BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

A study on the case of MRS.LV diagnosed with Type 2 Diabetes

Mellitus

SUBMITTED BY: BSN-3C Group#1

Alipio, Joana Marie E.
Amado, Erika Patricia B.
Antonio, Sunshine V.
Arnedo, Mari Fe
Balgos, Ana Margarita M.
Baltazar, Alona N.
Bautista, Jenna V.
Belizario, Marjorie Anne M.
Cabral, Romeo A.
Cuanico, Dea Karell F.
Matsuoka, Miguel

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SUBMITTED TO:
LEVEL THREE INSTRUCTORS

I.

INTRODUCTION
This case study is all about L.V, a 56 year old patient who diagnose with a Type 2 Diabetes Mellitus along with a
urinary tract infection at Bulacan Medical Center on December 19, 2012, with a chief complain of dizziness, weakness
and difficulty in breathing.
Diabetes Mellitus or simply diabetes, is a group of metabolic diseases characterized by increased levels of
glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Diabetes has its
major classification which varies in cause, clinical course, and treatment. These are the type 1 DM, type 2 DM,
gestational diabetes, and diabetes mellitus associated with other conditions or syndromes.
Type 2 diabetes mellitus or commonly known as Non- insulin dependent or an adult onset type described as a
relative deficiency of insulin production and a decreased insulin action and/or increased insulin resistance. It occurs
more commonly among people who are older than 30 years of age and obese although its incidence is rapidly
increasing in younger people that is because of the growing epidemic of obesity in children, adolescence and young
adults.
The clinical manifestations are depending on the patients level of hyperglycemia. It includes polyuria (increased
urination) and polydipsia (increased thirst) occurs as a result of excess loss of fluid associated with osmotic dieresis.
Patients also suffers polyphagia (increased appetite) that is the results from the catabolic state induced by insulin
deficiency and the breakdown of proteins and fats. Other manifestations such as fatigue, weakness, sudden vision
changes, tingling or numbness in hands or feet, dry skin and recurrent infections are noted.
Several procedures like fasting plasma glucose, random plasma glucose and glucose level two hours after
receiving glucose (2- hour postload) may indicate an abnormally high blood glucose level which is considered to be the
basic criterion for the diagnosis of diabetes. The major goal of the diabetes treatment is to normalize the insulin activity
and blood glucose level to reduce the development of vascular and neuropathic complications without patient
experiencing hypoglycemia: nutritional therapy, exercise, monitoring, pharmacologic therapy and education which are
the essential components of diabetic regimen.

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The incidence of diabetes is growing around the world. It is in the top ten leading causes of deaths. Filipinos are
not an exemption to this incidence as more and more Filipinos are affected by the disease. According to the survey
conducted by the Philippine Cardiovascular outcome study on Diabetes Mellitus in 2007 found out that 20.6 percent of
adults aged 30 and above were found to be diabetic. In 1998 only 3.9 percent of Filipinos living in the Philippines had
diabetes. On the other hand, the prevalence of diabetes according to the NNHES (National Nutrition Health Survey)
study is 4.8%.

REASONS OF STUDY
The group chose type 2 diabetes mellitus as our case study because aside from it is still fresh in our minds; our
group was interested in studying this. We are willing to do this case to challenge our own minds in analyzing the
problem and to enhance our knowledge, as well as to gain new experiences which could bring new learnings for the
group. This case study will also help the group in understanding the disease process of the patient. It would also help
the group in identifying the primary needs of the patient with a type 2 Diabetes Mellitus. By identifying such needs
and health problems arise the group can now formulate an individualized Nursing care plan for the patient that
would address these needs and problems effectively. Management of the identified problem will help the patient to
recover faster and maintain holistic sense of wellness. This will also equip the group with knowledge, skills and
attitude on how to manage future patient with the same disease.

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II.

OBJECTIVES

STUDENT- CENTERED
GENERAL OBJECTIVES
The purpose of this case study is to give the much needed knowledge and awareness to the nursing students who have or
might have handled cases of Type II Diabetes Mellitus associated with Urinary Tract Infection.

SPECIFIC OBJECTIVES
(STUDENT-CENTERED)
KNOWLEDGE:
To be able to have a better understanding at the case of the patient having a type 2 Diabetes Mellitus
associated with Urinary Tract Infection and the occurrence of its signs and symptoms.
To be able to know the disease process through its pathophysiology.
To be able to be knowledgeable about the patient drug study.
SKILLS:

ATTITUDE:

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To be able to formulate nursing care plans based on the prioritized health needs of the client.
To be able to discuss about the pathophysiology of the disease process.
To be able to familiarize on the aggravating factors and specific interventions to prevent complications
of Type 2 diabetes Mellitus and Urinary Tract Infection.
To be able to change any misconception about the said disease of the patient.

To be able to develop awareness in the proper care management for type 2 diabetes mellitus and urinary
tract infection.
To be able to serve our future clients with a higher level of holistic understanding as well as
individualized care.

(CLIENT-CENTERED)
GENERAL OBJECTIVES
This case study implies knowledge and awareness to people who have or might be at risk of the said
disease regarding its fatality and detection.
SPECIFIC OBJECTIVES
KNOWLEDGE:
To be able to impart knowledge regarding type 2 Diabetes Mellitus and Urinary Tract Infection.
To be able to determine signs and symptoms and its complications.
To be able to familiarize on the appropriate interventions with its rationale to improve patients condition.
SKILLS:
To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own.
To be able to explain the different factors that may cause type 2 diabetes mellitus and Urinary Tract
Infection and its danger.
To be able to participate in her plan of care.
ATTITUDE:
To help the patient in motivating her to continue the health care provided by the health workers.
To be able to complies with the treatment protocol and prevention strategies.
To be able to identify different measures to prevent further aggravation of the condition.

