INTRODUCTION

The case that is to be presented features a patient who has a type 2 Diabetes Mellitus. I as a nursing
student I'm involved in learning what type of nursing interventions that I will apply to this type of patient.
Beyond understanding the relevant health issue, this case will alsoe explore other factors that can enhance
my knowledge in the field of our nursing practice. This is also the primary reason why I choose this case
because I know that it is highly beneficial aside from it is being considered distinctive or unique. Included
with the case are the discussions of the natomical parts, through physical assessment of the
patient,laboratory results and their corresponding findings. Added to this I also have a discussion of the
patient’s daily activities andnl nursing care plans.

OBJECTIVES

General Objectives

To be able to apply what I have learned theoretically at the hospital and after that study, I can be able to
understand this disease more deeper together with the help of our Clinical Instructors and able to provide
optimum or standard quality care to the patient through making of the nursing intervention and health
education regimen.

Specific Objectives Student nurse Centered:

To gain knowledge about the disease process,predisposing factors, clinical manifestation and thedisease
management.

To gain skills and appropriate attitudes needed tofunction as a student-nurse in the community.

Identify problems: Develop a teaching plan andstrategies appropriate for the goal attainment.

To be able to use the nursing process as framework forcare of the patient.

To develop and establish interpersonal relationshipwhile the case is ongoing.

Client Centered:


To manage his disease.

To know the importance of his compliance to hisdisease.

To prevent and manage the potential complication thatmight occur.

Perform emphasized health teaching and follow dietaryinstruction and restriction as well as
performingappropriate exercise.
V. GENERAL DATA:
Name: Mr. A.S
Age: 45 y/o
Address: CITY OF ANTIPOLO, RIZAL
Occupation:
Work status:
Marital status: N/A
Religion: CATHOLIC

VI. CHIEF COMPLAINT:

Wound in heel part of his right foot.

VII. HISTORY OF PRESENT ILLNESS:

May 15 2019- According to the patient there was flooded in their area in Marikina. Suddenly he got
deeply spiked with nails on his heel part of his foot, Using of clean fabric he apply it to stop bleeding
from his wound. He hought that it's just a simple wound that will heal immidiately so he didn't mind to
take any medications. Aftet that incident he still go to his work but aggravating factors including walking
and he states that alleviated rest and avoiding activities that require use of the feet.

May 18 2019- The patient started feel pain and there's a presence of swelling and pus on his right foot
where he got spiked. He also started got a fever so take a medicine paracetamol. The patient was unable
to walk because of pain. His young brother suggest to used the boiled leaves of bayabas as a cleansing of
his wound.

1 week prior to admission- according to the patient his fever didn't stop and the swollen and pain getting
worst. So his brothers decide to brought him in Emang Rodriguez Hospistal for check up. Doctor
prescribed him a medication for his fever, antibiotics and pain reliever. He was advised to do annual
check up again for follow up if he's still having a fever after 1 week.

4 days prior to admission- The patient said that the medications that prescribed on him didn't worked but
more worsening on his condition. He still having a fever and the swelling getting bigger.

1 day prior to admission- The patient had difficulty sleeping because of the pain. The pain continued to
gradually increase in severity to an 8/10. he had high fever that came to febrile convulsion. His brothers
decide to brought him in ER QMMC.

May 25 2019- Mr. SM 49 y/o diagnose of DIABETES TYPE 2 in Quirino Memorial Medical Center. He
has no family history of Diabetes. According to the patient he suprised when he know that he is diabetic
because he has never had check for his blood sugar level. He stated that upon admission his blood glucose
level was found to
be 400 mg/dL

PAST MEDICAL HISTORY:

According to the patient he never had any serious illnesses during his childhood.

