University of the Cordilleras

College of Nursing
Governor Pack Road, Baguio City Philippines 2600

A Case Report:
Diabetes Type II (Non Insulin Dependent)

A Case Presentation Presented to the Faculty

of the University of the Cordilleras
College of Nursing

In Partial Fulfillment
of the Requirements in
Bachelor of Science in Nursing

By:

Antonio, Joseph Christopher

Cino, Christine
De Vera, Mawee
Escala, Monica
Hagada, Kim
Inagapad, Mhel Florence
Masadao, Daphne Yvonne
Natividad, Earl John
Ngolab, Kirk Lee Wayne
Padawil, Pearly Jhane
Porto, May Rhezalie
BSN 3-6B

March 8, 2010
 University of the Cordilleras
College of Nursing

I. General Profile/ Information

Name: Mr. R.R.H.
Age: 59 y/o
Birth Date: November 12, 1950
Sex: Male
Civil Status: Married
Occupation: Farmer
Address: Sta Lucia, Conconig East, Ilocos Sur
Religion: Roman Catholic
Nationality: Filipino
Date and Time of Admission: November 22, 2009/ 3:00pm
Admitting Diagnosis: Infected wound left foot, DM Type II

II. Chief Complaint/s

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).

III. History of Present Illness

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.

IV. Past Medical History

He was diagnosed with DM type II and he was also in and out of the Hospital.

V. Social and Environmental History

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

Mr. R.R.H is 59 years of age, married, a Roman Catholic diagnosed with DM

type II. His family belongs to the Ilocano tribe of the Ilocos Region. He is the Head of the
family, residing at Sta. Lucia, Conconig East, Ilocos Sur and where his birthplace is. He
drinks occasionally and smokes 3-4 sticks of cigarettes a day. Unaware of his sickness,
when he accidentally stepped on a nail, his wound becomes larger in size

II. Mental and Emotional Status

A. Mental

As for his level of consciousness, he responds accordingly to different stimuli

such as noise, pain, strenuous activities cannot be tolerated because of his infected wound
on the left foot. He cannot walk or stand in long periods of time. He was aware as to time
and date and the place where he was into. For his intellectual development there was no
problem, he can read and write, able to understand and follow directions. He is very open
to medical and nursing therapy since all he wants is to get well.

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.

III. ENVIRONMENTAL STATUS

At his age he is aware of his safety being an old aged person and at the same time
being the head of the family may it be regarding the location of their house, the weather,
management of the inherited or acquired disease. He gets medical attention if ever the
family can’t handle his illness.

IV. SENSORY STATUS

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.

VI. NUTRITIONAL STATUS

The physician Dr. G.G.R ordered for low sugar, low protein, and low phosphate diet
for Mr. R.R.H. But he has a good appetite, no problem noted on the nutrition of the
client. Hoever due to his condition,

VII. FLUIDS AND ELECTROLYTES STATUS

Mr. R.R.H has a normal patterns of intake. He perspires every once in awhile and
pass out minimal stool per day due to minimal amount of food taken in orally.
He has poor skin turgor with evidence of dry skin. Dryness of the infected wound
on the right leg was noted.
Medical therapy was introduced such as 1 liter PLRSX16 hours upon admission.
Insulin 20 “6”@ 3pm was given upon admission.
He has no allergies with any food or drinks of whatsoever upon interview.
 VIII. CIRCULATORY STATUS
His pulse rate was above normal which is 103 per minute upon assessment, he is
tachycardic with regular rhythm, and heart sounds are normal but a little bit weak for his
age. With regards to his blood pressure it was 140/90 which shows an evident
hypertension. He has a low hemoglobin count of 127 g/l taken November 29, 2009 in
which the normal range is from 130-160 g/L and has an increased FBS count upon
admission which is 147.82 mg/dL taken November 30, 2009 in which it is high. The
normal range for FBS is 70-115 mg/dL.

IX. RESPIRATORY STATUS

His Respiratory rate was normal which 20 cycles per minute is. No alterations
were noted upon assessing the patient.

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.

XIII. COMFORT AND REST STATUS.

1. Sleep
Before being hospitalized according to the interview of the student nurse, he
usually sleeps 8-10 hours daily.
He would just sleep for a limited number of hours and then wakes up feeling
stressed and tired.
He prefers to sleep in semi fowler’s position with 2 pillows to elevate him to an
estimated angle of 40 degrees.
 2. Comfort
There was a presence of discomfort due to his left foot infection and edema. He
gets easily irritated when something touches on his foot.

VIII. DIAGNOSTIC TEST

LABORATORY TEST

Significance and Test Results

DIAGNOSTIC SIGNIFICANCE RANGES INTERPRETATION
TEST
FBS ( fasting Is one test to • FBS < 100 Normal fasting blood
blood sugar) diagnose diabetes mg/dl (5.6 sugar;
mellitus. This test is mmol/l)
determined by • FBS 100– IFG (impaired fasting
taking a sample of 125 mg/dl glucose)
venous blood after (5.6–6.9
an overnight mmol/l)
fasting. The sugar • FBS ≥ 126 Provisional diagnosis
level is then mg/dl (7.0 of diabetes
evaluated in the mmol/l)
blood sample.

Hemoglobin count A blood sample • Women:

will be taken, 12.1 to 15.1
normally from the gm/dl
arm. • Men: 13.8 to
17.2 gm/dl
• Children: 11
to 16 g/dl
• Pregnant
women: 11
to 12 g/dl

FBS ( Fasting Blood Sugar)

Date Result Normal values Interpretation Significance

Nov. 25, 2009 104.43 mg/dl 70-115 mg/dl Normal value Normal
Nov. 27, 2009 149.55 mg/dl 70-115 mg/dl Increase Provisional
diagnosis of DM
Nov. 28, 2009 140.08 mg/dl 70-115 mg/dl Increase Provisional
diagnosis of DM
Nov. 29, 2009 141.87 mg/dl 70-115 mg/dl Increase Provisional
diagnosis of DM
Nov. 30, 2009 147. 82 mg/dl 70-115 mg/dl Increase Provisional
diagnosis of DM
Dec. 01, 2009 151.25 mg/dl 70-115 mg/dl Increase Provisional
diagnosis of DM
Hemoglobin Count

Date Result Normal value Interpretation Significance

oxygen
Nov. 29, 2009 127 g/L 130-160 g/L Decrease level Decrease
hemoglobin
level
DRUGS STUDY

Trade Name Generic Name Classification Mechanism of Action Side Effects Nursing Considerations

Ceftriaxone Anti-infectives 3rd generation CNS: fever, headaches, dizziness
Sodium cephalosporin that GI: pseudomembranous colitis,
inhibits cell-wall diarrhea
synthesis, promoting GU: genital pruritus, candidiasis
osmotic instability; Hematologic: eosinophilia,
usually bactericidal. thrombocytosis, leucopenia
Skin: pain, induration, tenderness at
injection site, rash, pruritus
Other: hypersensitivity reactions,
serum sickness, anaphylaxis,
chills
> Obtain specimen for culture
and sensitivity tests before
giving first dose.
> For I.M. administration, inject
deeply into a large muscle, such
as the gluteus maximus or the
lateral aspect of the thigh
> If large doses are given,
therapy is prolonged, or patient
is at high risk, monitor patient
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
Name
Skin: maculopapular and
erythematous rashes,
urticaria, pain, induration,
sterile abscesses,
temperature elevation,
tissue sloughing at I.M.
injection site.
Other: hypersensitivity, reactions,
serum sickness,
anaphylaxsis
Diclofenac Nonsteroidal anti- Produces anti- CNS: anxiety, depression,
Potassium inflammatory drug inflammatory, analgesic, dizziness, drowsiness, insomnia,
and antipyretic effects, irritability, headache, aseptic
possibly by inhibiting meningitis
prostaglandin synthesis. CV: heart failure, hypertension,
edema, fluid retention
EENT: tinnitus, laryngeal
edema, swelling of the lips and
Nursing Considerations
> Cefuroxime tablets may
be crushed, if absolutely
necessary, for patients
who can’t swallow tablets.
Tablets may be dissolved
in small amounts of juice
or milk.
> If large doses are given,
therapy is prolonged, or
patient is at high risk,
monitor patient for signs
and symptoms of super
infection.
> Monitor patients
closely for decrease
renal blood flow,
especially patients with
renal or heart failure.
> Liver function test
values may become
elevated during therapy.
Monitor transaminase,
especially
Trade Name Generic Name Classification Mechanism of Action Side Effects Nursing Considerations