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III. NURSING ASSESSMENT

A. Biographic Data
Name: Client LV
Address: Poblacion San Ildefonso Bulacan
Gender: Female
Birthday: October 12, 1956
Age: 56 years old
Civil Status: Married
Religion: Roman Catholic
Educational Attainment: College Undergraduate - Accountancy
Date of Consultation: March 5, 2013
Admitting Diagnosis: Type 2 Diabetes Mellitus
Final Diagnosis: T/C DKA, Type 2 Diabetes Mellitus
B. Chief complaint: Nahihilo kasi ako, tsaka nanlalata nahihirapan pa akong huminga as verbalized by the client.
C. History of Present Illness
Prior to consultaion, the client was experiencing weakness and she stated that she feels tired easily doing some
household chores. The night before she decided to go to hospital, she experienced difficulty of breathing and weakness,
which cause her inability to sleep. On the following day at 7:00AM, she seeks consultation at Bulacan Medical Center.
In the Out Patient Department the patient was diagnosed already of Type 2 Diabetes Mellitus and did an initial
assessment with positive weakness and pale, hyperlycemia with a blood pressure of 130/60, Respiratory rate of 29cpm, and
pulse rate of 107bpm. Part of the confirmation of the disease, the following test was requested to be done such as Capillary
Blood Glucose and certain blood test.

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Upon seeing the patient last March 5, 2013, he was able to communicate to us, has no manifestation of hyperglycemia
nor hypoglycemia. During our clinical rotation we seen our client with the following drugs Humulin 70/30, Lantus 16 units,
VAsalat 10mg, Micardis Plus 80mg and Catapress her blood pressure reaches 150.
D. Past Health History
According to the client, he experienced common diseases like fever, cough and colds. She also had Urinary Tract
infection last December and was given medication like Bactrim Forte. According to client she was also confined in the ICU for
1 week because of hyperglycemia associated by hypertension. He is also a hypertensive patient.
E. Family Health History
According to the patient, her family has a history of Asthma, diabetes Mellitus and Hypertension on the paternal
side.

F. Functional health pattern

Health Perception Health Management Pattern

With Diabetes Mellitus

According to the client she feels ill and weak whenever her sugar
level increased. She also added that she feels sad because she
wasnt able to do things that he used to do before like doing chores
in a longer period of time but the client has a positive outlook in life,
she stated that kahit na may diabetes ako at maraming bawal,
pagpapatuloy ko ang aking buhay.

Nutritional-Metabolic Pattern
With Diabetes Mellitus

BREAKFAST

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LUNCH

DINNER

TOTAL
INTAKE

March
2,
2013

1 bowl
Lugaw(275
ml)
1 cup
tea(250mL)

March
3,
2013

1 bowl of
lomi(275mL
)
1 glass of
water(250
mL)

March
4,
2013

bowl of
Quaker
oats(125mL
)
1 glass of
water(250
mL)

1 pc. Of fish
fillet
cup of
rice
1 glass of
water(250m
l)
bowl of
binagoonga
ng
baboy(150
mL)
cup rice
1 glass of
water(250m
L)

cup of
rice
serving
of adobong
manok
1 glass of
water(250m
L)

1 pc. Of
fish fillet
cup of
rice
1 cup
tea(250mL)

Approximat
ely:
1050mL

bowl of
binagoonga
ng
baboy(150
mL)
1 cup rice
1 glass of
water(250
mL)
1 pc Indian
mango
1 sachet of
skyflakes
1 cup
tea(250mL)

Approximat
ely:
1350mL

Approximat
ely:
1325mL

According to the client she has restriction on his diet. If we noticed her intake
in the span of 3 days, she limits her carbohydrates intake as well as fat

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intake. She also added that she was also limiting herself in eating sweet
foods. Our client stated that she drinks a lot everyday approximately 1
liters, she verbalized uhaw
uhaw akoMellitus
palagi. According to the
Withna
Diabetes
approximate Total intake per day it is normal, because the normal Total
ELIMINATION
intake is 2500mL per day. URINATION
And in the 72-hour diet recallBOWEL
it is shown
that her
intake isFREQUEN
minimal, compare
to her statement
prior to
her condition. COLO
COLOR/TR
DISCOMFO
FREQUENCY

CY

Elimination Pattern

Marc
h 2,
2013
Marc
h 3,
2013
Marc
h 4,
2013

9times(ap
prox.
625mL)
6times(ap
prox.
530mL
per shift)
8times(ap
prox.600)

ANPAREN
CY
Dark
Yellow

RT

NONE

once

Dark
Yellow

NONE

once

Dark
Yellow

NONE

once

NOT
RECAL
L
NOT
RECAL
L
NOT
RECAL
L

The clients frequency of urination is increase because of her

condition; she verbalized ihi ako ng ihi. The color of her urine varies
on the drugs that she was taking and according to the client the odor
of her urine was like a smell of medications.

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Sleep Rest Pattern

With Diabetes Mellitus

According to the client she sleeps at 2:00AM, she verbalized

nahihirapan akong kunin yung tulog ko ba, kaya nanunuod na lang
ako ng tv, pero kapag natulog na ako tuloy-tuloy na and she wakes
up at 6:00 in the morning. She doesnt take nap because she is busy
watching television.

Activity Exercise Pattern

With Diabetes Mellitus

According to the client, she was unable to do the things she
usually does because of her condition. Now that she has
diabetes mellitus she gets easily tired and feels weak.
0- FEEDING
0- HOME MAINTENANCE
0- DRESSING
0- TOILETING
N/A- SHOPPING
MOBILITY

0- BED MOBILITY
0- BATHING
0- COOKING
0- GROOMING
1- GENERAL

LEGEND:
Level 0- Full self Care
Level I- Requires Use of Equipment
Level II- Requires assistance or supervision from another
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person
Level III- Requires assistance from another person and
device
Level IV- Is Dependent and doesnt participate

Role Relationship Pattern

With Diabetes Mellitus

The Client feels sad and happy. Sad because she was not able to
things that may trigger her condition and happy because her family
is very supportive and concern about her present condition.

Cognitive-Perceptual Pattern
With Diabetes Mellitus

She is normal in cognitive pattern. In terms of perceptual pattern she

rated her condition as 8 out of 10(10 being the highest and 1 is the
lowest). The client was also diagnosed before having an early
cataract related to DM retinopathy.

