LEVEL 2 . NCM 102 .

2 SEM SY 2009-2010
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Level 3

CASE PRESENTATION
1st Semester SY 2010-11

I. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses on
how to care for patients with Diabetes Mellitus Type II effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to :

1. Define Diabetes Mellitus II and its effects to the body as a whole;
2. Illustrate the pathophysiology of Diabetes Mellitus Type II and in relation to the signs and
symptoms specifically observed in the client;
3. Describe and identify the common signs and symptoms of Diabetes Mellitus Type II;
4. Discuss the medical and surgical interventions for the management of Diabetes Mellitus
Type II;
5. Formulate appropriate nursing care plans suited for the client based on the assessment
findings;
6. Identify care measures to be given to the patient and family to promote continuity of care
and independence after discharge.

II. Client’s Profile

This portion provides general information about the client.

!!! ALERT !!! Anonimity should at all times be observed.
All data presented should not be linked with the identity of the client - unless
written and informed consent has been obtained to present identifying
information.

Name : Herico, Elena Bola

Age : 76 years old
Birth date : January 03, 1934
Sex : Female
Ethnic Background : Ilocano
Civil Status : Widow
Address : # 14 Ortega St., San Fernando City, La Union
Religion : Roman Catholic
Occupation : House Wife

Admitting Diagnosis : Diabetes Mellitus Type II

Final/Principal Diagnosis :
Admitting Physician : Dr. Flerida A.
Date and Time Admitted : July 13, 2010; 01:36pm

III. Chief Complaint

This presents the main complaint/s of the client, the reason consultation was sought and hence,
admitted.

The patient complains generalized body weakness.

IV. Present History of Illness

The patient started to feel need for consultation while at home when she felt generalized body
weakness and dizziness. Upon this condition, the patient decided to seek consultation.
July 13, 2010, the patient went to Bethany Hospital for consultation and undergone laboratory
examination (Hgt) and found out that her blood glucose is 273mg% above normal range which is 110-
170mg%. Prior to admission the blood pressure is 140/90mmHg. The doctor advised her to be
admitted in the hospital.

V. Past History of Illness

The patient has a history of Diabetes Mellitus Type II. She has a maintenance medication for her
diabetes and hypertension.
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VI. Family Health History

Narrative form. This portion describes the presence of any hereditary disorders/familial-tendency
illnesses experienced by the client or any member of the the client’s family.

The client claims to have familial history of Hypertension, Coronary Artery Disease and Cancer
on his mother’s family. Health problems such as Asthma, kidney diseases, diabetes, or mental illness
was verbalized to be absent. No present illness is currently experienced by any member of the
family.

VII. Developmental History

Narrative form. This portion describes significant patterns of the client’s behavior in line with his
current stage of development.

The client is the last son out of the other 5 siblings, which are composed of 4 males and a
female. He is a 19 year old teenager with the task of developing his Identity according to Erik Erikson’s
Developmental theory. He has verbalized no problems with self image and concept and reveals the
desire to achieve his goals in his studies especially in maintaining his place in the dean’s list and
hopefully graduating with honors or having a place in the Local Nursing Licensure examination. He
also noted no difficulty in interacting with people despite his silent nature. He tends to observe most
of the time but also recognized a great number of friends with whom he shared his childhood with.
He also loves music. His passion is seen in his ability to play the guitar with ease and is now learning
how to play the piano.

VIII. Social and Environmental History

Narrative form. As expressed in the sample below.

