After the procedure:
Apply brief pressure to prevent bleeding
Apply warm compress if Hematoma will develop at the venipuncture site.

Diagnostic/
Laboratory
Procedures
Date
Ordered
Date results
IN
Indication or
Purpose
Results Normal
Values
Analysis and
Interpretation
of results
Random
Blood Sugar
11/17/09





To measure
blood glucose
regardless of
when you last
ate.

145.3
mg/dl
< 140
mg/dl
The result is
above the
normal range
which
indicates too
little insulin/
diabetes
mellitus.

Nursing Responsibilities:
Prior to the procedure:
Inform patient that there are no food restrictions.
Wash your hands thoroughly before beginning procedure.
Ready your meter according to on-screen instructions or owner's manual (every
meter is slightly different).

During the procedure:
Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry
or dry with gauze.
Wipe away the first drop of blood
Squeeze slowly and rhythmically, gripping the digit firmly between the base of
thumb and first finger.

After the procedure:
Check for sample acceptance and allow time for the machine to work. Apply firm
pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
Record your glucose level and follow your physician's guidelines pertaining to
necessary actions for low or high glucose levels.

Diagnostic/
Laboratory
Procedures
Date
Ordered
Date results
IN
Indication or
Purpose
Results Normal
Values
Analysis and
Interpretation
of results
Kidney
Function
Test

Createnine
11/17/09








To monitor renal
function,
specifically the
ability of the
kidney to
excrete waste
products




3.7
mg/dl



0.4-1.4
mg/dl



Creatinine
level is above
the normal
range which
indicates
kidney
impairment.

Nursing Responsibilities:

Prior to the procedure:

Explain to the patient the purpose of the procedure.
Inform the patient that he need not restrict food or fluids before the test, NPO
post midnight
Check the patients history for use of drugs that may influence test results.
Inform the patient that the test requires blood sample. Explain whom will perform
the venipuncture and when it will be done
During the procedure:
Explain to the patient that may experience slight discomfort from the needle
puncture and the tourniquet but that collecting the sample usually takes less than 3
minutes
Instruct the patient to calm down to avoid uneasiness.

After the procedure:
Apply warm compress if Hematoma develops at the venipuncture site.
Apply pressure on the site to avoid bleeding.

Diagnostic/ Date Indication or Results Normal Analysis and
Laboratory
Procedures
Ordered
Date results
IN
Purpose Values Interpretation
of results
Serum
Electrolytes

Sodium (Na)





11/17/09









To reflect
water balance.



135.2
mmol/L






137 145
mmol/L






The result is
below the
normal range
which
indicates that
there is a
relative
increase in the
amount of
body water
relative to
sodium.
Potassium
(K)

To evaluate
fluid and
electrolyte
balances and
identify renal
dysfunction.
Potassium is
critical to
neuromuscular
function,
specifically
skeletal and
cardiac muscle
activity.
3.6
mmol/L

3.6 5.0
mmol/L

The result is
within the
normal level
which
indicates
normal
osmotic
pressure and
cardiac and
neuromuscular
electrical
conduction.
Chloride (Cl)

It reflects a
change in the
dilution or
concentration
of the ECF and
does so in
direct
proportion to
sodium
concentration.
97
mmol/L

96 110
mmol/L
The result is
within the
normal range
which
indicates
normal
balance of
fluids.

Before the procedure:
Explain to the patient that the test is used to evaluate the electrolytes content of
blood.
Inform the patient that he need not restrict food or fluids before the test, NPO
post midnight
Check the patients history for use of drugs that may influence test results.
Inform the patient that the test requires blood sample. Explain whom will perform
the venipuncture and when

During the procedure:
Explain to the patient that may experience slight discomfort from the needle
puncture and the tourniquet but that collecting the sample usually takes less than 3
minutes
Instruct the patient to calm down to avoid uneasiness.