Coping/Stress Tolerance Pattern

With Diabetes Mellitus

The client stated that she feels good when he see and feel the
presence of her family in the hospital.

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Self Perception/Self Concept Pattern

With Diabetes Mellitus

According to her, she became a stronger person because of his faith

in God and she was more motivated to do follow the proper regimen
for diabetes mellitus.

Sexuality/ReproductivePattern
With Diabetes Mellitus
We dont ask about this topic to him.

Value Belief Pattern

With Diabetes Mellitus

According to the client her faith in God increase and the only
person that she could ask for help is God.

IV. GROWTH AND DEVELOPMENT

STAGES

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Freud's Psycho-sexual
Theory

Erickson's Psycho-social
Theory

Piagets Theory of Cognitive

Kohlbergs Theory of
Moral

GENITAL
Puberty-Death

Generativity vs.
Stagnation
Middle Adulthood: 35 to 55 or 65

Formal Operational
12 - Adulthood

Post Conventional
-Universal Ethics
Orientation

DEFINITION

During final stage, the

individual develops a
strong sexual interest
in the opposite sex.
This stage begins
during puberty but
last throughout the
rest of person's life.

Adults need to
create/nurture things that
will outlast them, often by
having children/creating a
positive change that
benefits other people.
Success leads to feelings
of usefulness and
accomplishment, while
failure results in shallow
involvement in the world.

Can think logically about

abstract propositions and
test hypothesis
systematically, becomes
with hypothetical future and
ideological problems.

Few people operate at

this stage all the time. It
is based on abstract
reasoning and the
ability to put oneself in
other people's shoes. At
this stage, people have
principled conscience
and will follow universal
ethical principles
regardless of what the
official laws and rules
are.
.

RESOLUTION

V. THEORY
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The client was

successfully met the
psychosexual stage
not only because she
was able to have
children with her
husband but also in
genital stage affords
the person the ability
to confront and
resolve her remaining
psychosexual
childhood conflicts.

The client achieves this

stage because she knows
that she gave back to the
society through raising her
children and being
productive as being a
mother to her children.

The client thinks rationally

and logically. As a mother
and wife she was able to
solve the problems by
communicating to her
children and husband.

She lives autonomously

and defines the moral
personal identification
with group values and
principle that are
universally agreed on
the considers
appropriate that for life.
She makes decision
according to what her
conscience dictates.

THEORY

THEORIST

1. Health Promotion
Model

Nola J. Pender

2. Self-Care Deficit
Theory of Nursing

Dorothea E. Orem

3. Core, Care and Cure

Model

Lydia Hall

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DESCRIPTION

APPLICATION OF THEORY TO
THE PATIENT

A health promoting behavior

is an end point or action
outcome directed toward
attaining positive health
outcomes such as optimal well
being, personal fulfillment, and
productive living.

Health Promotion Model can help

the client to attain positive health
outcomes by eating of healthy diet,
exercise regularly, managing stress,
gaining adequate rest, spiritual
growth and building positive
relationships.

The central idea of the

theory of self-care deficit is that
the requirements of persons for
nursing are associated with
subjectivity of mature and
maturing persons to healthrelated or health care-related
action limitations

In this theory suggests that patients

recover quicker and more effectively
when they are allowed to meet their
own basic needs, such as eating,
grooming, and using the restroom.
We use it as a guide to provide care
and to help client to attain self-care.

Focusing on the notion that centers

around three components of Care, Core
and Cure. Care represents nurturance
and is exclusive to nursing. Core
involves the therapeutic use of self and
emphasizes the use of reflection. Cure
focuses on nursing related to the
physicians orders. Core and cure are
shared with the other health care
providers.

We use this theory as a guide for our care plan

to the client because the major purpose of care
is to achieve an interpersonal relationship
with the individual that will facilitate the
development of the core. Client is composed
of body, pathology, and person. People set
their own goals and are capable of learning
and growing.

PHYSICAL ASSESSMENT
ASSESSMENT

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS/INTERPRET
ATION

GENERAL APPEARANCE
BODY BUILT

INSPECTION

Proportionate, varies with lifestyle

Proportionate ( mesomorph )

Normal

POSTURE

INSPECTION

Not on an Erect posture

Not on an erect posture

Normal

OVER-ALLHYGIENE
BODY AND
BREATH ODOR

INSPECTION

Clean and neat appearance

Clean and neat appearance

Normal

INSPECTION

No body and breath odor

No body and no breath odor

Normal

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SIGNS OF
DISTRESS

INSPECTION

No signs of distress

Weak in appearance

Deviation from Normal

due to aging

OBVIOUS SIGN
OF HEALTH OR
ILLNESS

INSPECTION

No signs of illness or disease

Obvious signs of illness or

disease

Deviation from Normal

due to the presence of
the disease.

INSPECTION

Conscious and coherent

Conscious and coherent

Normal

INSPECTION

Oriented to time, place, situation

Oriented to time, place, situation

Normal

MENTAL STATUS
LEVEL OF
CONSCIOUSNE
SS
ORIENTATION

BODY
PART
INTEGUMENTARY
a.) SKIN

b.)

NAILS

TECHNIQUE
INPECTION
PALPATION

INSPECTION
PALPATION

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NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Uniform in color, no presence of

edema ,no skin lesions, normal
temperature, long skin turgor, dry
skin

Dry skin and theres presence

of skin pigmentations on the
body

Deviation from Normal

due to hydration status
& melatonin deficiency
of the client.

Convex curvature about 160,

smooth in texture, have an intact
epidermis tissue surrounding the
nails, less than 4 sec. returning to
its normal color (pink) when
performing blanch test

Convex curvature about 160,

smooth in texture, have an intact
epidermis tissue surrounding the
nails, having a normal blanch test
with pale color of nail beds. &
presence of dead toe nail.

Deviation from Normal

due to decrease of
oxygen in the tissue
cells.