tongue, blurred vision, eye pain, night ALT levels.

blindness, epistaxis, reversible hearing > NSAIDs may mask the
loss sign and symptoms of
GI: abdominal pain or cramps, infection.
constipation, diarrhea, indigestion, > Serious GI toxicity,
nausea, abdominal Distention, including peptic ulcers
flatulence, taste disorder, peptic and bleeding, can occur in
ulceration, bleeding patient taking NSAIDs,
GU: proteinuria, acute renal failure, despite lack of symptoms
oliguria, interstitial nephritis, papillary
necrosis, Nephritic syndrome, fluid
retention.
Hepatic: jaundice, hepatitis,
hepatotoxicity
Metabolic: hypoglycemia,
hyperglycemia
Musculoskeletal: back, leg, or join
pain
Respiratory: asthma
Skin: rash, pruritus, urticaria, eczema,
dermatitis, alopecia,
Bullous eruption, allergic purpura
Other: anaphylaxis, anaphylactoid
reactions, angioedema.
Trade Name Generic Name Classification Mechanism of Action Side Effects Nursing Considerations
Tramadol Opioid analgesics A centrally acting
hydrochloride synthetic analgesic > Reassess patient’s level
CNS: dizziness, vertigo, headache,
compound not of pain at least 30 minutes
somnolence, CNS stimulation,
chemically related to after administration
asthenia, anxiety, confusion,
opiates. > Monitor CV and
coordination disturbance, euphoria,
Thought to bind to respiratory status
nervousness, sleep disorder, seizures,
opioid receptors and > Monitor bowel and
malaise.
inhibit reuptake of bladder function.
CV: vasodilation
norepinephrine and > For better analgesic
EENT: visual disturbances
serotonin. effect, give drug before
GI: nausea, constipation, vomiting,
onset of intense pain.
dyspepsia, dry mouth, diarrhea,
> Monitor patients at risk
abdominal pain, Anorexia, flatulence
for seizures
GU: urine retention, urinary frequency,
> In the case of an
menopausal symptoms, proteinuria
overdose, naloxone may
Musculoskeletal: hypertonia
also increase risk of
Respiratory: respiratory depression
seizures.
Skin: pruritus, diaphoresis, rash
> Monitor patient for
drug dependence
> Withdrawal symptoms
may occur if drug is
stopped abruptly. Reduce
dosage gradually.

Trade Name Generic Classification Mechanism of Action Side Effects Nursing Considerations
Name
Clindamycin Anti-infective Inhibits bacterial protein
synthesis by binding to the
50S subunit of the
ribosome.
Cloxacillin Anti-infective Exerts a bactericidal action
against susceptible
microorganisms during the
stage of
active multiplication. It
acts through the inhibition
of biosynthesis of cell wall
mucopeptides.
CV: thrombophlebitis
GI: nausea, vomiting, abdominal
pain, diarrhea, pseudomembranous
colitis
Hematologic: transient leucopenia,
eosinophilia, thrombocytopenia
Hepatic: jaundice
Skin: maculopapular rash, urticaria
Other: anaphylaxis
seizures,
diarrhea, abdominal pain, nausea,
vomiting
unusual bleeding or bruising,
white patches on the tongue, black
hairy tongue or sore mouth or
tongue.
> I.M. injection may raise
CK level in response to
muscle irritation.
> Monitor renal, hepatic,
and hematopoietic
functions during
prolonged therapy.
> Observe patient for
signs and symptoms of
superinfection.
> Don’t give opioid
antidiarrheals to treat
drug-induced diarrhea.
> Cloxacillin Sodium
should be taken on an
empty stomach.
> The liquid suspension
form of Cloxacillin
Sodium must be shaken
well before using.
> Antibiotics work best
when the amount of
medicine in your body is
 Trade Name Generic Classification Mechanism of Action Side Effects Nursing Considerations
Name
kept at a constant level.
> Continue to take
Cloxacillin Sodium until
the full prescribed amount
is finished even if
symptoms disappear after
a few days.
> Stopping the medication
too early may allow
bacteria to continue to
grow resulting in a relapse
of the infection.
> Cloxacillin Sodium may
cause stomach upset,
diarrhea, nausea, and
vomiting during the first
few days as your body
adjusts to the medication.