The client is non-smoker and non-alcoholic beverage drinker. No verbalized vices were
identified. However, he is constantly exposed to noxious fumes from outside air pollution and from
second hand smokers. He lives in a rented apartment together with his three other cousins near the
main highway where jitneys frequently pass. He commutes daily using the public utility jitneys for
his transport to school.
The house where they stay is made up of semi-permanent and permanent materials such as
wood and cement. Privacy is maintained with the 4 separate rooms present. Water used daily is
being supplied by the city water district while the source of drinking water is the water refilling
stations nearby.
Client also verbalized that he did not have any direct contact to harmful chemicals nor has
prepared any chemotherapeutic drugs. As a nursing student however, he is able to care for various
patients with having different respiratory health problems such as tuberculosis, pneumonia and
cough. The community exposure they had as a part of the Clinical RLE allows them to travel to
different areas where he experiences changes in the weather and differences in altitude.
The client belongs to a family with two licensed nurses, hence, the value of maintaining a
healthy lifestyle is promoted. The client with his family visits the local hospital from health problems
unresolved by home remedies and rest. The client after experiencing the same sudden pain
immediately went to the hospital to confirm the initial findings he had when he was admitted in
Sublime City. As a family that belongs to the middle class, access to health care facilities and
interventions is not much of a problem.

IX. Lifestyle and Health Practices

Narrative form. As expressed in the sample below.

As a nursing student, he is aware of the potential health threats associated with lifestyle
related vices like cancer for smoking and liver cirrhosis for alcoholic beverage drinking. He ensures
that he receives adequate nutrients by allowing himself to eat three complete meals in a day with
snacks included specially during his duty times. Food is prepared at home together with his cousins
or is bought in fast-food chains. He prefers pasta dishes and pizza. Fluid and electrolyte intake is a
total of 2 – 3 liters a day coming from fruit juices, carbonated beverages, water and milk. For
maintenance he takes Vitamin C for supplement.

X. Health Assessment

This portion presents assessments performed as seen in the example below.

A. General Survey

The client was received awake, lying on bed with a moderate high back rest elevation.
Client with ongoing IVF’s of D5LRS I L x 30 gtts per minute and a Tramadol drip (tramal)
300 mg in D5W 250 cc x 24 hours infusing well on the left arm and with oxygen inhalation
 LEVEL 2 . NCM 102 . 2 SEM SY 2009-2010
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at 2-3 LPM/ via the nasal cannula. He is connected to a three way bottle system chest
drainage with the first bottle having 300cc bloody discharge. Suction control is applied and
there is bubbling noted in the third bottle.
Client appears weak, needs assistance when assuming activities of daily living like toileting
and feeding or in changing positions. He wears a neat gown, hygiene is fair. Client is
conversant speech is well formulated, oriented to the self and others around him,
able to determine the time and date and is aware that he stays in a private room for 3 days
now.
Client is an ectomorph. He verbalized that he is 5’6” tall and weighs 51 kilograms.

