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Case Press Final
Case Press Final
College of Nursing
Governor Pack Road, Baguio City Philippines 2600
A Case Report:
Diabetes Type II (Non Insulin Dependent)
In Partial Fulfillment
of the Requirements in
Bachelor of Science in Nursing
By:
March 8, 2010
University of the Cordilleras
College of Nursing
The client complains of long healing process of his wound on his left foot and
edema on his left lower extremity prior to admission in Tagudin General Hospital and
Capillariasis Center (TGHCC).
The client has stepped on a sharp thing and he noticed that his wound on his left
foot took a long time to heal and noted with edema. The complaint started a week after he
got a cut on his left foot at around 8pm of November 9, 2009. He went to another hospital
around their place but he said that they made the wound worst. Then he was referred to
TGHCC where Doctor E.J.D started debridement on his left foot 4 days after admission.
He was diagnosed with DM type II and he was also in and out of the Hospital.
They have a small farm that he handles. He is the head of the family and he is also
a full time dad of his children. He is a farmer. He is a father of 6 children, 3 females and
3 males.
VI. Family History
XX XX
(+)DM
(+)HPN
59 y/o 51 y/o
(+) (+)
DM HPN
32 y/o
38 y/o (+) DM 24 y/o
(+) HPN
27 y/o 19 y/o
34 y/o
(+) HPN
LEGEND:
Male - Patient
P
Female
X-dead
VII. Physical Examination
I. Psychosocial Status
A. Mental
B. Emotional
Mr. R.R.H is good all in all. He is not restless, he can easily verbalize what he
feels and he can be easily approached. He is not irritable but he is always cooperative
with the health team.
1. Visual Status
He can distinguish objects, pupils equally reactive to light and accommodation.
No observed visual deficits present.
2. Auditory Status
There are no auditory deficits that were observed on Mr. R.R.H. He can
distinguish different voices and can easily determine soft and loud sounds.
3. Olfactory Status
He can easily distinguish different odors around him.
4. Gustatory Status
No alterations on his gustatory function. He can taste the food that he is eating.
He inhales through his nose and exhales through his mouth.
5. Tactile Statuserenti
The client was able to discriminate light touch when his hands was stroked using
a cotton ball. He is reactive to warm touch or painful objects of pinching by
reacting or moving away from the stimulus or moving away from the stimulus. He
can differentiate cold and water using a face towel . He can also different by
touch. However, when left foot was assessed there was pain noted characterized
by intermittent pricking pain
6. Language Perception and Formation
He has the ability to understand, initiates speech and can read. He does not
initiates the conversation and only respond when talk to. No noted abnormalities such as
cleft lift palate or mouth sore that would affect his speech. No difficulty in speech and
breathing was noted. Mouth, teeth, tongue and palate are intact.
V. MOTOR STATUS
Minimal restriction on prolonged walking and standing because he has a risk for
injury.
He has poor muscle strength due to the physical stress and imbalance, muscle tone
is normal and symmetrical. Range of motion is limited due to weakness and infected left
leg. He needs assistance when performing ADL.
X. TEMPERATURE STATUS
His temperature status is at normal range at 37. 2 to 37.5◦c as per axilla with no
sign of hyperthermia nor hypothermia, despite the hot weather in Ilocos Sur.
XI. INTEGUMENTARY SYSTEM
The client has dark brown complexion. His upper and lower extremities are dry,
the wound is moist. Legs have scars, skin texture is rough, patient’s nails were not
clean, there’s no presence of dandruff noted. The patient changes clothes every day.
He doesn’t practice hand washing, oral hygiene was not observed.
XII. ELIMINATION
There were no signs of urinary retention, constipation, diarrhea and abnormal
bowel sounds. He has a regular bowel movement. The client usually defecates 2 times a
day. The urine was amber in color. He used toilet for defecation and urination.