FAMILY HISTORY:

(+) Hypertension

(-) Diabetes

(-) Cancer

(-) Stroke

SOCIAL HISTORY:

Patient lives in marikina with father nd four siblings. Patient works at materials supplier, The patient
denies tobacco, alcohol and drug use
PHYSICAL ASSESSMENT

VITAL SIGNS:

BP= 110/70 mmHg Temperature= 36.3°C Pulse rate= 81 bpm Respiratory rate= 19 per minute

Pain Scale= 6/10

Weight: 53 kg (116lbs)

Height: 5’1”

BMI: 22.1

Attitude and Mood: Cooperative and coherent

General appearnce: Patient lying semi-fowlers position in bed appropriately groomed, obvious in pain
and discomfort. He appears underweight.

HEAD: Round,normocephalic and symmetrical, Hair is evenly distributed, medium brown in color, no
apparent lesion or foreign bodies. No tenderness on palpation.

FACE: Symmetrical, No voluntarymovement

EYES: Lids are normal, conjuctiva are pale bilaterally, reactive to light, no discharge.

Visual fields: blurry vision

ENT: External ears and nose are of symmetric, of regular shape and size. No scars, lesions, masses or
foreign bodies. No tenderness to palpation of ears, nose, or sinuses

MOUTH: Slightly reddish-brown, dry lips, Complete teeth, no apparent lesion.

NECK: Neck is symmetric, with no apparent masses, lesions, foreign bodies, or other abnormalities.
There is no tenderness to palpation. No palpable lymph nodes.

BREAST: Uniform in color, No mass palpated no tenderness

RESPIRATORY: Chest is of regular shape and size, There is no apparent use of accessory muscles
for normal breathing. Chest expands symmetrically and bilaterally on inhalation. No tactile
fremitus is symmetric bilaterally, Normal breath sounds.

CARDIOVASCULAR: Jugular venous distention is within normal limits. normal rhythm, no murmur, rub, or
gallop; no thrill or palpable murmurs on palpation.

ABDOMEN: Non-tender and non-distended abdomen with no massess, bowel sounds hyperactive by
auscultation.
SKIN: Lower extremities appears discoloration.

MUSCULOSKELETAL: Right Lower Extremity appears irregular and asymmetric with the Left Lower
Extremity. There is wound in his heel part, there a tenderness to palpation. Joints are unstable. Range of
motion and tone are limited Strength is 2/5

Left Lower Extremity appears asymmetric with the Right Lower Extremity. There is a scar left from boil
in his left leg. No tenderness to palpation. Joints are stable. Range of motion and tone are within normal
limits. Strength is 5/5

NEUROLOGICAL: Patient is alert, relaxed and cooperative. Thought process is coherent. Oriented to
person, place and time.

PSYCHIATRIC: Patient exhibits no deficits of insight or judgment.

Alert and oriented to time, place and person. Thought process is coherent. No apparent deficits in recent
or remote memory. Denies depression, anxiety or agitation. Mood and affect are congruent and
appropriate to environment
VIII. REVIEW OF SYSTEM

A. GENERAL: The patient awake lying semi-fowlers position in bed appropriately groomed, obvious in
pain and discomfort. He appears underweight

B. MUSCULOSKELETAL:

“Sobrang sakit po nung paa ko sa kanan”

C. HEAD AND NECK:

EYES: “Lumalabo po yung parehong mata ko”

EARS: " Wala naman akong problema sa pangdinig"

NOSE: "Wala din naman"

THROAT AND MOUTH: “Minsan minamalat ako lalo na pag sinisipon o inuubo”

D. RESPIRATORY:7

“Minsan nahihirapan ako huminga pag umaakyat ako hanggang 3rd floor”

E. CARDIOVASCULAR:

Patient hasn’t had any experience heart and vessels problem.

F. GASTROINTESTINAL:

Patient hasn’t had any experience GI problem.

G. GENITOURINARY:

“Hindi naman ako ihi ng ihi"

“Madilaw yung ihi ko medyo mabula"

H. ENDOCRINE:

Patient hasn’t had any experience endocrine problem.

I. NEUROLOGICAL:

“Nawawalan ako minsan ng malay at kinukumbulsyon rin”

J. PSYCHIATRIC: