A client Situation: Diabetes Mellitus

Mr. R.S. a type 2 diabetic (Formerly a non-insulin dependent diabetic, or NIDDM) for 10 years, presented
to his physician’s office with non healing ulcer of 3 weeks duration on his left foot. Screening studies
done during the exam revealed blood glucose (BG) of 356/ fingerstick and urine Chemstix of 2%.
Because of distance from medical provider and lack of local community services, he is admitted to the
hospital.
Admitting Physician’s order:
Culture/sensitivity and Gram’s stain of foot ulcer
Random blood glucose on admission and finger stick BG qid
CBC, electrolytes, serum lipid profile, glycosylated Hb in AM
Chest x-ray and ECG in AM
DiaBeta 10 mg, PO, bid
Glucophage 500 mg, PO, daily to start- will increase gradually
Humulin N 10 U SC q AM and hs. Begin insulin instruction for post-discharge self-care, if necessary.
Dicloxacillin 500 mg PO, q6h start after culture obtained
Darvocet-N 100 mg q4h PRN pain
Diet 2400 calories/three meals with two snacks
Up in chair ad lib with feet elevated
Foot cradle for bed
Irrigate lesion L foot with normal saline TID then apply wet to dry sterile dressing
Vital Signs qid

Client Assessment Database

Name: R.S. Informant: Client reliability (scale 1-4), 3, Age 73, DOB: 5/3/31 Race: white Gender: M
Admission date: 6 /28/2004

Acti vity/rest:
Reports (Subjective): Occupation: Farmer
Usual activities/hobbies: Reading, playing cards, “Don’t have time to do much. Anyway
im too tired most of the time to do anything after the chore’s”
Limitations imposed by illness: “Have to watch what I order If I eat out.”
Sleep: hours: 6-8/night
Naps: No
Aids: No
Insomnia: “Not unless I drink coffee after supper.”
Usually feels rested when awakens at 4:30 am

Exhibits (Objective data) Observe response to activity: Limps, favors L foot when walking
Mental status: Alert/ active
Neuromuscular assessment: Muscle mass/ tone: bilaterally equal/ firm
Posture: Erect ROM; Normal all extremities
Strength: equal 3 extremities/ favors L leg currently

Circulati on:
Reports (Subjective): Slow healing: Lesion L Foot, 3 weeks duration
 Extremities: Numbness/tingling: my feet feel cold and tingly like sharp pins poking the
bottom of my feet when I walk the quarter mile to the mail box.”
Cough/character of sputum: Occasional/white
Change in frequency/ amount of urine: Yes, voiding more lately

Exhibits (Objective data): Peripheral pulses: Radial 3+, popliteal, dorsalis, posttibial/ pedal, all 1+
BP: R: Lying: 146/90 Sitting: 140/86 Standing: 138/90
L: Lying: 142/90 Sitting: 138/88 Standing 138/84
Pulse: Apical: 86 Radial: 86 Quality: strong rhythm: regular
Chest auscultations: Few wheezes clear with cough, no murmurs/ rubs
JVD: -0-
Extremities: temperature: Feet cool bilateral/legs warm
Color: Skin: Legs Pale capillary refill: Slow both feet (Approx 5 secs)
Homan’s Sign: -0- Varicosities: few enlarged superficial veins both calves
Nails: Toe nails, thickened, yellow brittle
Distribution and quality of hair: Coarse hair to midcalf, none on ankles/ toes
Color: General: Ruddy face/arms Mucous membranes/lips: Pink
Nail beds: Fingers blanch well conjunctiva and sclera: white

Ego Integrity:
Reports (Subjective): Stress factors: “Normal farmer’s problems: weather, pests bankers, and so on”
Ways of handling stress: “I get busy with the chores and talk things over with my
livestock, they listen pretty well”
Financial concerns: No supplemental insurance; needs to hire someone to do chores
while in hospital
Relationship status: Married 45-years
Cultural factors: Rural/ agrarian, Eastern European descent, “American,” no ethnic ties
Religion: Protestant /practicing
Lifestyle: Middle class/self-sufficient farmer
Recent changes: -0-
Feelings: “I’m in control of most things, except the weather and this diabetes
Concerned regarding possible therapy “Change from pills to shots”

Exhibits (Objective data): Emotional status: generally calm: appears frustrated at times
Observe physiologic response (s): Occasionally sighs deeply/frowns, fidgeting with coin,
shoulders tense, shrug shoulders/ throws up hands

Eliminati on:
Reports (Subjective): Usual bowel pattern: almost every pm
Last bowel movement: last night character of stool: Firm/brown
Bleeding: -0- hemorrhoids: -0- Constipation: Occasional
Laxative used: Hot prune juice as needed
Urinary: no Problems character of urine: Pale yellow
Exhibits (Objective data): Abdomen tender: No soft/firm: Soft palpable mass: -0-
Bowel sounds: Active all 4 quads