IV Fluids
 Plain LRS D5LRS

Component of the Fluid [Na+] (mmol/L)- 130 [Na+] (mmol/L)- 130

[Cl-] (mmol/L)- 109 [Cl-] (mmol/L)- 109
[Glucose] (mmol/L)- 278
[Glucose] (mg/dL)- 5000

Classification of the Fluid Isotonic Hypertonic

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

Precipitating factors: Predisposing factors:

1. eating too much sweets 1. family history of
2. diet (high cholesterol, high DM
sodium, High glucose) 2. Age above 40
Insulin resistance
3. sedentary lifestyle
(smoking cigarettes and
drinking alcohol)
Exhaustion of beta cells

Decreased Insulin production/

decreased secretion of insulin

Increased
Degradation of proteins Decreased absorption of glucose by the cell Breakdown of fats

Accumulation of glucose in the Cell starvation

blood (unutilized)

Nerve Stimulation of hunger

Demyelinization Hyperglycemia mechanism via hypothalamus

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

Wound that does not heal

Acute pain Risk for

Ineffective imbalance
tissue perfusion nutrition: less
than body
Risk for injury Impaired skin requirement
integrity
Dx:
>Assessed coping abilities
that may result in injury
>Determined history of
hypertension or any changes
in the body that increases
risk for injury
>Assessed ability to ambulate
with minimal assistance
>Evaluated environment for
safety hazards
>Assess mood, coping
abilities, personal styles
> Assess client’s cognitive
status
Tx:
>Kept floor of the room clean
and dry
>Attended to needs and
assisted with activities as
needed
>Provided positioning as
required by situation
>Demonstrated use of
assistive devices such as
crutch
Edx:
>Stressed importance of
changing position slowly
>Obtained assistance when
need arises
>Reinforce participation in
self-care programs such as
passive exercises on the
affected area
Dx:
>Assess pain characteristics:
-Quality (sharp, burning, shooting)
-Severity (scale of 1 to 10, with 10
being the most severe)
-Location (anatomical description)
-Onset (gradual or sudden)
-Duration (how long: intermittent or
continuous)
-Precipitating or relieving factors
>Observe or monitor signs and
symptoms associated with pain or
non-verbal cue
>Assessed contributory factors
> Evaluate patient’s response to pain
and medications or therapeutic
aimed at abolishing or relieving pain
Tx:
> Anticipated need for pain relief.
>Assisted in repositioning for
comfortable position
>Respond immediately to complaint
of pain.
>Facilitated in giving medications as
ordered
> Provide rest periods to facilitate
comfort, sleep, and relaxation.
Edx:
>Instructed to adhere to treatment
regimen
>Demonstrated non-
pharmacological relief of pain such
DBE
>Encouraged to do diversional
activities such as talking to S.O or
visitors, listening to music or reading
Dx:
>Assessed lower extremities,
noting the texture, presence of
edema, non-healing wounds
>Monitored quality of all
pulses
>Measured capillary refill
>Assessed for possible
causative factors related
temporary impaired arterial
blood flow
>Noted presence of
conditions/situations that can
affect multiple systems
Tx:
>Positioned patient into semi
fowler’s position with left foot
elevated
>Measured circumference of
lower extremities
>Performed assistive/active
range-of-motion exercises
>Elevated the legs when
sitting, avoiding sharp
angulations of the hips or
knees
Edx
>Discussed individual risk
factors: family history,
smoking, diabetes, obesity and
potential outcomes of
atherosclerosis
>Demonstrated and
encouraged use of relaxation
activities, exercises and
techniques
>Discussed care of dependent
limbs, body hygiene, foot care
when circulation is impaired
Dx:
>Assessed lower extremities,
noting the texture, presence of
edema, non-healing wounds
>Monitored quality of all pulses
>Measured capillary refill
>Assessed for possible causative
factors related temporary impaired
arterial blood flow
>Noted presence of
conditions/situations that can affect
multiple systems
Tx:
>Positioned patient into semi
fowler’s position with left foot
elevated
>Measured circumference of lower
extremities
>Performed assistive/active range-
of-motion exercises
>Elevated the legs when sitting,
avoiding sharp angulations of the
hips or knees
Edx
>Discussed individual risk factors:
family history, smoking, diabetes.
obesity; and potential outcomes of
atherosclerosis
>Demonstrated and encouraged use
of relaxation activities, exercises
and techniques
Discussed care of dependent limbs,
body hygiene, foot care when
circulation is impaired
Dx:
>Assessed integrity of the left
foot wound surrounding skin
and skin structure.
>Assessed blood supply and
sensation of affected area.
>Assessed skin color, texture
and turgor.
Tx:
>Removed wet/wrinkled
linens.
>Aseptically dressed wounds
> Keep the wound and its
surrounding clean and dry.
Edx:
> Encouraged to eat nutritious
foods especially vit.C and
adequate protein and low
sugar diet.
>Encouraged ambulation with
the use of assistive device
>Discussed importance of
early detection of skin changes
and complications.
>Explained the importance of
exercise in maintaining or
reducing weight
PRIORITIZATION:

1. Ineffective tissue perfusion related to interruption of blood flow secondary to

traumatized tissue
First priority is ineffective tissue perfusion, because there is problem in
circulation. When there is decrease in oxygen, it would result to failure in nourishing the
tissues in the capillary level that contributes to another complication to the patient.
Decreased tissue perfusion can be transient with few or minimal consequences to the
health of the patient. If the decreased perfusion is acute and protracted, it can have
devastating effects on the patient such as ischemia. Diminished tissue perfusion, which is
chronic in nature, invariably results in tissue or organ damage or death.

2. Impaired skin integrity related to tissue trauma secondary to Diabetes Mellitus

type II
Second priority was impaired skin integrity, because of patient’s defense for
infection is already impaired which is the skin that serves as our first line of defense.
After we’ve manage circulation, we need to prevent complications that might occur in
our patient. In Type II Ddiabetes Milletus normal flora of the skin thrive and feed
themselves to the glucose in the blood. If there is a cut and becomes worst and untreated,
there’s a need for amputation of the infected leg.

3. Severe pain related to tissue trauma secondary to Diabetes Mellitus Type II

delayed wound healing
The International Association for the Study of Pain defines pain as an
unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage.
We give priority to acute Pain because it is a major symptom in many medical
conditions, and can significantly interfere with a person's quality of life and general
functioning. Pain could lead also to anaphylactic shock. However, since we have natural
pain killers in our body and medications to be given to our patient, so it is best to first
prioritize ineffective tissue perfusion and impaired skin integrity, respectively.

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

S> “Nasakit Insufficient Dx: STO:

unay daytoy insulin STO: >Assess pain >To be able to diagnose the After 1 to 2 hours of
sugat diay After 1 to 2 characteristics: appropriate management. appropriate nursing
sakak” Reduced tissue hours of -Quality (sharp, burning, Other methods such as intervention, the patient
uptake of glucose appropriate shooting) descriptive scales can be would:
O nursing -Severity (scale of 1 to 10, used to identify extent of a. verbalize adequate
>characterized Hyperglycemic state intervention, the with 10 being the most pain relief of pain
by intermittent patient would severe) b. use non-
sudden pricking Diabetes type II verbalize -Location (anatomical pharmacological
and cramping a. verbalize description) relief of pain such as
pain rated as Peripheral relief of pain by: -Onset (gradual or sudden) DBE prior to
7/10, using the Neurophaty - Use of non- -Duration (how long: facilitating decrease
pain scale ,0 as pharmacological intermittent or continuous) level of pain severity
no pain and 10 as Tissue trauma relief of pain such -Precipitating or relieving
the highest as DBE and factors
possible pain Delayed wound coughing exercise. >Observe or monitor signs >Attention to associated LTO:
> grimaces noted healing and symptoms associated signs may help the nurse in After 2 to 3 days of
> guarding LTO: with pain or non-verbal cue evaluating pain appropriate nursing
behavior on the Severe Pain After 1 to 2 hours >Assessed contributory >Determine other factors intervention, goal met if the
left foot of appropriate factors causing pain such as patient would be able to:
>irritable at Reference: nursing activities of daily living a) exhibit wellness and
times Suddhart and intervention, the > Evaluate patient’s .> Discrepancies between comfortability in bed
.>with limited Brunner Medical patient would: response to pain and behavior and appearance b) verbalize complete relief
th
movement Surgical book, 10 a. Verbalize medications or therapeutic and what patience says may of pain
observed ed. relief of pain aimed at abolishing or be a more reflection of other
>needs http://en.wikipedia.o by using non- relieving pain methods patient is using to
assistance when rg/wiki/Diabetes_me pharmacologi cope with than the pain
moving llitus_type_2 c relief of Tx: itself.
> responsive to pain such as
therapeutic DBE and > Anticipated need for pain > Early intervention may
regimen given coughing relief. decrease the total amount of
exercise analgesic required.
A> Severe pain >Assisted in repositioning > Provide relaxation and
related to tissue for comfortable position lessen the pain felt.
trauma >Respond immediately to .>In the midst of painful
secondary to complaint of pain. experiences a patient’s
Diabetes type II perception of time may
delayed wound become distorted. Prompt
healing responses to complaints can
lessen concern of pain.
ASSESMENT EXPLANATION OF GOALS AND INTERVENTION
RATIONALE EVALUATION
THE PROBLEM OBJECTIVES

S>”Nanlalamig ang paa
ko”
O>Weak peripheral
pulses
>Delayed healing of
wound
> (+) swelling on the left Decreased Abosprtion of
leg
>prolonged capillary
refill of 3 seconds
>rough skin noted
Hyperviscosity of Blood
A> Ineffective tissue
perfusion related to
interruption of blood
flow secondary to
Diabetes Mellitus Type
II.
STO: Dx: STO:
 After of nursing  Assessed lower >Serves as baseline data  Goal met, the
interventions, the extremities, noting patient was able
Decreased Insulin patient will be the texture, presence to demonstrate
Production able to of edema, non- behaviors to
↓ demonstrate healing wounds >Loss of peripheral improve
behaviors to  Monitored quality of pulses must be reported circulation as
improve all pulses and treated immediately manifested by:
glucose in the blood circulation. >Slow capillary refill a.) Cessation of
(unutilized)  Measured capillary indicates preventive smoking
↓ refill interventions to prevent
Hypergylycemia peripheral vascular b.) Relaxation
↓ diseases techniques
>Early detection of cause
↓  Assessed for facilitates prompt, c.)
Interruption of blood LTO: possible causative effective treatment Exercises/dietary
flow  After of nursing factors related programs
↓ interventions, the temporary impaired >To assess causative and
Ineffective tissue patient will be arterial blood flow contributing factors LTO:
perfusion able to  Noted presence of  Goal met, the
demonstrate conditions/situations >This promotes optimal patient was able
increased that can affect lung ventilation and to demonstrate
perfusion as multiple systems keeping left foot elevated increased
individually Tx: for venous return. perfusion as
appropriate:  Positioned patient individually
a. Absence of into semi fowler’s >Useful in identifying appropriate
edema position with left edema in affected a.) Absence of
 Free of pain or foot elevated extremities edema
discomfort >To promote blood b.) Free of pain or
 Normal capillary  Measured circulation discomfort
refill
 circumference of c.) Normal
lower extremities capillary refill
>To promote venous
 Performed return
assistive/active
range-of-motion
exercises
 Elevated the legs
when sitting,  Information
avoiding sharp necessary for
angulations of the client to make
hips or knees informed choices
Edx about remedial
 Discussed risk factors and
individual risk commitment to
factors: family lifestyle changes,
history, smoking, as appropriate to
diabetes. obesity; prevent onset of
and potential complications/
outcomes of manage
atherosclerosis symptoms when
condition is
 Demonstrated present
and encouraged
use of relaxation
activities,  To decrease
exercises and tension level
techniques

