I NTRODUCTION

Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles. According to the study, the number of diabetics has risen from thirty million to two hundred forty six million over the past twenty years. Their study further reveals that seven out of the top ten countries with the highest number of diabetics are found in the developing world. The top developing countries with the highest percentage of diabetes sufferers are in China and in India. The highest density of population sufferers are found in the Caribbean and the Middle East, with their population numbering from twelve to twenty percent of their total populations. There are 18.2 million people in the United States, or 6.3% of the population, who have diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2million people (or nearly one-third) are unaware that they have the disease. 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. Diabetes mortality rate has increased by 92% over a ten year period from 1986 to 1995 and it is estimated that there are currently 3 million Filipinos who are diabetic. The World Health Organization projected that by 2030, the number of cases of diabetes worldwide is estimated at 334 million. Based on the WHO study, the Philippines is projected to have an estimated number of 7.8 million cases by
1

2030 and eventually may rank ninth in the list of countries with the highest estimated cases worldwide. The primary goals of treatment for patients with diabetes include controlling blood glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for diabetic patients must assist them to develop self-care management skills. Our patient given the code name: Mr. R.A is a hardworking farmer in Davao City. He was admitted to DMSFH to treat his body weakness in relation to his present Diabetes Mellitus condition. We were able to choose Mr. R.A as our case with the aid of our ever supportive Clinical Instructor. Mr. R.As condition was in relevance with our previous semesters concept Medical Surgical Nursing and was given us the confirmation to interview him and his wife. It can be implied to nursing profession for as we all know DM type 2 is a common disorder not just in the country but in the whole world. By having a background on it and sufficient knowledge, we can help other people by giving appropriate health teachings and nursing care. Throughout this case presentation, numerous data were presented about Mr. R.As disease for the deepened understanding of his disease, Diabetes Mellitus Type 2.

O BJECTIVES

I.

General Objectives:

At the end of our rotation the group will be able to understand Diabetes Mellitus particularly Type 2 Diabetes.

II.

Specific Objectives

To organize our patients data and to formulate a good

background information of the patient.

To evaluate the patients family health history as well as the

history of present illness to be able to know the contributing factors of the patients condition.

To illustrate the Genogram to trace out the hereditary risk factors

of the patient.

To distinguish the different description of the patients illness to

fully understand the disorder.

To have the accurate description of the patient through the use of

Physical Assessment method.

To fully explain the Diabetes Mellitus anatomy and physiology by

explaining the different parts affected in the said disorder.

To record all the signs and symptoms that are present or absent

in our patient.

To draw a flow chart about the pathophysiology of Diabetes

Mellitus to have a comprehensible visualization on how it affects a person. To list the various doctors order to our patient and its rationale

for a general knowledge of what consists of the medical management for Diabetes Mellitus.

To have apparent results of our patients diagnostic exams

together with the normal values to be able to know what suddenly alter in the disease condition.

To identify the different drugs used by the patient to be able to

properly know its functions and purposes.

To analyze the different nursing theories that can be applied to

our patient.

To create nursing care plans in applicable to our patient.

To create a discharge plan by using the correct method format in

doing it.

To validate a prognosis according to a specific criteria.

To gather all the necessary conclusions and recommendations in

the condition.

To list down all the helpful references used all throughout the

case study.

D ATABASE

1. Biographical Data Name: R.A Gender: Male Age: 61 years old Birthday: May 24, 1949 Place of birth: Davao City Nationality: Filipino
5

Address: Purok 7 upper Catitipan, Davao City Religion: Baptist Educational Level: College Graduate (Management Business Administration4years); Accounting (4th year college 1st Semester) Occupation: Farmer Monthly income: Sibling: 1 Marital status: Married Informant: Wife 2. Clinical Data Chief Complaint: Generalized Body Weakness Date of admission: January 10, 2011 Admission Time: 2:05am Room #: 440/ Bed 1 Admitting diagnosis: Diabetes Mellitus Type 2 Date of Discharge: January 13, 2011 Final Diagnosis: Diabetes Mellitus Type 2

3. Family Health History GENOGRAM PATERNAL SIDE MATERNAL SIDE Mr. S.A Mrs. S.V.A Mr.J.P
Mrs.P .P

Mr.