B. Head to Toe Assessment

1. Head Normocephalic, hair evenly distributed, oiliness and flaking noted, no

areas of pain or tenderness during palpation
2. Eyes Able to distinguish colors, (+) for astigmatism, verbalized difficulty to
identify objects 6 feet away, wears corrective lenses, sclera is anicteric,
pupils are equally round, reactive to light and accommodation, EOM is
intact, able to follow penlight with gaze, no detectable oscillations,
mucous membranes are moist and light pink
3. Ears Able to understand and hear spoken language correctly, with minimal
cerumen build – up in the ear canal, sliver and intact tympanic
membrane
4. Nose and Nose is patent, septum is located midline, no flaring noted, able to
sinuses distinguish the scent of alcohol and perfume, no episodes of epistaxis
during the shift, sinuses are not tender on palpation
5. Mouth Complete set of adult teeth, pearly white in color, and no mal aligned
tooth, had braces for 1 year and a half year. No dental caries noted.
Oral mucosa is moist and pinkish, no lesions noted, tonsils are not
inflamed, Grade 1 bilaterally present, uvula is located midline
6. Neck ROM intact, able to change direction of head slowly but with without
complaints of pain, carotid pulse are bilaterally symmetrical, full and
strong pulses, 2+, jugular vein is not distended, superficial cervical
lymph nodes are palpable but non tender. Thyroid is located midline, no
enlargement noted, trachea is located midline
7. Chest Shape of the chest is elliptical, asymmetrical chest wall expansion
noted, with respiratory excursion best appreciated on the left side of the
thorax, decreased tactile fremitus in the right lung area, decreased
breath sounds in the right, no crackles, no wheeze, no stridor,
production of hollow drum like sounds in percussion of the right side
and resonant sound appreciated on the left. Client with an Axillary
thoracotomy, dressing intact and dry, chest tube draining to a bloody
discharge 300 cc in amount. With limited movement on the right
shoulder. Client verbalized, “mahina daw ung lungs ko, spontaneous
rupture of the bleb, kaya may pneumothorax ako” “Masakit tlaga ung
sugat, parang 8/10 din, pati ata sa loob masakit talaga, ditto lang
naman sya sa may incision, parang may tumutusok kaya binigyan nila
ako ng analgesic, ngayon, ayos ng konte pero may pain pa din at 6 na
cguro ung scale nya out of 10”. Client is observed to guard area and
grimaces when a painful stimulus is felt. Diaphoresis noted, hands are
cool to touch. Maintains the supine position with head of bed elevated
to a moderate high back rest
8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI at 50 ICS LMCL,
no murmur noted, no visible pulsations in the precordium, palpable
apical pulse
9. Breast (-) for gynecomastia, skin color is similar with the rest of the body,
nipple is dark colored, no discharges
10. Abdomen Flat, with normoactive bowels sounds heard in all the quadrants, soft,
no direct tenderness or rebound tenderness upon palpation, tympanitic,
no organomegaly.
11. Genitals Patient verbalized that he had been inserted with a catheter when he
was in the OR. No complaints of dysuria or urinary retention or
incontinence post operatively
12. Musculoskeletal muscle strength at the right side is 4/5 while the rest of extremities are
5/5.
No visible tremors noted, no complaints of pain
13. Integumentary

XI. Diagnostics
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This shows all diagnostic procedures performed with the client. Tabular form. Content of the table
must follow the format below.

Significance/Purpo
Diagnostic Description of Date of
se of the Findings & Implications
Procedure the Procedure Procedure
Procedure
Chest X-ray Chest radiography It is used to April 20, Follow-up study of the chest taken on
is the first determine the 2009 the same day, SIP CIT insertion reveals
investigation severity of the a relative partial reduction in the size of
performed to patients the previously noted right-sided
assess pneumothorax and pneumothorax. There is however no
pneumothorax to determine the significant change in the extent and
because it is progress of his appearance of the massive atelectasis
simple, medical and surgical of the right lung field. A right sided CTT
inexpensive, rapid, management. is now seen.
and noninvasive; April 22, Follow-up study of the chest since
however, it is much 2009 6/20/2009 S/p Axillary thoracotomy
less sensitive than shows complete resolution of the
chest CT in pneumothorax on the right with
detecting a small complete re-expansion of the right lung.
pneumothorax, A right sided CTT is still seen in SITU. No
blebs, and bullae. other internal change of note.
April 26, Follow-up study of the chest since
2009 6/22/09 reveals the presence of
confluent hazy densities at the right
paracardiac areas, presenting a
pneumonic process with consolidation.
There is now a homogenous opacity
with meniscus level seen at the right
lower hemithorax obscuring the right
hemi diaphragm and costrophenic angle
representing fluid.
April 26, Follow-up chest study since 6-26-2009
2009 reveals minimal clearing of the
confluent hazy densities at the right
paracardiac area. There is however,
decrease in the volume of the
previously noted fluid in the right
HEMITHORAX. A right sided CTT is still
seen in SITU.
No other internal change of note.
Ultrasound Abcdeflkjdlj alkdjf Adfjlskdjf jldkjflasd April 29, aljkdhfklashdfa
2009
Pathology Kdljfoijuelasldfjm Dgsdgasdufods April 24, Csalksdjfoi dlfjs;dfsa;fjds
2009
Blood Chem Olkdf djf;olsd Sdfdsf;luio April 27, Dsadfeds ldjoldjjw clkdjf dlkdjfld
ojasedl 2009
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XII. Comprehensive Pathophysiology

This is a diagrammatic presentation of the course of the disease. Predisposing factors, signs &
symptoms, management and nursing diagnoses presented must be in line with actual events that
occurred with the client.

PREDISPOSING FACTORS

Exposure to 2nd hand Smoking & Pollution Height (tall person), Male, 19 years
old

Chemicals (Tar) Gradient of Pleural pressure increases

from
lung base to apex
Blocks airway passages and degrade
elastic fibers of the lungs

Influx of neutrophils and macrophages Alveoli of lung apex receives the

is induced greater distension pressure

Imbalanced enzymes (protease & anti-protease)

and antioxidant system

________________Bullae/Blebs Formation______________________ N

Inflammation-induced obstructions of the airway Shearing forces

Increased alveolar pressure

Leakage to the lung interstitium, hilum and pneumomediastinum Rupture of blebs

Increased mediastinal pressure

Rupture of the mediastinal parietal pleura

_______________Pneumothorax____________________

Disequilibrium in the intrapulmonary and intrapleural pressure

Activation of the receptors that monitor Tidal volume affected Changes in the thoracic pressure
lung volume
Distortion of movement of air
Sympathetic stimulation in and out of the lungs

Tachypnea Air flows out of the alveoli

into the Pleural space

Lung collapse during recoil

Dyspnea Sudden, sharp, stabbing pain

Admission to the Hospital

---INEFFECTIVE BREATHING PATTERN---
Partial collapse of the affected lung

Impairment of gas conduction Air trapping in the collapsed lung Ruptured bleb and
lung collapse
in the lower respiratory airways activate inflammatory
response

Decreased tactile fremitus Hyper resonance on percussion Lung assymetry

---------------------IMPAIRED GAS EXCHANGE-------------------

Transudation of fluid and blood from surrounding Axillary

Thoracotomy blood vessels of the injured lung
and Bleb Excision

-------PAIN RELATED TO TISSUE TRAUMA-------

Pleural Effusion

Transudate accumulation in the pleural space

Further restriction of lung expansion Collapse of alveoli Disequilibrium in pulmonary and