After the procedure:
Apply warm compress if Hematoma develops at the venipuncture site.
Apply pressure on the site to avoid bleeding.

Diagnostic/
Laboratory
Procedures
Date
Ordered
Date results
IN
Indication or
Purpose
Results Normal
Values
Analysis and
Interpretation
of results
Fasting
Blood Sugar
(FBS)
11/18/09






To measure
blood glucose
after you have
not eaten for at
least 8 hours. It
often is the first
test done to
check and
monitor
treatment of
diabetes.
146
mg/dl
70 110
mg/dl
The result is
above normal
range which
indicates too
little insulin/
diabetes
mellitus.

Nursing Responsibilities:
Prior to the procedure:
Ask patient if he/she had not eaten at least 8 hours.
Wash your hands thoroughly before beginning procedure.
Ready your meter according to on-screen instructions or owner's manual (every
meter is slightly different).

During the procedure:
Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry
or dry with gauze.
Wipe away the first drop of blood
Squeeze slowly and rhythmically, gripping the digit firmly between the base of
thumb and first finger.

After the procedure:
Check for sample acceptance and allow time for the machine to work. Apply firm
pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
Record your glucose level and follow your physician's guidelines pertaining to
necessary actions for low or high glucose levels.

III. ANATOMY AND PHYSIOLOGY













Every cell in the human body needs energy in order to function. The bodys
primary energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food circulates
in the blood as a ready energy source for any cells that need it. Insulin is a hormone or
chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin
bonds to a receptor site on the outside of cell and acts like a key to open a doorway into
the cell through which glucose can enter. Some of the glucose can be converted to
concentrated energy sources like glycogen or fatty acids and saved for later use. When
there is not enough insulin produced or when the doorway no longer recognizes the
insulin key, glucose stays in the blood rather entering the cells.

Anatomy of the pancreas:
The pancreas is an elongated, tapered organ located across the back of the
abdomen, behind the stomach. The right side of the organ (called the head) is the widest
part of the organ and lies in the curve of the duodenum (the first section of the small
intestine). The tapered left side extends slightly upward (called the body of the pancreas)
and ends near the spleen (called the tail).
The pancreas is made up of two types of tissue:
Exocrine tissue
The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a
network of ducts that join the main pancreatic duct, which runs the length of the
pancreas.
Endocrine tissue
The endocrine tissue, which consists of the islets of Langerhans, secretes
hormones into the bloodstream.

Functions of the pancreas:
The pancreas has digestive and hormonal functions:
The enzymes secreted by the exocrine tissue in the pancreas help break down
carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel
down the pancreatic duct into the bile duct in an inactive form. When they enter
the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate
to neutralize stomach acid in the duodenum.
The hormones secreted by the endocrine tissue in the pancreas are insulin and
glucagon (which regulate the level of glucose in the blood), and somatostatin
(which prevents the release of the other two hormones.


Anatomy of kidney

The kidneys play key roles in body function, not
only by filtering the blood and getting rid of waste
products, but also by balancing levels of electrolytes in the
body, controlling blood pressure, and stimulating the
production of red blood cells.
The kidneys are located in the abdomen toward the
back, normally one of each side of the spine. They get their blood supply through the
renal arteries directly from the aorta and send blood back to the heart via the renal veins
to the vena cava. (The term "renal" is derived from the Latin name for kidney.)
The kidneys have the ability to monitor the amount of body fluid, the
concentrations of electrolytes like sodium and potassium, and the acid-base balance of
the body. They filter waste products of body metabolism, like urea from protein
metabolism and uric acid from DNA breakdown. Two waste products in the blood can be
measured: blood urea nitrogen (BUN) and creatinine (Cr).
Kidneys are also the source of erythropoietin in the body, a hormone that
stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor
the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the
body starts to manufacture more red blood cells.