SKULL

SCALP

INSPECTION

Rounded Normocephalic and

symmetrical with frontal, parietal,
and occipital prominences,
Smooth skull contour

Normal

PALPATION

Rounded Normocephalic and

symmetrical with frontal, parietal,
and occipital prominences, Smooth
skull contour

INSPECTION

No presence of dandruff or lesions

Normal

PALPATION

Smooth

No presence of dandruff or
lesions

Color is lighter than facial skin

No tenderness

Smooth
Color is lighter than facial skin
No tenderness

HAIR

INSPECTION

Not Evenly distributed, thin, dry

hair

Not Evenly distributed, thin, dry

hair

Normal

FACE

INSPECTION

Symmetric/slightly asymmetrical
facial features
Symmetrical facial movements.

Symmetrical facial features and

coordinated facial movements.

Normal

a. Eyebrows

INSPECTION

Skin intact. Eyebrows symmetrically

aligned. Evenly distributed.

Skin intact. Eyebrows

symmetrically aligned. Evenly
distributed.

EYES

b. Eyelashes
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Equally distributed and is curled

Normal

INSPECTION

slightly outward.

Equally distributed and is curled

slightly outward.

Normal

Skin is intact

c. Eyelids
NSPECTION

No discharge and discoloration

Lids close symmetrically
the cornea.

Skin is intact

Normal

No discharge and discoloration

Lids close symmetrically

d. Conjunctiva
Red or pink.

e. Cornea
INSPECTION

Capillaries sometimes evident.

Pink in color

Normal

Capillaries sometimes evident.

INSPECTION
f. Lacrimal
gland,
lacrimal sac
and
nasolacrima
l duct

g. Pupils
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Transparent, shiny and smooth.

Details of iris are visible.

Normal
Transparent, shiny and smooth.
Details of iris are visible

INSPECTION

No edema or tearing
No edema or tearing

PALPATION

Pupil constricts when looking in

Normal

INSPECTION

near objects and pupil dilates when

looking at far objects.
Non illuminated eye constricts and
illuminated eye also constricts.
PERRLA (pupil equally round and
react to light and accommodation)

j. Visual
Acuity

Non illuminated eye constricts

and illuminated eye also
constricts.
PERRLA (pupil equally round and
react to light and
accommodation)

h. Visual
Fields

i. Ocular
movements

Pupil constricts when looking in

near objects and pupil dilates
when looking at far objects.

INSPECTION

The client can see object in the

periphery when looking straight
ahead.

INSPECTION

Both eyes coordinated.

Normal

Normal

Moves in unison.

Both eyes coordinated.

In parallel alignment.

Moves in unison.
In parallel alignment.

INSPECTION

20/20 vision on Snellen chart

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Normal

The client can see object in the

periphery when looking straight
ahead.

Distance vision:

EARS

Normal

Both Eyes has a grade of 250

Deviation from normal

due to aging and the
disease process.

a. Auricles

INSPECTION

Color same as facial skin.

Color same as facial skin.

PALPATION

Symmetrical

Symmetrical

Aligned with the outer canthus of

the eye about 10 degrees from
vertical.

Aligned with the outer canthus of

the eye about 10 degrees from
vertical.

Mobile, firm and not tender.

Mobile, firm and not tender.

The pinna recoils after it is folded.

The pinna recoils after it is folded.

Absence of cerumen, pus, or blood.

Absence of cerumen, pus, there

is no presence of blood.

Symmetrical and straight. No

discharge or flaring.

Symmetrical and straight. No

discharge or flaring.

Uniform color.

Uniform color.

No tenderness or lesions.

No tenderness or lesions.

Mucosa is pink.

Mucosa is pink.

Clear, watery discharge

Clear, watery discharge

Nasal patency:

Nasal patency:

Normal

b. External ear
INSPECTION

NOSE

INSPECTION
PALPATION

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Normal

Normal

Normal

Normal

MOUTH
a. Lips and
buccal

Air moves freely as the client

breathes through the nares.

Nasal septum intact and in the

midline.

Nasal septum intact and in the

midline.

Air moves freely as the client

breathes through the nares.

Frontal and maxillary sinuses: not

tender

Frontal and maxillary sinuses: not

tender.

INSPECTION

Uniform pink in color

Uniform pink in color

PALPATION

Moist, smooth, soft, glistening,

elastic texture

Moist, smooth, soft, glistening,

elastic texture

mucosa

INSPECTION
b. Teeth and
gums

PALPATION

32 adult teeth

Presence of dentures ,Pink gums

Smooth and shiny white teeth

Moist, firm gum texture

Pink gums

No retraction of gums

Normal

Normal

Deviation from Normal

due to presence of
dentures.

Moist, firm gum texture

No retraction of gums

Central position
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Central position

Normal

c. Tongue

INSPECTION

Pink color

Pink color

PALPATION

Smooth lateral margins

Smooth lateral margins

No lesions

No lesions

Moves freely

Moves freely

No tenderness

No tenderness

PALPATION

Normal

Normal
INSPECTION
d. Mouth floor
and roof

Smooth tongue base with

prominent veins

Normal
Soft palate: light pink

INSPECTION
e. Hard and
soft palate

Soft palate: light pink

Hard palate: lighter pink, more
irregular in texture
INSPECTION

f. Uvula

Hard palate: lighter pink, more

irregular in texture
Normal
Uvula in the midline of soft palate
Normal

Uvula in the midline of soft palate

INSPECTION

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Smooth tongue base with

prominent veins

Pink and smooth

e. Tonsils and

Pink and smooth

oropharynx

Normal
Present

Present

INSPECTION

Muscles equal in size

Muscles equal in size

PALPATION

Coordinated, smooth movements

with no discomfort

Coordinated, smooth movements

with no discomfort

Equal strength

Equal strength

Not palpable

The lymph nodes are not

palpable.