 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 thepatient 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 foodforDetermined
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 detectionofPromote 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
A. Activities
 Instructed the client not to
walk bare footed
 Encouraged the patient to
perform active and passive
ROM
 Encouraged the patient to
interact or socialize with
significant others and other
people around him
B. Diet
 Teach patient to read labels
of "health" foods because
they contain sugar product
such as honey, brown sugar
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
intake of saturated fat and
cholesterol.
 Encouraged the patient to
avoid drinking alcoholic
beverages.
 Food should be high in fiber
(apples, pineapples)
C. Medications
 Instruct the patient not to
crush, chew or break the
medications unless he has
difficulty swallowing
 Instructed the client to take
Diclofenac potassium with
full stomach
 Advised the patient not to
abruptly discontinue the
medication even if he feels
better unless instructed by
the physician
Rationale
 To prevent unnoticeable skin injuries
or breaks during ambulation due to
diabetic neuropathy
 To promote good circulation in the
distal body parts and to prevent
compromised circulation in the
peripheries which can lead to tissue
necrosis
 To avoid low self-esteem. Social
support is very important to the
client.
 To prevent worsening the present
condition and for the patient to
know how to control his blood sugar
level independently
 It may increase the glucose level in
the blood due to gluconeogenesis to
meet the metabolic needs of the
body. Increase cholesterol level may
lead to hypertension.
 It is one of the precipitating factors
of diabetes mellitus
 This slows glucose absorption and
soothes post prandial glucose levels.
 Because there will be a bitter
after taste, and there will be
alteration on the effectiveness on the
medication
 One of the side effects of this
drug is gastric irritation that may
cause ulceration.
 If the patient abruptly
discontinue the medication this may
cause resistance to drugs and may
need higher dosage.
D. Others
 Proper fitting of shoes
 Alternatives to wound care
such as Guava leaves
 The appropriate time for
buying shoes is late in the afternoon
because the feet are fully expanded.
 It has antiseptic effect and it
can be use for wound cleaning
proven by the DOH.
CONCLUSIONS AND RECOMMENDATIONS:

Diabetes mellitus type 2 (formerly called non-insulin-dependent diabetes mellitus

(NIDDM), or adult-onset diabetes) is a disorder that is characterized by high blood
glucose in the context of insulin resistance and relative insulin deficiency. There is
currently no known cure for the condition, but it is often initially managed by increasing
exercise and dietary modification. As the condition progresses, medications are typically
needed.
Therefore, in the making of this case study and understanding how this disease
affects a person through appreciating its pathophysiology. This study makes us student
nurses more competent and gain more confidence in handling our patients with diabetes
mellitus.
Lifestyle modification is necessesary to patient with diabetic mellitus type 2 to at
least prevent the occurrence of complications and how to control diabetes mellitus. The
following are some recommendations:
• Diet- Essential requirements to be maintained are:

 Adequate caloric value.

 Balanced food with respect to protein, carbohydrate and fats.
 A permissive diet for elderly.
 Food intake to be divided into regularly spaced meals of similar size.
 Food should be high in fiber, which glucose absorption and soothes post
prandial glucose levels.

• 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.

• Self-monotoring of glucose level to help him in adjusting dietary intake and to

warn rapidly changing glucose level.

• Restrict consumption of alcohol because of the reoccurence of hyperglycemia

• Use of assisting device for easy mobility

References:

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