Pre-disposing Factors:
Age > 40 y/o
Hereditary
Race (African-Americans, Hispanic
Americans)
Precipitating Factors:
Obesity
Lifestyle
Diet
Environmental Stress
Destruction of Beta-cells in the
pancreas
production of
insulin
insulin
resistance
Hyperglyce
mia
Hyperosmolarity of
serum
Insufficient intracellular
glucose supply
Chronic elevation of blood
glucose
Renal threshold for
glucose reabsorption
Satiety center responds
by increasing appetite
Glucose become
glycoproteins
Accelerated
atherosclerosis
in the blood vessel walls
Polyphagi
a
Aability of the kidney to
reabsorb glucose was
surpassed
blood flow is blocked
pressure against the blood
vessels
Decrease
energy
production
Weakness/
fatigue
IV. THE PATIENT AND HIS ILLNESS
a. Schematic diagram
Pathophysiology (bookbased)







b.1. Definition of the disease
Diabetes Mellitus
Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly
known as adult-onset diabetes, it usually affects people aged over 40 and
progresses gradually. In this type the pancreas has not ceased to produce insulin,
but the quantity is insufficient, or the hormone is not stimulating the glucose
uptake in muscles and tissues required for energy. The result is a build-up of
glucose in blood and urine.
Although the cause of this malfunctioning is unclear, non-insulin
dependent diabetes mellitus tends to run in families. Other risk factors, such as
increasing age, obesity, and a sedentary lifestyle, probably contribute to its
increased incidence in developed countries.
Non-insulin dependent diabetes mellitus can often be controlled initially
by diet alone, or in combination with tablets that reduce the amount of blood
glucose. There are two main types of blood glucose-reducing drugs:
sulphonylureas work mainly by stimulating the pancreass islet cells (known as
the islets of Langerhans) to produce more insulin and biguanides increase the
effectiveness of insulin on cells. Eventually, however, patients may need insulin
injections.

Prerenal Acute Renal Failure
It is categorized as an acute renal failure which is characterized by inadequate
blood circulation (perfusion) to the kidneys, which leaves them unable to clean
the blood properly. Many patients with prerenal ARF are critically ill and
experience shock (very low blood pressure).There often is poor perfusion within
many organs, which may lead to multiple organ failure.
Prerenal ARF is associated with a number of preexisting medical
conditions, such as atherosclerosis ("hardening" of the arteries with fatty
deposits), which reduces blood flow. Dehydration caused by drastically reduced
fluid intake or excessive use of diuretics (water pills) is a major cause of prerenal
ARF. Many people with severe heart conditions are kept slightly dehydrated by
the diuretics they take to prevent fluid buildup in their lungs, and they often have
reduced blood flow (underperfusion) to the kidneys
b.2. Predisposing Factors
Age - Type 2 DM usually occurs at the age 40 years old and above. Type 2 DM
occurs most commonly in people older than 30 years who are obese.
Family history of DM - Type 2 DM has a strong genetic component. Although the
major gene that places the patient at risk is not yet identified, it is clear that the
disease is polygenic and multifactorial. Individuals with a parent with type 2 DM
have an increased risk for diabetes. Genetic factors are thought to play a role in
insulin rsistance and impaired insulin secretion in type 2 DM.
Race (African-Americans, Hispanic-Americans) - The risk for type 2 diabetes
varies among population groups. Diabetes also seems to pose higher or lower
risks for specific complications among racial groups.

Precipitating Factors
Obesity - Elevated levels of free fatty acids, a common feature of obesity, may
contribute to the pathogenesis of type 2 DM. It can impair glucose utilization in
skeletal muscles, promote glucose production by the liver and impair beta cell
function.
Environmental Factors/Stress An increase in stress hormone triggers the release
of epinephrine and norepinephrine which will promote the secretion of glucose
leading to hyperglycemia.
Inactive Lifestyle A risk factor that had contributed in the occurrence of DM
due to the fact that lack of muscle activities decreases the need for the body to
utilize glucose as a form of energy.
Diet Foods rich in carbohydrates can easily promote the increasing level of
glucose along the bloodstream.