pleural pressures

Increased respiratory difficulty Bleeding Surgical Incision and Insertion of CTT

Stasis of pulmonary sections Decreased Hct and Hgb Tissue trauma and
injury
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Growth of microorganisms Decreased oxygen carrying
capacity of the lungs
---RISK FOR INFECTION---
---ACTIVITY INTOLERANCE---
XIII. Treatment/Management
This shows all treatments, including medical procedures, performed with the client. Tabular form.
Content of the table must follow the format below.
A. Drugs
Classificatio Mechanism of
Name
n Action
Dosage Dosage
Generic: Cefotaxime Cephalosporin Inhibits bacterial cell wall
Na 1 gram IV every synthesis by binding to
Brand: Zefocent 12 hours one or more of the
penicillin-binding
proteins (PBPs) which in
turn inhibits the final
transpeptidation step of
peptidoglycan synthesis
in bacterial cell walls,
thus inhibiting cell wall
biosynthesis. Bacteria
eventually lyse due to
ongoing activity of cell
wall autolytic enzymes
(autolysins and murein
hydrolases) while cell
wall assembly is arrested
Generic: Cinnarizine Antivertigo Cinnarizine inhibits
Brand:Stugeron® Drugs, contractions of vascular
[Forte cap] Peripheral smooth muscle cells by
Vasodilators & blocking calcium
Cerebral channels. In addition to
Activators this direct calcium
1 tab now (75 antagonism, cinnarizine
mg) decreases the contractile
activity of vasoactive
substances eg,
norepinephrine and
serotonin, by blocking
receptor-operated
calcium channels.
Blockade of the cellular
influx of calcium is
tissue-selective and
results in anti-
vasoconstrictor
properties without effect
on blood pressure and
heart rate.
B. IV Fluids
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Pain on the incision site
---IMPAIRED MOBILITY---
Nursing Implication Significance
Asses drug allergies, hepatic and For the treatment
cardiac functions, and other of the patients
laboratory test. nosocomial
Be sure to obtain thorough infection, or to be
patient health history including specific, for the
immune status treatment of his
Assess for potential drug hospital acquired
interaction pneumonia
It is essential to obtain cultures
from appropriate sites before
starting antibiotic therapy
Patient should be instructed to
take the medications as
prescribed
Assess for signs and symptoms
of super infection: fever, cough,
lethargy or unusual discharge
For safety reasons, check the
name of the medication carefully
because there are many sound
alike or have familiar spelling
Assess patient for any redness,
swelling, burning, or pain at
injection/infusion site
Assess patient for nausea,
vomiting, abdominal distention,
and bowel sounds before and
after administration.
Observe for signs and symptoms
of anaphylaxis during first dose
May cause drowsiness.
Advise patient to Report
unresolved or persistent
diarrhea; opportunistic infection
(vaginal itching or drainage,
sores in mouth, blood in stool or
urine, easy bleeding or bruising,
unusual fever or chills); or
respiratory difficult
Assess patient for nausea, To reduce or
vomiting and caution patient for treat the patient
dizziness and sedation may feeling of
occur. dizziness and
Assess patient for blurred vision, vertigo
difficulty in micturition, dysuria,
dryness of mouth and tightness
of chest.
Patients should not operate
hazardous machinery or drive
motor vehicles or perform
potentially hazardous tasks
where loss of concentration may
lead to accidents.
Always have analgesic antidote
or antagonist : naloxone
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Name Classificatio Component/s Use & Effects Significance

n

C. Surgeries

Procedure Description & Indication Nursing Care

Thoracotomy the process of making of a
surgical incision into the chest
wall which allowed for the study
of the condition of the lungs and
removal of part of a lung. The
client had undergone an Axillary
thoracotomy. This method is
used by a majority of thoracic
surgeons for all pulmonary
resections. Its major indication is
now for pneumothorax surgery,
allowing easily apical resection
and pleurectomy with excellent
long-term results
Pleurodesis a procedure aimed at making The patient should keep the wound from the chest tube clean and
adhesions between the visceral dry until it heals. Also, the patient should watch for signs of wound
and parietal pleura, obliterating infection such as redness, swelling, and/or drainage, and be alert
the potential pleural space to symptoms indicating that the effusion recurred.
indicated for conditions such as
pneumothoraxPleurodesis is
achieved by putting one of any
number of chemicals (sclerosing
agents or sclerosants) into the
pleural space. The sclerosant
irritates the pleurae which results
in inflammation (pleuritis) and
causes the pleurae to stick
together. The patient is given a
narcotic pain reliever and
lidocaine, a local pain killer, is
added to the sclerosant. A variety
of different chemicals are used as
sclerosing agents. There is no one
sclerosant that is more effective
or safer than the others.
Chest Tube procedure made to place a The chest tube typically remains secure and in place until imaging
studies such as X rays show that air or fluid has been removed
Drainage flexible, hollows drainage tube
from the pleural cavity.
into the chest in order to remove Nurses must also note for such complications like:
bleeding from an injured intercostal artery (running from the
an abnormal collection of air or
aorta)
fluid from the pleural space. accidental injury to the heart, arteries, or lung resulting from
the chest tube insertion
The client was attached to a three
a local or generalized infection from the procedure
way bottle system with the first persistent or unexplained air leaks in the tube
the tube can be dislodged or inserted incorrectly
bottle as the drainage, the
insertion of chest tube can cause open or tension
second as the water seal and the pneumothorax
third bottle connected to a
suction control

XIV. Nursing Care Plans

A. Prioritization of Problems
1. List of Problems

This portion lists the health problems according to priority (No. 1 having the highest priority).