INSPECTION
f. Gag reflex
NECK
a. Lymph nodes

b. Trachea

INSPECTION

Normal

Normal

PALPATION
c. Thyroid
gland

INSPECTION
PALPATION

Central placement in the midline

Spaces are equal in both sides
Not visible on inspection
Glands ascend during swallowing
but not visible

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Central placement in the midline

Spaces are equal in both sides
Not visible on inspection
Glands ascend during swallowing

Normal

Lobes may not be palpable

but not visible

Lobes are not be palpable

POSTERIOR THORAX
a. Posterior
thorax

b. Respiratory
excursion
c. Vocal tactile
fremitus.

INSPECTION
PALPATION

INSPECTION
PALPATION
INSPECTION
PALPATION

Anteroposterior to transverse
diameter in ratio of 1:2

Anteroposterior to transverse
diameter in ratio of 1:2

Spine vertically aligned

Spine vertically aligned

Uniform temperature skin intact

Uniform temperature skin intact

No tenderness

No tenderness

No masses

No masses

Symmetrical chest expansion

Symmetrical chest expansion

3-5cm thumb separation at

inspiration

3-5cmThumb separate at
inspiration.

Bilateral symmetry of vocal

fremitus

Bilateral symmetry of vocal

fremitus

Fremitus is heard most clearly at

the apex of the heart

Fremitus is heard most clearly at

the apex of the heart

Normal

Normal

Normal
Deviation from Normal
due to mucus
secrtions.
Normal

d. Percussion
e. Auscultation
24 | P a g e

PERCUSSION

Resonance except over the scapula

Dullness over the ribs

Resonance except over the

scapula

ANTERIOR THORAX
a. Anterior
Thorax

AUSCULTATIO
N

Vesicular and bronchovesicular

breath sounds

Dullness over the ribs

INSPECTION

Quiet, rhythmic, and effortless

respirations

Quiet, rhythmic, and effortless

respirations

Uniform temperature

Uniform temperature

No tenderness

No tenderness

No masses or any lesions

No masses or any lesions

PALPATION

Vesicular and bronchovesicular

breath sounds

INSPECTION
b. Respiratory
excursion

PALPATION

Normal

Normal

Normal
Symmetrical chest expansion

Symmetrical chest expansion

3-5cm thumb separation at

inspiration

3-5cm thumb separation at

inspiration

Resonance down at the 6th rib at

diaphragm level

Resonance down at the 6th rib at

diaphragm level

Flat over heavy muscles and bone

Flat over heavy muscles and

bone

PERCUSSION
c. Percussion

Dull over heart and liver

Tympanic over underlying stomach

Dull over heart and liver

Tympanic over underlying

25 | P a g e

Normal

d. Auscultation

AUSCULTATIO
N

Trachea; Brochial breath sounds

Anterior chest; Bronchovesicular
and vesicular breath sounds

stomach

Trachea; Brochial breath sounds

Anterior chest; Bronchovesicular
and vesicular breath sounds

CARDIOVASCULAR
a. Heart

AUSCULTATIO
N

No pulsations at the aortic,

pulmonic, tricuspid and mitral area.

PALPATION

Aortic pulsations at the epigastric

area

INSPECTION

No pulsations at the aortic,

pulmonic, tricuspid and mitral
area.
Aortic pulsations at the epigastric
area

Normal

S1 all sites
S2 all sites
S3- in children/young adults
S4 older adults

b. Carotid
artery

AUSCULTATIO
N

No sound heard on auscultation

26 | P a g e

S1 is heard at all sites especially

at the apical site and S2 is heard
at all sites especially at the base
of the heart.

Normal

Symmetric pulse volumes

Elastic arterial wall

Normal

Symmetric pulse volumes

Elastic arterial wall

No sound heard on auscultation

c. Jugular
veins
BREAST

Veins are not visible

INSPECTION

Normal
Veins are not visible

INSPECTION

Rounded shape

Rounded shape

PALPATION

Slightly unequal in size

Slightly assymetric

Generally symmetric

Skin uniform in color, skin intact

and smooth

Skin uniform in color, skin intact

and smooth

Normal

Normal
No tenderness, masses or nodules.

No tenderness, masses or
nodules.
Normal

Round, everted, pointing in the

same direction.
a. Nipples and
Areola

Dark brown color of areola

The nipples and areola are

rounded, equal in size and similar
in color.

No discharge, tenderness, or
masses
No discharge, tenderness, or

27 | P a g e

Normal

masses, presence of breast milk

ABDOMEN

INSPECTION

Uniform in color, unblemished skin

Uniform in color

Flat, rounded (convex), or scaphoid

(concave)

Rounded (convex)

Symmetric contour
Symmetric movements caused by
respirations

Normal

Symmetric contour
Symmetric movements caused by
respirations

Bowel sounds are audible.

Bowel sounds are audible.
AUSCULTATIO
N

PERCUSSION

Absence of friction rub and arterial

bruits.

Tympany over the stomach and

gas-filled bowels
Dullness over the liver and spleen.

PALPATION

28 | P a g e

Liver size:

Absence of friction rub and

arterial bruits.

Tympany over the stomach and

gas-filled bowels

Normal

Normal

Dullness over the liver and

spleen.

The liver size is determined when

percussed, 6 12cm MCL.

Normal

MCL: 6 12cm
MSL: 4 8cm

No tenderness, relaxed abdomen

with smooth consistent tension.

No tenderness, relaxed abdomen

with smooth consistent tension.

Normal

Normal
Liver: no enlargement may not be
palpable

Gall bladder:

UPPER EXTREMITIES
a. Shoulders,
arms, elbows,
wrists hands
and fingers
b. Shoulders and
arms:
movement and
force

29 | P a g e

The liver is not enlarged.

No distention

There is no distention in the gall

bladder when palpated.

Symmetrical

Symmetrical

No redness, swelling, deformities,

masses and tenderness

No redness, swelling, deformities,

masses and tenderness

Extent of forward flexion should be

180 degrees; hyperextension, 50
degrees; adduction, 50 degrees and
abduction 180 degrees

The client can flex, extend,

adduct, abduct and hyperextend
without pain and with equal
force.

Normal

Normal

Normal

c. Elbows:
movement and
force

Normal ranges of motion are 160

degrees of flexion; 180 degrees of
extension, 90 degrees of pronation,
90 degrees of supination.