Prerenal Risk Factors
Atherosclerosis cause obstruction to the flow of blood reaching the kidneys
Blood loss can lead to the constriction of the arteries carrying blood throughout
the body, reducing the volume of blood reaching various organs including the
kidney
Heart disease can lead to a reduction in the pumping effect of the heart, reducing
the amount of blood reaching the kidneys and other organs.
b.3. Signs and Symptoms with Rationale
Diabetes Mellitus
HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)
May be due to lack of physiologically active insulin that transports
glucose from extracellular to intracellular leading to accumulation of
glucose in the intravascular space. The glucose is not utilized by the body
and it remains in the blood streams.
POLYURIA
Increased frequency of urination. This may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.
POLYDIPSIA
Increased thirst and fluid intake. This may be due to the activation of the
thirst center in the hypothalamus resulting form the intracellular
dehydration or volume depletion.
POLYPHAGIA
Increased hunger and food intake. This may be due to the decrease glucose
uptake by the cells leading the stimulation of the satiety center in the
hypothalamus resulting to the hunger sensation.
WEAKNESS/ FATIGUE
This is due to the decreased glucose uptake by the cells leading to
decreased energy production.


GLYCOSURIA
The kidney filters the blood, making it to its normal state. Glucose was
filtered out and excreted in the urine.
Due to the excess glucose ad compared to the kidney threshold, which
results to the excretion of glucose in the urine.
GASTROPARESIS (Stomach fullness) ,CONSTIPATION and BLOATING
This is due to changes in nerves and damages the blood vessels that carry
oxygen and nutrients to the nerves. Over time, high blood glucose can
damage the vagus nerve. The stomach fails to empty properly and is likely
due to the generalized neuropathy.
NAUSEA/ VOMITING
Due to stomach fullness, there will be an involuntary emptying of
stomach contents that are forcefully expelled by the mouth.
A compensatory mechanism due to acidity of body because of decrease
excretion of metabolic waste.
PALE
Due to decreased production of erythropoietin.


a. Schematic diagram of the disease
PATHOPHYSIOLOGY(client-centered)




b.1. Predisposing/ Precipitating Factors
Predisposing Factors
Age- 52 years old.
Heredity- patients grandfather and father has DM
Precipitating Factors
Sedentary lifestyle

b.2. Signs and Symptoms
Gastroparesis( Stomach fullness) and Constipation
o November 13, 2009
o This is due to changes in nerves and damages the blood vessels
that carry oxygen and nutrients to the nerves. Over time, high
blood glucose can damage the vagus nerve. The stomach fails to
empty properly and is likely due to the generalized neuropathy.
Nausea/vomiting
o November 15, 2009
o Due to stomach fullness, there is a involuntary emptying of
stomach contents that are forcefully expelled by the mouth.
o A compensatory mechanism due to acidity of body because of
decrease excretion of metabolic waste.
Hyperglycemia
o November 17, 2009
o Due to lack of physiologically active insulin that transports
glucose from extracellular to intracellular will lead to
accumulation of glucose in the intravascular space. The glucose is
not utilized by the body and it remains in the blood streams.
Hypertension
o November 17, 2009 160/110 mmHg
o Due to increase in osmotic pressure, fluid goes to the vascular
space increasing the blood volume.
Weakness/fatigue
o November 17, 2009
o Due to decreased glucose uptake by the cells leading to decreased
energy production.
Pale
o November 17, 2009
o Due to decreased production of erythropoietin.

V. PATIENT AND HIS CARE
1. Medical Management
a. IVF
Medical
Management
Treatment
Date Ordered/
Date
Performed/
Date
Changed/
D/C
General
Description
Indication or
Purpose
Clients
response to the
treatment
Plain Normal
Saline
Solution
(PNSS)
1L x
40gtts/min.