LABORATORY TEST
Trade Name Generic Name Classification Mechanism of Action Side Effects Nursing Considerations
Ceftriaxone Anti-infectives 3rd generation CNS: fever, headaches, dizziness > Obtain specimen for culture
Sodium cephalosporin that GI: pseudomembranous colitis, and sensitivity tests before
inhibits cell-wall diarrhea giving first dose.
synthesis, promoting GU: genital pruritus, candidiasis > For I.M. administration, inject
osmotic instability; Hematologic: eosinophilia, deeply into a large muscle, such
usually bactericidal. thrombocytosis, leucopenia as the gluteus maximus or the
Skin: pain, induration, tenderness at lateral aspect of the thigh
injection site, rash, pruritus > If large doses are given,
Other: hypersensitivity reactions, therapy is prolonged, or patient
serum sickness, anaphylaxis, is at high risk, monitor patient
chills for signs and symptoms of super
infection.
Cefuroxime Anti-Infectives 2nd generation CV: phlebitis, thrombophlebitis > For I.M. administration, inject
cephalosporin that GI: pseudomembranous colitis, deeply into a large muscle mass,
inhibits cell-wall nausea, anorexia, vomiting, such as the gluteus maximus or
synthesis, promoting diarrhea the lateral aspect of the thigh.
osmotic Hematologic: transient neutropenia, > Absorption of cefuroxime is
instability; usually eosinophilia, hemolytic anemia, enhanced by food
bactericidal. thrombocytopenia.
Trade Name Generic Classification Mechanism of Action Side Effects Nursing Considerations
Name
> Cefuroxime tablets may
Skin: maculopapular and be crushed, if absolutely
erythematous rashes, necessary, for patients
urticaria, pain, induration, who can’t swallow tablets.
sterile abscesses, Tablets may be dissolved
temperature elevation, in small amounts of juice
tissue sloughing at I.M. or milk.
injection site. > If large doses are given,
Other: hypersensitivity, reactions, therapy is prolonged, or
serum sickness, patient is at high risk,
anaphylaxsis monitor patient for signs
and symptoms of super
infection.
Diclofenac Nonsteroidal anti- Produces anti- CNS: anxiety, depression, > Monitor patients
Potassium inflammatory drug inflammatory, analgesic, dizziness, drowsiness, insomnia, closely for decrease
and antipyretic effects, irritability, headache, aseptic renal blood flow,
possibly by inhibiting meningitis especially patients with
prostaglandin synthesis. CV: heart failure, hypertension, renal or heart failure.
edema, fluid retention > Liver function test
EENT: tinnitus, laryngeal values may become
edema, swelling of the lips and elevated during therapy.
Monitor transaminase,
especially
Trade Name Generic Name Classification Mechanism of Action Side Effects Nursing Considerations
Trade Name Generic Classification Mechanism of Action Side Effects Nursing Considerations
Name
Clindamycin Anti-infective Inhibits bacterial protein CV: thrombophlebitis > I.M. injection may raise
synthesis by binding to the GI: nausea, vomiting, abdominal CK level in response to
50S subunit of the pain, diarrhea, pseudomembranous muscle irritation.
ribosome. colitis > Monitor renal, hepatic,
Hematologic: transient leucopenia, and hematopoietic
eosinophilia, thrombocytopenia functions during
Hepatic: jaundice prolonged therapy.
Skin: maculopapular rash, urticaria > Observe patient for
Other: anaphylaxis signs and symptoms of
superinfection.
> Don’t give opioid
antidiarrheals to treat
drug-induced diarrhea.
IV Fluids
Plain LRS D5LRS
Effect or Uses It stays where it is infused (intravascular space). It Pulls fluid and electrolytes from the intracellular
expands this compartment without pulling the and interstitial compartments into the intravascular
fluid from other compartments (intracellular and compartment.
interstitial).