The client can flex, extend, and

hyperextend without pain and
with equal force.

Normal

d. Wrists:
movement and
force

Normal ranges of motion are 90

degrees, flexion 70 degrees,
hyperextension; 55 degrees, ulnar
deviation; and 20 degrees, radial
deviation

The client can flex, extend, and

hyperextend without pain

Normal

There is full range of motion

against resistance

Should have full ROM against

resistance

e. Hands and
fingers:
movement and
force

Normal ranges are 20 degrees of

abduction, full adduction of fingers,
90 degrees of flexion and 30
degrees of hyperextension
The thumb should easily move
away from other fingers and 50
degrees of thumb flexion is normal
Should have full ROM against
resistance

LOWER EXTREMITIES
30 | P a g e

The client can flex, extend,

adduct, abduct and hyperextend
without pain.
There is full range of motion
against resistance

Normal

a. Hips, knees,
ankles and
feet:

b. Hips:
movement and
force

Symmetrical, No redness, swelling,

deformity

Symmetrical, No redness,
swelling, deformity

Muscles are fully developed

Muscles are fully developed

Normal ROM: 90 degrees of hip

flexion with knee straight and 120
degrees of hip flexion with the knee
bent and the other leg remaining
straight

The client can flex, knees bent

and the other leg remaining
straight.

Normal

Normal

There is full range of motion

against resistance.

Full ROM against resistance

c. Knees:
movement and
force

Normal ranges: 120 degrees to 130

degrees of flexion; 0 degrees of
extension to 15 degrees of
hyperextension

The client can flex, extend and

hyperextend.

Normal

There is full range of motion

against resistance.

Full ROM against resistance

d. Ankles and
Feet:
movement and
force

Normal ranges:
20 degrees dorsiflexion of ankle
and foot; 45 degrees plantar flexion
of ankle and foot
20 degrees of eversion 30 degrees
of inversion
10 degrees of abduction; 20

31 | P a g e

The client can perform

dorsiflexion, plantar flexion,
eversion, inversion,abduction,
adduction, flexion and extension
without pain.
There is full range of motion
against resistance.

Normal

degrees of adduction
40 degrees of flexion; 40 degrees of
extension
Full ROM against resistance.

SUMMARY OF SIGNIFICANT FINDINGS:

Weak in appearance due to aging
Dry skin and poor skin turgor due to hydration status of the cliet.
Presence of skin pigmentation over the body due to melatonin deficiency.
Obvious sign of illness or disease because of his resent condition.
Paleness of lip/ buccal mucosa caused by decreased oxygen in the tissue cells.
Presence of dentures
Visual acquity with the grade of 250 in both eyes.
Nails are pale in color due to decreased oxygen supply in the tissue cells and dead toe nail.

32 | P a g e

VIII. DRUGS/MEDICATIONS
DRUG NAME

MECHANISM OF
ACTIONS

Generic Name:
HUMULIN 70/30
Classification:
Antihyperglycemic /
Antidiabetic
Route/Dosage:
Subcutaneous;
10ml

Decreases blood
glucose by
transport of glucose
into cells;
conversion of
glucose to glycogen
.

33 | P a g e

INDICATION

Management of
type 2 Nondependent
diabetes mellitus

CONTRAINDICATI
ON
Hypoglycemia and
hypersensivity
reactions

SIDE EFFECTS

NURSING
RESPONSIBILITIE
S

Lipodystrophy;
insulin resistance;
allergic reactions;
hypoglycemia

Obtain patience
history, including
drug history and
any known
allergies.
Monitor fasting
blood glucose, 2hrs
after meals.
Monitor urine
ketones during
illness.
Monitor body
weight
Monitor for
hypoglycemic
/hyper glycemic

reactions.
Generic Name:
Simvastatin
Classification:
Antihyperlipidemic
agent/HMG-CoA
reductase inhibitor
Route/Dosage:
40mg/tab OD

Inhibits HMG-CoA
reductase enzyme,
which reduces
cholesterol
synthesis

Generic Name:
Telmisartan
(micardis)
Classification:
Angiotensin II
antagonist/
Antihypertensive
Route/Dosage:
80mg/tab OD

Blocks the
Treatment for
vasoconstrictive
Hypertension
and aldosteronesecreting effects of
angiotensin II by
selectively
blocking the
binding of
angiotensin II to the
AT1 receptor in

34 | P a g e

Treatment of
Hyprlipidemias

Pregnancy and
Hypersensitivity to
any components of
preparation.

Abdominal pain;
constipation;
headache;
dizziness

Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.

Pregnancy and
lactation. Biliary
obstructive disorder.
hypersensivity

Diarrhea;
headache; fatigue;
Urinary tract
infection

Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:

many tissues

Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.

Generic Name:
Amlodipine
Classification:
Antihypertensive
agent
Route/Dosage:
10mg/tab OD
sublingual

Decreases
pheripheral
vascular resistance
of smooth muscle
(decrease blood
pressure)

Treatment for
hypertension

Generic Name:

Blocks the

Treatment for

35 | P a g e

Hypersensivity to

Palpitations;
headache;
dizziness; fatigue;

Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.

Headache;

Prior:

Valsartan
Classification:
Angiotensin II
receptor blocker /
Antihypertensive
agent
Route/Dosage:
80mg OD

Generic Name:
Clonidine
Classification:
AntiHypertensive
agent
Route/Dosage:
750mcg/Tab BID

36 | P a g e

vasoconstrictive
Hypertension
and aldosteronesecreting effects of
angiotensin II by
selectively
blocking the
binding of
angiotensin II to the
AT1 receptor in
many tissues.

the components

Stimulates central
alpha-adrenergic
receptors to inhibit
symphatetic
cardioaccelerator
and vasoconstrictor
centers

Hypersensitivity to
clonidine

Management of all
grades of
hypertension

dizziness; fatigue
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF
,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Drowsiness, dry
mouth, headache,
urinary retention
hypotension

Prior:
Assess BP and
apical pulse before
the initial dose
Monitor baseline for
renal, liver
functions tests
before therapy
begins.
During:
Assess for
symptoms of CHF

,edema,dyspnea
wet rales. BP
weight gain, report
significant changes.
After:
Note for allergic
rteactions monitor
blood pressure.