Mr.V Mr.P Ms.

Mr.

Mr.

Ms.
7

Mr.I Ms. F

Ms. E

Ms. C

Ms. S

Mr. M

Mr.RA

Ms.LA

Mrs.TA

Mr. RAB

Mr. CR

Mr. RF

LEGEND: DM HEART DSE. ARTHRITIS ULCER HYPERTENSION ASTHMA HEALTHY

8

NARRATIVE: The patient has a disorder of Diabetes Mellitus type 2, most of his Family has mainly Diabetes Mellitus, Hypertension, Heart Disease, Asthma, Ulcer, and Arthritis. From the patient's father side, his grandfather Mr. S.A has hypertension, then his wife has died out of old age without any presence of illness. They had 7 offsprings, the first was Mr. M which has hypertension, next is Mr. V who has ulcer, thirdly Mr. P who has the presence of heart problem and ulcer, next is Ms. M who has hypertension, next was Mr. C who has heart problem, next is Mr. R who has hypertension and Diabetes Mellitus type 2, lastly is Ms. A who has ulcer and heart problem. Looking from the genetic trace, hypertension was the first disorder noted to be from their grandfather, which can be related to heart problem also. Some had ulcer because of taking advantage of their health, and not eating at the right time. Moving on to the maternal side, Their grandfather Mr. P.P has died out of heart failure while his wife also has the same illness as him. They bore 6 children, the eldest namely Mr. I has Diabetes Mellitus type 2 and hypertension,next is Ms. F who also has DM type 2, Ms. E is the next with heart failure, Ms. C has arthritis as well as Ms. M, the youngest namely Mr.M has DM type 2 also. From all those aforementioned, Mr. P and Ms. F married and bore 2 children who were Mr. R.A (our patient) has not only experiencing DM but with heart problem, and Ms. L.A who also has DM type 2 together with hypertension. Mr. R.A married Mrs. T.A who has asthma and arthritis occasionally. They had 3 offsprings, the eldest was Mr. R.A.B who inherited his fathers heart problem, next is Mr. C.R

who inherited his asthma from his mother, and lastly was Mr. R.F who luckily has no illness except for the usual colds and fever sometimes. 4. Past Health History Dring the childhood of our patient Mr.R.A, he has not complained of any illnesses except for the common sicknesses we can get from our daily living, he became a healthy child enjoying life until he reached 35 years old. By the time he reached his 35th age, unfortunately he has stepped upon a pointy object that brought his feet to bleed. He thought it was just ordinary and that it will heal very soon. But, what Mr.R.As belief was the opposite. The wound took time to heal, and thats when he checked-up and gone tests leading him to be diagnosed as a positive in Diabetes Mellitus at the same age aforementioned. Not only that he has DM type 2,he also has a heart problem making him often feel chest pains.

5. History of Present illness Mr.R.A recently has undergone hospitalization at the Hospital we had duty because he felt a general body malaise all over that it needed medical help as soon as possible. Fortunately, our patient only stayed inside the hospital for less than 1 week because of their good compliance in medicines, and through Gods aid. He still then feels very minimal numbness by the time we went on duty, but it was tolerable, he just rests, but he can walk with assistance and can sit and talk to us.

Developmental Tasks

Eriksons Eight Stages of Development

10

Stage

Age

Central Task

Stage

Result Justification

and

Infancy

Birth

to Trust Mistrust

vs.

Reported that he grew Children develop normally a sense of trust young when provide reliability, caregivers kid, demonstrated a steady as up a

18 mos.

care, normal and affection. A growth.

lack of this will Nourished with lead to mistrust. breast milk for a year and a half.

Toddler

18 to

mos. Autonomy 3 vs. Shame Children need to develop a sense of control physical personal over skills and Doubt

Can alone

fully

walk onto

without

years

holding

support bars at the age of 1 year and 8 months. Was claimed to be very anxious about things enjoys alone. negativistic about things. many many and playing Very

and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.