Significance Used for large-volume fluid replacement Stabilize blood pressure, increase urine output,
and reduce edema
COMPREHENSIVE PATHOPHYSIOLOGY AND MANAGEMENT
DIABETES TYPE II
Increased
Degradation of proteins Decreased absorption of glucose by the cell Breakdown of fats
FBS to 180
Hunger
Hyperviscosity of the
blood POLYPHAGIA
Imbalance
between intake
and utilization of
glucose
Decreased circulation
Impaired pain
sensation Increased
(superficial) thirst
Delayed wound healing Hyperglycemia
Increased
urination
4. Risk for imbalance nutrition less than body requirements related to decrease oral
intake as evidenced by lack of interest of food
According to Maslow’s hierarchy of needs the first thing to be prioritized is
physiologic needs such as the food that we take in. That is why we considered risk for
imbalanced nutrition less than body requirements to be prioritized among the potential
problems because adequate nutrition plays an important role in healing and recovery of
patient R.R.H much so that he has Diabetes Mellitus Type II.
Adequate nutrition also is necessary to meet the body’s demands. However, we
need to consider that nutritional status can be affected by the disease like DM Type II.
Physical factors such as muscle weakness and pain can also be a factor. Social factors
like lack of financial resources to obtain nutritious foods can also be a reason which
could affect client’s demand for nutrition and psychological factors such as depression
and boredom observed from Mr. R.R.H.
5. Risk for injury related to gait and balance impairment secondary to tremors
Lastly our client’s safety is our last priority because of the presence of the wound
on his left foot, therefore he cat walk normally and has a limited range of motion. To
further prevent injury and relate this with impairment of patient’s mobility is necessary to
ensure optimum wellness.
ASSESSMENT EXPLANATION GOALS AND INTERVENTION RATIONALE EXPECTED OUTCOME
OF THE OBJECTIVES
PROBLEM
To promote
Discussed care of wellness
dependent limbs,
body hygiene, .
foot care when
circulation is
impaired
Assessment Explanation
Explanation
of the of the Goal and Nursing Diagnosis Rationale Evaluation
Assessment Goals and objective Intervention Rationale Evaluation
Problem problem Objective
S> “Mayat metten, Alcohol drinker STO: After 8 hours of Dx: Goal STO>
met if:Goal met after 8
talaga
O> Visible
nga daytoy sugat STO: appropriate nursing Dx: >Assessed integrity of > Assessing the skin and Patient hourswill
of nursing
verbalize
ko lang.” in muscle
decrease Afterintervention
30 thepatient the
Assessed copingleft foot wound skin structure
To evaluate degree or will tell understanding
interventionof potential
the patient:
tone Diabetes
Diabetes
mellitus mellitus
type typeminutes
2 will:
of nursing abilities surrounding
that may skin andsource ofyou any
risk in abnormality
the that
risk factors
a. showsthatpicking
contribute
of
O>bandaged infected
limited range 2 intervention,
a. showthe in picking skin
result in injury structure. can result
individual situation to infection to possibility
appropriate
of injury
food for
likehis
wound of at left foot
motion patient will
appropriate
be able foodforDetermined
his history To assess especially
causativewhen or purulent musclenutrition.
cramps and
>reddened and
Generalized dark Loss of sensation on
to the
verbalize
nutrition. of hypertension or drainage
contributing factor is present. decrease
b. starts
muscle
to show
tone some
surrounding
body of the lower extremities understanding
b. startsofto show some >Assessed
any changes in the blood supply >To evaluate impairment limited exercises that he
wound weakness potential limited
risk exercises that he and sensation
body that increases of affected of circulation to lower can tolerate.