11/17/09








An aqueous
solution of 0.9
percent sodium
chloride,
isotonic with the
blood and tissue
fluid, used in
medicine chiefly
for bathing
tissue and, in
sterile form.



It can be used for
hydration, and,
as a solvent for
drugs that are to
be administered
parenterally.
The drug was
administered
properly, with
expected effects
achieved, and
the patient did
not experience
dehydration.

Nursing Responsibilities:
Prior the procedure:
Read the doctors order
Check IV label
During the procedure:
Check for patency of tubing
Regulate as ordered
After the procedure:
Check IV infusion and amount every 2 hours



b. Drugs
Name of Drug
Date
Ordered/
Date Taken/
Date
Changed/
D/C
Route of
administration,
Dosage and
Frequency of
administration
General Action,
Classification
Mechanism of
Action
Clients
response to the
medication

Generic Name:
metoclopramide

Brand Name:
Plasil






11/17/09









1 amp, IV
STAT then q 8


An anti-emetic
drug that blocks
dopamine, but also
stimulates
acetylcholine to
increase gastric
emptying. It
increases the force
of gastric
contraction, relaxes
pyloric sphincter,
and increases
peristalsis in the
duodenum and
jejunum without
affecting the
motility of the
large intestine.

The patient did
not vomit the
day after the
medication was
given and has
bowel
movement.

Nursing Responsibilities:
Prior to Administration
-Check patients name before administration
-Check the doctors order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.
After Administration
-Monitor bowel movement.
-Instruct patient not to drink alcohol during therapy.
Name of
Drug
Date
Ordered/
Date Taken/
Date
Changed/
D/C
Route of
administration,
Dosage and
Frequency of
administration
General Action,
Classification
Mechanism of
Action
Clients
response to the
medication

Generic
Name:
Senna


Brand Name:
Senokot





11/17/09






2 tabs,


It is laxative that is
used as a short-term
treatment of
constipation and to
evacuate the colon
for bowel or rectal
examinations.

The patient had
defecated.
Prior to Administration
-Check patients name before administration
-Check the doctors order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.
After Administration
-Monitor bowel movement.
-Instruct patient not to drink alcohol during therapy.

Name of Drug
Date
Ordered/
Date Taken/
Date
Changed/
D/C
Route of
administration,
Dosage and
Frequency of
administration
General Action,
Classification
Mechanism of
Action
Clients
response to the
medication

Generic
Name:
metoprolol


Brand Name:
Neobloc





11/17/09









1 tab, PO, OD


Metoprolol is in a
group of drugs
called beta-
blockers. It is a
selective inhibitor
of beta1-adrenergic
receptors affecting
the heart and
circulation. It is
used to treat angina
and hypertension.

Patients blood
pressure is still
high. From
160/110 mmHg
upon admission
rises to 170/ 90
mmHg.
Nursing Responsibilities:
Prior to Administration
-Check patients name before administration
-Check the doctors order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.

After Administration
-Monitor for signs of tachycardia, palpitations and especially blood pressure
-Instruct patient to sit before standing

Name of
Drug
Date
Ordered/
Date Taken/
Date
Changed/
D/C
Route of
administration,
Dosage and
Frequency of
administration
General Action,
Classification
Mechanism of
Action
Clients
response to the
medication

Generic
Name:
losartan


Brand Name:
Combizar





11/17/09









1 tab, PO, OD


Losartan is in a
group of drugs
called angiotensin II
receptor
antagonists.
Losartan keeps
blood vessels from
narrowing, which
lowers blood
pressure and
improves blood
flow. It is also used
to slow long-term
kidney damage in
people with type 2
diabetes who also
have high blood
pressure


Patients blood
pressure is still
high. From
160/110 mmHg
upon admission
rises to 170/ 90
mmHg.

Nursing Responsibilities:
Prior to Administration
-Check patients name before administration
-Check the doctors order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.