IX. LABORATORY/DIAGNOSTIC PROCEDURE

Laboratory
procedure

Date
Indication/ purposes
Analytes
ordered/
date
result
Hematology December
White Blood
I t provides
19, 2012
Cell
valuable
information
about the blood
and some
extent the bone
37 | P a g e

Result

Normal

Interpretation

Nursing responsibilities

14.7

4.1-11.1

The result is above

normal it indicates:
there is a
presence of
leukocytosis
infection

Prior to examination:
Check the doctors order.
Explain the procedure to the
client.
Assess for the presence of
hematophobia.

marrow, which
is the blood
forming tissue.
It is used for
the following
purposes:
To ensure both
adequate
oxygen
carrying
capacity and
hemostasis.
To identify
persons who
may have an
infection.
To identify
acute and
chronic illness,
bleeding
tendencies.and
number of
circulating
white blood
cells.

Lymphocytes% 14.1

16.0-46.0

The result is below

normal it indicates :
Presence of
autoimmune
disease.

Monocytes %
Granulocytes
%

2.9
83.0

2.3-8.5
48.7-81.2

Red Blood
Cells
Hemoglobin

4.53

3.90-5.20

127

120-151

Hematocrit

0.377

0.364-0.460

MCHC(Mean

377

318-342

Within normal result

The result is above
normal level it
indicates:
The patient
may develop
an anemia
The result is within
normal
The result is within
normal.
The result is within
normal.
The result is above
normal it indicates:
The patient
may suffer
from anemia.

14.7

11.9-14.4

corpuscular
hemoglobin
concentration)

RDW(red
38 | P a g e

The result is above

Check the medications of the

patient that may affect the
result.
During:
Provide comfort to lessen
patients anxiety while
waiting for the result.
After:
Secure laboratory result to
the chart of the patient.
( refer result to the physician)

blood cell
distribution
width)

Laboratory
procedure
Urinalysis

39 | P a g e

Date ordered/
date result
December
19,2012

Indication/
purpose

It is an
essential
procedure
for
patients
undergoin
g hospital
admission
or
physical
examinati
on.

Platelet

402

169-418

MPV(mean
platelet
volume)

6.7

7.0-10.5

Analytes

Result

Color

Light yellow

Transparency

Slightly
turbid

normal it indicates:
That the
patient
develop
cardiovascular
disease.
The result is within
normal.
The result is below
normal it indicates
that :
The patient
may develop
leukemia.

Normal

Pale
yellow
to
amber
clear to
slightly
hazy

Interpretation

Nursing
consideration

Normal

Prior:
1. Review

Normal

2. Gather all
the
necessary
materials

CHEMICAL
EXAMINATION:
Glucose

+1

Negative

physicians
order.

Positive result of
glucose in the urine
may indicate:

needed.
3. Explain the
procedure to

It is a
useful
indicator
of a
healthy or
diseased
state and
Specific gravity
has
remained
an
integral
part of the MICROSCOPIC
patient
EXAMINATION:
examinati
on.

Amorphous urate

Bacteria

1.030

Faint aromatic

Rare

1.010-1.025

Rare

Negative

high blood
glucose level
undiagnosed or
uncontrolled
diabetes
mellitus
The result is above
normal level it
indicates that:
Urine is concentrated
The result is abnormal
it indicate that:
the patient eats
food cause
musty odor.
Infected urine
Urine that have
glucose.
Abnormal result
indicates:
Infection
process.

the patient.
4. 4 .Instruct
the patient
to void
directly into
a clean, dry
container.
Sterile,
disposable
containers
are
recommend
ed. Women
should
always have
a cleancatch
specimen if
a
microscopic
examination
is ordered.
Feces,
discharges,
vaginal
secretions
and
menstrual
blood will
contaminate
the urine

40 | P a g e

specimen.
After:
1. Cover all
specimens
tightly, label
properly and
send
immediately
to the
laboratory.
2. If a urine
sample is
obtained
from an
indwelling
catheter, it
may be
necessary
to clamp the
catheter for
about 15-30
minutes
before
obtaining
the sample.
Clean the
specimen
port with
antiseptic

41 | P a g e

The
process of
urinalysis
determine
s the
abnormal
constituen
ts
revealed
by
microsco
pic
examinati
on of the
urine
sediment.

before
aspirating
the urine
sample with
a needle
and a
syringe.
3. Observe
standard
precautions
when
handling
urine
specimens.
4. If the
specimen
cannot be
delivered to
the
laboratory or
tested within
an hour, it
should be
refrigerated
or have an
appropriate
preservative
added.

42 | P a g e

X. NURSING PRIORITIZATION
NURSING PROBLEM
1. Altered Tissue Perfusion

43 | P a g e

JUSTIFICATION
We consider this problem as our first priority because diabetes
mellitus has a primary feature of constricted blood vessels which
caused by an inadequate oxygenated blood circulate in the body
which is the reason of having a fatigue in relation to the decrease
muscle strength

2. Fatigue

We choose the fatigue as our 2nd priority because it is more

important than the deficient knowledge and considered to be a
physiologic needs of an individual.

3. Deficient Knowledge

We consider the deficient knowledge as the 3 rd priority because it

is very important to know the care, course and the treatment of
her condition, for her to be aware in her body.

4.Risk for Activity Intolerance

Intolerance of activity is our 4th priority because if we resolved the

problems in the circulation or the fluid volume, fatigue and the
possible unstable blood glucose level, our client will have a
capacity to tolerate activities just like before because our client
has a sufficient energy to perform desired activities.