>Destruction
Small steps of skin Decrease insulin factors that
can tolerate. area.
risk for injury extremities that might be c.shows appropriate way
layerswhen
on the left leg Production
Bruise in the left footcontributec. shows
to appropriate way
Assessed ability to For safetycause of the bandage.
measures on protecting his wound
>invasion of body
walking with possibility
on protecting
of injury his wound >Assessed
ambulate with skin color, > Can identify good or
structures
assistance like muscle cramps minimal texture and turgor.
assistance poor blood circulation of LTO> Goal met after 2
>wound characterized
Responsive DecreaseNormal
absorption
flora in
oftheand
skindecrease
LTO: After 2 to 3 days
Evaluated To reduce therisk
affected part.
for injury to 3 days of appropriate
with to
yellowish
stimuli drainage.glucose thrive
by theintocell
the wound
muscle tone
of appropriate nursing Tx: for
environment nursing intervention the
because of increase intervention the patient >Removed
safety hazards wet/wrinkled >Moisture potentiates patient:
A> Impaired skin glucose level in the will: Assess mood,linens.coping Individual’s skin breakdown
temperament, that a. display timely healing
integrity related
A> Risk for to tissue blood LTO: a. display timely healing
abilities, personal cause additional
typical behavior, stressor LTO: ofGoal
skinmet
wound
if: without
trauma
injury secondary
related to to Accumulation of Withofinskin
2 to wound
3 without
styles and levelcomplication
of self-esteem to the
can The patient
complication
will be able to
diabetes mellitus
gait and balance type 2glucose in the blood days of complication
nursing patient.
affect attitude towards demonstrate
b. Maintain
appropriate
optimal
impairment ( unutilized)
Decreased woundintervention,
b. maintain
the optimal >Aseptically dressed > Promotes faster
safety issues, resulting in healing
lifestyle
nutrition
changesand tophysical
reduce
secondary to DM healing patient and nutrition and physical wounds and infection
carelessness or increased risk for
well
injury.
being.
type II significant
well others
being. > Keep the wound and its >To prevent
risk talking without infection
will demonstrate surrounding clean and consideration
Wound increase inappropriate
size dry.
> Assess client’s Cognitive status affects
Hyerglycemia lifestyle changes to cognitive status
client’s ability and own
reduce risk for Edx:
limitations in risk for injury
Tissue trauma injury > Encouraged to eat > To aid in further
nutritious foods supplementation.
especially vit.C and Adequate protein helps in
Nerve demyelinazation Tx: adequate protein. and wound healing. Low
Resources: 10th edition low sugar diet. To decrease sugarriskdietofwill
injury
decrease
Kept floor of the by providing a safe
medical-surgical nursing the skin’s inability to heal
room clean and dry environment
Loss ofbysensation
Suddarthonand theBrunner quickly whenever there is
lower extremities Attended to needs To promote safety measures
a wound.
(Superficial) and assisted with
>Encouraged ambulation >Promotes better blood
activitieswith
as needed May improve
the use of assistive muscle
circulation.
Provideddevicepositioning Tone
Risk for Injury as required by
>Discussed importance > Early detection leads to
situationof early detectionofPromote safety
skin early measuresand
prevention
th
Resources: 10 edition Demonstratedchanges useand
of cure.
medical-surgical assistive devices
complications.
ASSESSMENT EXPLANATION OF GOALS AND INTERVENTIONS RATIONALE EXPECTED
THE PROBLEM OBJECTIVES OUTCOME
O Decreased absorption STO: Dx:
>weight loss of about of glucose by the cell After 8 hours Documented actual T o obtain Goal Met, if client
2 kgs prior to of nursing weight baseline data such will be able to
admission:78kgs to 76 interventions the as loosing or verbalize
kgs. Cell Startvation client will be able gaining weight of understanding on the
>with sleep to: patient importance of proper
disturbances a. Verbalize Obtained Patient’s diet and enumerate
>weak in appearance Stimulation of hunger understanding on the nutritional history perception of foods to be included in
>fatigue noted mechanism via importance of proper including family, actual intake may his diet.