After Administration
-Monitor for signs of tachycardia, palpitations and especially blood pressure
-Instruct patient to sit before standing

Name of Drug
Date
Ordered/
Date Taken/
Date
Changed/
D/C
Route of
administration,
Dosage and
Frequency of
administration
General Action,
Classification
Mechanism of
Action
Clients
response to the
medication

Generic
Name:
metformin


Brand Name:
Glucophage




11/17/09









1 tab, PO, OD


It decreases hepatic
glucose production,
decreasing
intestinal absorption
of glucose and
improves insulin
sensitivity

Glucose level of
the patient may
decrease. ( No
available data)

Nursing Responsibilities:
Prior to Administration
-Check patients name before administration
-Check the doctors order
-Prepare the medication as ordered.
-Explain the purpose, indication and possible adverse effects of the medication.

During Administration
-Instruct the patient to calm down to avoid uneasiness.

After Administration
-Monitor glucose level closely in this patient because severe hypoglycemia may result
before the patient develops symptoms.
-Advice patient to avoid vigorous exercise immediately after dose.
-Inform patient to avoid alcohol, which lowers glucose level.
c. Diet
Type of diet
Date started/
Date changed
General
description
Indication or
purpose.
Clients
response and/or
reaction to the
diet
Nothing per
orem (NPO)
11/17/19 It is a type of
diet that
withholds oral
fluids and
foods.
Indicated for
patients unable
to consume a
regular diet and
patients wild
mild G.I.
problems.
Since the patient
was oriented
and understands
needed
interventions, he
followed with
the doctors
prescriptions.
Nursing Responsibilities
Prior
Verify doctors order.
Explain the diet prescribed to the patient.
Instruct patient to withhold oral fluids and foods.
During
Ensure that the patient strictly follow the diet.
After
Assess for patients condition; how he responds to the diet.

d. Exercise/ Activity

Type of
exercise
General
description
Indication or
Purpose
Date
Ordered,
Date
Started,
Date
Changed or
D/C
Clients Response
and/or reaction to
activity
Keep rested An activity
where strenuous
activities should
be avoided. Bed
rest should be
implemented
but with
Indicated to
avoid fatigue.
11/17/09



Patient responded
to doctors order
and stated
decreased body
weakness.
assisted
bathroom
privilege to
avoid further
aggravation of
the gangrene
and to reduce
pain as well.

Nursing Responsibilities
Prior
Check doctors order for any other considerations needed.
Explain the activity to the patient.
Explain why it is important and what it could improve in her condition.
During
Assess patients present condition.
Reinforce information as appropriate.
After
Note patients response to activity.



NURSING CARE PLAN
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
Subjective:
Risk for After 8 hours Observe for signs Patient may be After 8
infection Type 2 diabetes of nursing of infection and admitted with hours of
Hindi gumagaling related to high mellitus occurs interventions, inflammation. infection, which nursing
ang sugat ko (My glucose levels, when the the patient could have intervention
wounds are not
decreased pancreas will identify precipitated the s, the
healing) as
leukocyte produces interventions ketoacidotic patient was
verbalized by the
function. insufficient to prevent or state, or may able to
patient.
amounts of the reduce risk develop a identify
hormone insulin of infection. nosocomial intervention
Objective:
and/or the body's infection. s to prevent
tissues become
or reduce
Flushed
resistant to normal Promote good Reduces the risk of
appearance.
or even high handwashing by risk of cross- infection.
levels of insulin. nurse and patient. contamination
Wound
This causes high
drainage. blood glucose
Maintain aseptic High glucose in
(sugar) levels, technique for IV the blood
V/S taken as which can lead to insertion creates an
follows: a number of
procedure, excellent
complications if administration of medium for
T:37.4 untreated. medications, and bacterial
P:87
providing growth.
R:19
maintenance and
BP: 120/90
site care. Rotate
IV sites as
indicated.

Provide catheter Minimizes the
or perineal care. risk for
Teach the female infection.
patient to clean
from front to back
after elimination.