Food/fluid:
Reports (Subjective): usual diet (type): 2400 calories (Occasionally “Cheats” with dessert; “My wife
watches it pretty closely.”) number of meals daily; 3/1 snack
Dietary pattern: Breakfast: Fruit juice, toast, ham, decaf coffee
Lunch: Meat, potatoes, vegetables, fruit, milk
Dinner: Meat sandwich, soup, fruit decaf, coffee
Snack: Milk/cracker at hs. Usual beverage; skim milk, 2-3 decaf coffee
Drinks “a lot of water”- several qt
Last meal/ intake: Dinner: Hot roast beef sandwich, vegetable soup, pear with chees,
decaf coffee
Loss of appetite: “Never, but lately I don’t feel as hungry as usual.”
Nausea/ vomiting: -0- food allergies: none
Heartburn/food intolerance: Cabbage causes gas, coffee after supper causes heart burn
Mastication/ swallowing problems: -0- Dentures: partial upper plate fits OK
Usual weigth: 175 lb recent changes: Has lost about 5lb this month
Diuretic therapy: No

Exhibits (Objective data): Wt. 171 lb Ht: 5 ft 10 in build: Stocky

Skin turgor: Good leathery
Appearance of tongue: Midline, pink Mucous membranes: pink, intact
Condition of teeth/gums: Good; no irritation/ bleeding noted
Breath sounds: Few wheezes cleared with cough
Bowel sounds: active all 4 quads
Urine chemstix: 2% fingerstick: 356 (Dr. office) random BG drawn on admission 450

Hygiene
Reports (Subjective): Activities of daily living: Independent in all areas
Preferred time of bath: pm

Exhibits (Objective data): General appearance: Clean, shaven, short-cut hair, hands rough and dry, skin
on feet dry, cracked and scaly

Neurosensory
Reports (Subjective): Headaches: “Occasionally behind my eyes when I worry too much.”
Tingling/ numbness: Feet, once or twice a week (as noted)
Eyes: Vision loss: farsighted, “Seems a little blurry now.” Examination 2 years ago
Ears: Hearing loss: R: “some”. L: No (Has not been tested)
Nose: Epistaxis: -0- Sense of smell: “No problem”
Exhibits (Objective data): Mental status: Alert, oriented to time, place person, situation
 Affect: Concerned Memory: remote/recent: clear and intact
Speech: clear, coherent, appropriate
Pupil reaction: PERRLA/ small glasses: Reading hearing aid: No
Handgrip/ Release: Strong equal

Pain/Discomfort
Reports (Subjective): Primary focus: L foot location: Medial aspect, heel of L foot
Intensity (0-10): 4-5/10 Quality: Dull ache with occasional sharp stabbing sensation
Frequency/duration: “Seems like all the time” Radiation: No
Precipitating factors: Shoes, Walking
How relieved: ASA not working
Additional complaints; Sometimes has a back pain following chores/ heavy lifting
Relieved By: ASA/ liniment rubdown

Exhibits (Objective data): Facial Grimacing: when Lesion border palpated

Guarding affected area: Pulls foot away, narrowed focus: -0-
Emotional response: Tense, irritated

Respiratory
Reports (Subjective): Dyspnea:-0- cough: occasional morning cough, white sputum
Emphysema: -0- bronchitis:-0- asthma: -0- Tuberculosis: -0-
Smoker: filters Packs/day: ½ Number of pack Years: 25
Use of respiratory aids: -0-
Exhibits (Objective data): Respiratory rate: 22 depth: good symmetry: equal, bilateral
Auscultation: Few wheezes, clear with cough
Cyanosis: -0- clubbing fingers: -0-
Sputum characteristics: None to observe
Mentation/restlessness: Alert/oriented/fairly relaxed

Safety
Reports (Subjective): Allergies: -0- Blood transfusions: -0-
Sexually transmitted disease: -0-
Fractures/dislocations: L clavicle, 1966 , fell getting off tractor
Arthritis/unstable joints: “think I’ve got some arthritis in my knees.”
Back problems: Occasional lower back pain
Vision impaired: Requires glasses for reading
Hearing impaired: Slightly Right, compensates by turning “good ear” toward speaker

Exhibits (Objective data): Temperature: 99.4F (37.4C) tympanic

Skin integrity: Impaired L foot scars: R Ing, surgical
Rashes: -0- Bruises:-0- Lacerations:-0- Blisters:-0-
Ulcerations: Medical aspect L heel, 2.5 cm diameter, approximately 3 mm deep, draining
small amount cream colored/pink- tinged matter, no odor noted

Strength (general): equal 3 extremities/ favors L leg muscle tome firm

ROM: Good. Gait. Favors L foot paresthesia