XI. NURSING CARE PLAN

ASSESSMENT

44 | P a g e

NURSING
DIAGNOSIS

PLANNING

NURSING
INTERVENTION/S

RATIONALE

EVALUATION

OBJECTIVE CUES:

Verbalization
of the
problem
Statement of
misconception

Vital Signs:
BP: 130/70 mmHg
RR: 29cpm

Ineffective tissue
perfusion related
to weakening due
to vasoconstriction
of blood vessels

After 8 hours of
nursing
intervention, the
patient will be
able to achieve a
normal circulation
in the peripheral.

Teach the patient to

mobilize.

Teach about the factors

which can increase blood
flow :

Elevate feet slightly

lower than the
heart (the position
of elevation at
rest), avoid
crossing legs,
avoiding tight
bandage, avoid the
use of pillows,
hamstrings and so
forth.

Teach about the

modification of risk
factors such as:
Avoid a diet high
in cholesterol, relax
ation
techniques, smokin
g cessation, and
45 | P a g e

the mobilization improves blood

circulation

To increase blood flow through so

that does not happen edema.

High cholesterol can accelerate

the occurrence of atherosclerosis;
smoking can cause
vasoconstriction of blood vessels,
relaxation to reduce the effects of
stress.

Giving vasodilators will increase

drug use
vasoconstriction.

the dilation of blood vessels so

that tissue perfusion can be
improved, while checking blood
sugar regularly to know the
progress and state of the patient.

Collaborate with other

health team in giving
vasodilators and checking
blood sugar regularly

SUBJECTIVE:
OBJECTIVE:

generalized
weakness
increased
respiratory
rate of 25cpm
body
weakness

46 | P a g e

Fatigue
related to
decrease
muscle
strength

LONG TERM GOAL:

After 3 days of nursing

interventions, the patient
will be free from signs of
fatigue
SHORT TERM GOAL:
After 2-3 hours of nursing
interventions, the patient

Assess
response to
activity

Response to an
activity can be
evaluated to achieve

weight loss
fatigue
-limited ROM
inability to
perform ADL
altered VS
altered
sensorium

will be able to identify

measures to conserve and
increase body energy.

47 | P a g e

Asses
muscle
strength of
patient and
functional
level of
activity.
Discuss with
patient the
need for
activity

Alternate
activity with
periods of
rest/
uninterrupte
d sleep.
Monitor
pulse,
respiration
rate and
blood
pressure
before/after
activity
Perform
activity
slowly with

desired level of
tolerance.
To determine the
level of activity

Education may
provide motivation
to increase activity
level even though
patient may feel too
weak initially

Prevents excessive
fatigue.

Indicates
physiological
levels of tolerance.

Interventions should
be directed at
delaying the onset of
fatigue and
optimizing muscle
efficiency.
Symptoms of fatigue

frequent rest
periods

48 | P a g e

Promote
energy
conservation
techniques
by
discussing
ways of
conserving
energy while
bathing,
transferring
and so on.
Provide
adequate
ventilation
Provide
comfort and
safety
Instruct
patient to
perform
deep
breathing
exercises
Instruct
client to
increase

are alleviated with

rest. Also, patient
will be able to
accomplish more
with a decreased
expenditure of
energy.

For proper
oxygenation

To be free from
injury

Promotes relaxation
For muscle strength
and tissue repair

To prevent weakness
and paleness

To provide proper
ventilation

ASSESSMENT

OBJECTIVE CUES:

49 | P a g e

Verbalization

NURSING
DIAGNOSIS

Deficient knowledge
related to the
disease process due
to lack of

PLANNING

After 8 hours of
nursing
intervention, the
patient will be able

Vitamins A, C
and D and
protein in
her diet.
Instruct also
patient to
increase iron
in diet
Administer
oxygen as
ordered.

NURSING
INTERVENTION/S

Encourage client to
do self monitoring of
her glucose level.

RATIONALE

For the client to do

self monitoring of
her condition.

EVALUATION

of the
problem
Statement of
misconception

Vital Signs:
BP: 130/70 mmHg
RR: 29cpm

information or
information
misinterpretation

to verbalize
accurate
information, report
understanding of
condition and
discuss process and
treatment.

Provide explanations
of reasons for the
procedure and the
preparation needed.
Identify individual
restrictions such as
too sugar in the
food.

Review the patient

to maintain an
optimal nutritional
status.

Information can
decrease the
anxiety of the
patient.

Any things that can

aggravate her
condition.

Promotes well being

of the patient and
her recovery

XII. CONCLUSION
At the end of our case study, our group learned things about Type II Diabetes Mellitus and Urinary Tract Infection that are
needed for us to know. We therefore conclude that we, as nursing students must give time in knowing disease or illness like our
case. These things would help us further in giving or disseminating information to people who are concerned or involved in this
condition.
On the other hand, this case study is not only for nursing student but this can be also helpful to other professionals and
ordinary people. We studied about the risk factors, its sign and symptoms, treatment, medication for Type II Diabetes Mellitus

50 | P a g e

and Urinary Tract Infection. Hence, we learned that any individual is prone to this condition if their lifestyle puts them to a higher
risk. Thats why we must all be well-informed to prevent its occurrence.
Lastly, at the end of our case study we, student nurses apprehend all essential things about Type II Diabetes Mellitus and
Urinary Tract Infection. Avoid exposure, proper lifestyle, proper hygiene and proper nutrition is the best way to prevent the
acquiring of Type II Diabetes Mellitus and Urinary Tract Infection and any other diseases.

XII. BIBLIOGRAPHY
-

Kozier B. et al: Fundamentals of Nursing 10th edition Pearson education Inc. New jersey Copyright 2004
p.434
Moorhouse , Doenges, M.: Nurses Pocket Guide: Nursing Diagnoses with Interventions
Brunner and Suddart: textbook of Medical and Surgical Nursing 12 th edition, hippincott, Williams & Wilkins

51 | P a g e

-http://www.justmommies.com/articles/anemia-during-pregnancy.shtml#ixzz1lN1GVpZL
http://en.wikipedia.org/wiki/Pain#Management
http://www.livestrong.com/article/202712-a-nursing-diagnosis-of-limited-mobility/
http://nurseslabs.com/d5w-iv-fluid-study/\

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