11

Preschool er

3 to

years Initiative vs. 5 Guilt Children need to begin control power Success over in environment. this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. asserting and the

Play most

was of to

the the go for At

important

years

activity day. Started and

along with peers look adventures.

this age, she can manage to wash himself and training established. alone toilet was

School Age

6 to 12 Industry vs. years Inferiority

Started grade 1 at the age of 6 Children need to years old. cope with new enjoyed social academic
12

He the

and company of his

demands. a while sense

friends and also of Shows interest in studying and failure playing.

Success leads to loves to study. competence, results in feelings of inferiority. Adolescen ce 12 to 20 Identity vs. years Role confusion Teens of need self to and develop a sense personal identity. Success leads to an ability to stay true to yourself, while leads weak self. Early Adulthood 18 to 25 Intimacy vs.Already got married at the Already Young adults years Isolation got married at need to form the age of 22 intimate, loving years old. And he relationships with had 3 children; other people. some were Success leads to already strong professional and relationships, some got while failure married and results in have children
13

This was marked as the most memorable time of the patients life that already experienced boy to relationship. girl especially at this

stage, she had

failure to sense role of

confusion and a

loneliness isolation.

and too.

Now, Middle Adulthood 40 to 65 Generativit years y Stagnation Adults things outlast children creating positive that other feelings usefulness while need that to will vs. create or nurture them, or a change benefits people. of and failure in more

its

his

concern to have grandchildren and his children would raise them properly. ever his been supportive these times. He is has very in glad family that

often by having

Success leads to

accomplishment, results in shallow involvement the world.

14

PHYSICAL ASSESSMENT

DEFINITION OF DIAGNOSIS

1. Diabetes Mellitus is a group of metabolic diseases in which defects in insulin secretion or action results in high blood sugar ( hyperglycemia). Diabetes is a serious disease that can cause complications such as blindness, kidney failure, heart attacks, and strokes, -Understanding Medical Surgical Nursing (2nd edition) By: Linda S. Williams/ Paula D. Hopper

2. Type 2 DM, previously called NIDDM or adult-onset Diabetes, also appears to be a heterogenous disorder involving both genetic and environmental factors. It is unclear whether impaired tissue ( liver and muscle) sensitivity to insulin or impaired insulin secretion is the primary defect in this type of Diabetes. -Medical Surgical Nrsing(6th edition, Vol.2)
15

By: Joyce M. Black/ Jane Hokansons Hawks/ Annabelle M. Keene

3. The two main problems related to insulin in type 2 Diabetes are insulin resistance and impaired insulin secretion. Insulin resistance refers to a decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 Diabetes, these intracellular reactions are diminished, thus rendering insulin less effective at stimulating glucose uptake by the tissues and at regulations glucose released by the liver. -Medical Surgical Nursing(10th edition, Vol. 2) By: Suzanne C. Smeltzer/ Brenda G. Bare ANATOMY AND PHYSIOLOGY

16

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. PANCREAS Glandular organ are organs that secretes digestive enzymes and hormones. In humans, the pancreas is a yellowish organ about 7 in. (17.8cm) long and 1.5 in., 1.5 in. (3.8cm) wide. It lies beneath the stomach and is connected to the small intestine at the duodenum. Most of the pancreatic tissue consists of grapelike clusters of cells that produce a clear fluid (pancreatic juice) that flows into the duodenum through a common duct along with bile from the liver. Pancreatic juice contains three digestive enzymes: tryptase, amylase, and lipase that, along with intestinal enzymes, complete the digestion of proteins, carbohydrates, and fats, respectively. Scattered among the enzyme producing cells of the pancreas are small groups of endocrine cells, called the islets of langerhans that secrete two hormones, insulin and glucagons. The pancreatic islets contain several types of cells: alpha-2 cells, which produce the hormone glucagons; beta cells, which manufacture the hormone insulin; and alpha-1 cells, which produce the regulatory agent glucagons has the opposite action. Failure of the insulinsecreting cells to function properly results in which can occur in two major forms, the division being between juvenile onset and onset in maturity.
17