Health Problems are stated as Nursing Diagnoses using the Basic 3-Part Statement : PES Format
- Problem Statement + Etiology + Signs and Symptoms
- Three parts are joined together by “related to” or “associated with” and “as manifested by” or
“as evidenced by”
- Ex: Self-Esteem Disturbance related to rejection by husband as manifested by hypersensitivity to
criticism, stating "I don't know if I can manage by myself", and rejecting positive feedback
- Variations to the PES format in order to make the problem statement more descriptive
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(e.g. adding "Secondary to") is acceptable as long as the part following “secondary to” is a
disease process
(Ex: High-Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to
Diabetes)

Problems should comprise AT LEAST 3 Actual Problems and 1 Potential Problem ranked in order of
priority.

2. Basis of Prioritization

This portion presents the basis of how the health problems were prioritized. Prioritization should also
be discussed.

B. Nursing Care Plans

The Care Plans for the Nursing Diagnoses shall be presented here.
The format discussed during the Orientation shall be followed.
XV. List of References

This portion cites all books, journals and other references that were used as shown in the example
below

American Lung Association. (2000). Asthma statistics. [On-line.] Available: http://lungusa.org/data.

Babu K.S., Salvi S.S. (2000). Aspirin and asthma. Chest 118, 1470– 1476.

Busse W.W., Lemanske R.F. (2001Asthma. New England Journal of Medicine 344, 350–362.

Chan-Yeung M., Malo J. (1995). Occupational asthma. New England Journal of Medicine 333, 107–112.

Chestnut M.S., Prendergast T.J. (2002). Lung. In Tierney L.M., McPhee S.J., Papadakis M.A. (Eds.),
Current medical diagnosis and treatment (41st ed., pp. 350–355). New York: Lange Medical Books/
McGraw-Hill.

Cotran R.S., Kumar V., Collins T. (1999). Robbins pathologic basis of disease (6th ed., p. 713). : W.B.
Saunders.

Dubuske D.M. (1994). Asthma: Diagnosis and management of nocturnal symptoms. Comprehensive
Therapy 20, 628–639.

Gilliland F.D., Berhane K., McConnell R., et al. (2000). Maternal smoking during pregnancy,
environmental tobacco smoke exposureand childhood lung function. Thorax 55, 271–276.

Light R.W. (1995). Diseases of the pleura, mediastinum, chest wall, and diaphragm. In George R.B.,
Light R.W.,

Matthay M.A., et al. Eds.), Chest medicine (3rd ed., pp. 501–520). Baltimore: Williams
& Wilkins.

McFadden E.R., Gilbert I.A. (1994). Exercise-induced asthma. NewEngland Journal of Medicine 330,
1362–1366.

National Asthma Education and Prevention Program. (1997,2002). Expert Panel report 2: Guidelines for
the diagnosis and management ofasthma, and Guidelines for the diagnosis and management of
asthma—Update on selected topics 2002. Bethesda, MD: National Institutes of Health, National Heart,
Lung, and Blood Institute. Available: http://www.nhlbi.nih.gov/guidelines/asthma.

Romero S. (2000). Nontraumatic chylothorax. Current Opinion in Pulmonary Medicine 6, 287–291.

Sahn S.A., Heffner J.E. (2000). Spontaneous pneumothorax. New England Journal of Medicine 342, 868–
874.

Sly M. (2000). Allergic disorders. In Behrman R.E., Kliegman R.M., Jenson H.B. (Eds.), Nelson textbook
of pediatrics (16th ed., pp. 664–685). Philadelphia: W.B. Saunders.

Tan K.S., McFarlane L.C., Lipworth B.J. (1997). Loss of normal cyclical B2 adrenoreceptor regulation and
increased premenstrual responsiveness to adenosine monophosphate in stable female asthmatic
patients.Thorax 52, 608–611.

Young S., LeSouef P.N., Geelhoed G.C., et al. (1991). The influence ofa family history of asthma and
parental smoking on airway responsiveness in early infancy. New England Journal of Medicine
324,1168–1173.
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