Provide Peripheral
conscientious circulation may
skin care, gently be impaired,



massage bony placing patient
areas. Keep the at increased
skin dry, linens risk for skin
dry and wrinkle irritation or
free. breakdown and
infection.


Place in semi - Facilitates lung
fowlers position. expansion and
reduces risk of
aspiration.


Encourage Decrease
adequate dietary susceptibility to
and fluid intake of infection.
3000 ml per day.

Collaborative:
Obtain specimen Identifies
for culture and organisms so
sensitivities as that most
indicated. appropriate
drug therapy
can be
instituted.



VII. DISCHARGE PLANNING
1. General Condition of the Client
Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair disheveled,
with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left hand. He reported that
he had already two bowel movements.
2. METHODS
M-edication
Metoprolol 1tab PO,OD
Losartan 1tab PO,OD
Metformin 1tab PO,OD

E-xercise
Instruct to exercise at least 3 days a week and avoid strenuous activity.
>Regular exercise, even of moderate intensity (such as brisk walking), improves
insulin sensitivity and may play a significant role in preventing type 2 diabetes
T-reatment
Follow-up check up on his private doctor.
H-
Instruct pt. to comply with the given diet.
Explain the importance of exercise in maintaining or losing weight.
Advise patient to check blood glucose level before doing any activities and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
>Blood glucose levels should be monitored before and after exercise to establish
blood glucose response patterns to the exercise regimen. If blood glucose is >250
mg/dl, the patient should delay the exercise session.
O-PD follow-up
D-iet
Diabetic Diet
>Carbohydrates should provide 45 - 65% of total daily calories. Best choices are
vegetables, fruits, beans, and whole grains. These foods are also high in fiber.
Carbohydrate counting or meal planning exchange lists.
>Fats should provide 25 - 35% of daily calories. Limit saturated fat.
>Protein should provide 12 - 20% of daily calories, although this may vary
depending on a patient individual health requirements
Avoid eating too much sweet foods.
Eat foods rich in fiber such as banana.
VIII. CONCLUSION
In this study, the student nurses aim is to understand the disease more, manifestations,
risk factors and complications. Diabetes mellitus is a condition in which the pancreas no longer
produces enough insulin or cells stop responding to the insulin that is produced, so that glucose
in the blood cannot be absorbed into the cells of the body.
Mr. Sugars diabetes mellitus was caused mainly by his sedentary lifestyle, his food
preference and due to hereditary factor since his grandfather and his father both had diabetes.
Diabetic retinopathy, a complication of diabetes mellitus, also occurred and Mr. Sugar opted to
undergo laser therapy a month ago.

It is best managed with a team approach to empower the client to successfully manage
the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the
various health disciplines involved; provides care and education and promotes the clients health
and well being. Diabetes is a major public health worldwide. Its complications cause many
devastating health problems.

Through this case study, we should be able to learn and understand the disease Diabetes
Mellitus type 2 and therefore give us knowledge in proper management, prevention and
treatment. As a student nurse, it is very important to know many things including the said disease
condition. After the hardships of completing our case study, a reward of self-fulfillment and
credential to our knowledge and skills has been added to us being student nurses as well as
professionals in the near future.



IX. RECOMMENDATION
The researchers would recommend the further study of this case as this is a disease that is
interesting. It would be better if another causative factor would be studied to be able to provide
diverse information about this disease and to be able to compare to spot similarities and
differences in the manifestations of this disease if there is a different causative factor. To be able
to appreciate the physical manifestations of this disease, we advise future researchers to
investigate this case on the onset of the disease to be able to assess and note more overt
manifestations both for educational and documentation purposes.
X. BIBLIOGRAPHY
http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes
http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm
http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-
philippines-and-worldwide/
http://nursingcrib.com/diabetes-mellitus-case-study/
Brunner&Suddarth.Textbook of medical-surgical nursing.2008.Lippincott Williams &
Wilkins.