EYES Eyes are organs that detect light, and convert it to electro-chemical impulses in neurons. The simplest photoreceptors in conscious vision connect light to movement. In higher organisms the eye is a complex optical system which collects light from the surrounding environment; regulates its intensity through a diaphragm; focuses it through an adjustable assembly of lenses to form an image; converts this image into a set of electrical signals; and transmits these signals to the brain, through complex neural pathways that connect the eye, via the optic nerve, to the visual cortex and other areas of the brain. Eyes with resolving power have come in ten fundamentally different forms, and 96% of animal species possess a complex optical system. Imageresolving eyes are present in molluscs, chordates and arthropods. KIDNEY One of a pair of bean-shaped, purplish brown urinary organs in the dorsal part of the abdomen, located on each side of the vertebral column between the twelfth thoracic and third lumbar vertebrae. In most individuals the right kidney is slightly lower than the left. Each kidney is about 11 cm long, 6 cm wide, and 2.5 cm thick. In the newborn the kidneys are about three times as large in proportion to the body weight as in the adult. The kidneys filter the blood and eliminate wastes in the urine through a complex filtration network and resorption system comprising more than 2 million nephrons. The nephrons are composed of glomeruli and renal tubules that filter blood under high pressure, removing urea, salts, and other soluble wastes from blood plasma and returning the purified filtrate to the blood. More than 1183 L of blood pass through the kidneys every day, entering the kidneys through the renal arteries and leaving through the renal veins. All the blood in the body passes through the kidneys about 20 times every hour, but only about one fifth of the blood volume is routed through the nephrons. The kidneys remove water as urine and return water that has been filtered to the blood plasma, thus helping to
18

maintain the water balance of the body. Hormones produced by the pituitary gland, especially the antidiuretic hormone, control the function of the kidneys in regulating the water-electrolyte balance of the body. ARTERIES Arteries are blood vessels that carry blood away from the heart. This blood is normally oxygenated, exceptions made for thepulmonary and umbilical arteries. The circulatory system is extremely important for sustaining life. Its proper functioning is responsible for the delivery of oxygen andnutrients to all cells, as well as the removal of carbon dioxide and waste products, maintenance of optimum pH, and the mobility of the elements, proteins and cells of the immune system. In developed countries, the two leading causes of death, myocardial infarction andstroke, each may directly result from an arterial system that has been slowly and progressively compromised by years of deterioration.

HEART The heart is a myogenic muscular organ found in all animals with a circulatory system (including all vertebrates), that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions. The term cardiac (as incardiology) means "related to the heart" and comes from the Greek , kardia, for "heart". The chambered muscular organ in vertebrates that pumps blood received from the veins into the arteries, thereby maintaining the flow of blood through the entire circulatory system. SKIN The skin is the outer covering of the body. In humans, it is the largest organ of the integumentary system made up of multiple layers ofectodermal tissue, and guards the underlying muscles, bones, ligaments and internal organs.
19

Human skin is similar to that of most other mammals except that it is not protected by a pelt and appears hairless though in fact nearly all human skin is covered with hair follicles. There are two general types of skin, hairy and glabrous skin. The adjective cutaneous literally means "of the skin" (from Latincutis, skin). BONES Bones are rigid organs that form part of the endoskeleton of vertebrates. They function to move, support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue. Bones come in a variety of shapes and have a complex internal and external structure they are lightweight, yet strong and hard, in addition to fulfilling their many otherfunctions. One of the types of tissue that makes up bone is the mineralized osseous tissue, also called bone tissue, that gives it rigidity and ahoneycomb-like three-dimensional internal structure. Other types of tissue found in bones include marrow, endosteum and periosteum, nerves,blood vessels and cartilage. There are 206 bones in the adult human body and 270 in an infant. The largest bone in the human body is the femur.

20