>increased food intake hypothalamus diet. significant others differ
>good dentition b. Enumerate Determine Proper assessment
foods to be etiological factors guide
hunger included in for reduced intervention. Goal met, if client will
A>Risk for his diet nutritional intake be able to demonstrate
Imbalanced nutrition Monitor and Psychological, changes and maintain
less than body polyphagia LTO: explore attitudes psychosocial and proper diet.
requirement related to After 2 days of toward eating cultural factors
decrease oral intake as Imbalance between nursing interventions, behavior determine the
evidenced by lack of intake and utilization the type, amount and
interest in food of glucose client will be able appropriateness of
to: Monitor food consumed.
As evidenced by : a. demonstrate environment in This could affect
hyperglycemia, changes in which eating client’s appetite to
increase urination, his diet as occurs. eat.
increased thirst manifested Tx:
by proper Consulted dietician Determination of
weight loss food selection b. for further type, amount and
Maintained proper assessment and pattern if food or
Imbalanced Nutrition diet recommendations fluid intake is
less than body regarding food facilitated
requirement preferences and
nutritional support
for the client
Assisted in feeding Maintaining
proper nutrition
Edx:
Encouraged
patients It serves a
participation in baseline data and
recording daily awareness of
food intake patient’s own
condition
DISCHARGE PLAN
Patient Teaching Rationale
A. Activities
Instructed the client not to To prevent unnoticeable skin injuries
walk bare footed or breaks during ambulation due to
diabetic neuropathy
Encouraged the patient to To promote good circulation in the
perform active and passive distal body parts and to prevent
ROM compromised circulation in the
peripheries which can lead to tissue
necrosis
Encouraged the patient to To avoid low self-esteem. Social
interact or socialize with support is very important to the
significant others and other client.
people around him
B. Diet
Teach patient to read labels To prevent worsening the present
of "health" foods because condition and for the patient to
they contain sugar product know how to control his blood sugar
such as honey, brown sugar level independently
and corn syrup, jams, ,
syrups, tinned food, sweets,
chocolates, lemonade,
proprietary milk cakes,
sweet biscuits, pies,
puddings and thick sauces
and others that contains and
are prepared with the use of
sugar
Advised the patient to limit It may increase the glucose level in
intake of saturated fat and the blood due to gluconeogenesis to
cholesterol. meet the metabolic needs of the
body. Increase cholesterol level may
lead to hypertension.
Encouraged the patient to It is one of the precipitating factors
avoid drinking alcoholic of diabetes mellitus
beverages.
Food should be high in fiber This slows glucose absorption and
(apples, pineapples) soothes post prandial glucose levels.
C. Medications
Instruct the patient not to Because there will be a bitter
crush, chew or break the after taste, and there will be
medications unless he has alteration on the effectiveness on the
difficulty swallowing medication
Instructed the client to take
Diclofenac potassium with One of the side effects of this
full stomach drug is gastric irritation that may
Advised the patient not to cause ulceration.
abruptly discontinue the If the patient abruptly
medication even if he feels discontinue the medication this may
better unless instructed by cause resistance to drugs and may
the physician need higher dosage.
D. Others
Proper fitting of shoes The appropriate time for
buying shoes is late in the afternoon
because the feet are fully expanded.
Alternatives to wound care It has antiseptic effect and it
such as Guava leaves can be use for wound cleaning
proven by the DOH.
CONCLUSIONS AND RECOMMENDATIONS:
• Exercise daily, aerobic exercise is better for weight loss and protects from heart
disease. Additionally, weight loss is recommended and is often helpful in persons
suffering from type 2 diabetes.
http://www.tandurust.com/diabetes/type-2-diabetes-mellitus-diet.html
http://www.healthypinoy.com/health/articles/diabetes/fasting-blood-sugar.html
Suddhart and Brunner, Medical Surgical Nursing, Edition 10th and 11th,2008
Doenges, Moorhouse and Murr, Nurse’s pocket guide, Edition 11, 2008
Lippincott 2008
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?
plan=37
http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2