I. INTRODUCTION Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles. There are 18.2 million people in the United States, or 6.3% of the population, who have diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2 million people (or nearly one-third) are unaware that they have the disease. The primary goals of treatment for patients with diabetes include controlling blood glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for diabetic patients must assist them to develop self-care management skills. I chose the case for my case study. I have taken care of him for 2 consecutive days. Let’s find out more about Diabetes Mellitus! My patient specifically has Type 2 (Non- Insulin Dependent Diabetes Mellitus) I hope you will learn many things through my case study. II. GENERAL DATA Patient’s name: S., B. Z. Address: No. GBA Pitogo Consolacion, Cebu Birthday: October 4, 1952 Age: 54 years old Birthplace: Poro, Camotes Sex: Male Citizenship: Filipino 1
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I. INTRODUCTION
Diabetes is a disease in which the body does not produce or properly use insulin. Insulin
is a hormone that is needed to convert sugar, starches and other food into energy needed for daily
life. The cause of diabetes continues to be a mystery, although both genetics and environmental
factors such as obesity and lack of exercise appear to play roles.
There are 18.2 million people in the United States, or 6.3% of the population, who have
diabetes. While an estimated 13 million have been diagnosed with diabetes, unfortunately, 5.2
million people (or nearly one-third) are unaware that they have the disease.
The primary goals of treatment for patients with diabetes include controlling blood
glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for
diabetic patients must assist them to develop self-care management skills.
I chose the case for my case study. I have taken care of him for 2 consecutive days.
Let’s find out more about Diabetes Mellitus! My patient specifically has Type 2 (Non-
Insulin Dependent Diabetes Mellitus) I hope you will learn many things through my case study.
II. GENERAL DATA
Patient’s name: S., B. Z.
Address: No. GBA Pitogo Consolacion, Cebu
Birthday: October 4, 1952
Age: 54 years old
Birthplace: Poro, Camotes
Sex: Male
Citizenship: Filipino
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Occupation: None
Height: 5’ 6”
Weight: 140 lbs.
Religion: Roman Catholic
Status: Married
Wife’s name: Diomedes Sotto
Occupation: Teacher
III. HISTORY OF PRESENT ILLNESS
Twenty days prior to admission, patient noted onset of bullae at left foot dorsum about
the size of one peso coin. A days prior to admission, spontaneously ruptured, applied Betadine
one a day with no relief. Wound noted to ulcerate spreading over foot dorsum up to proximal
tibia. Fever admitted one day PTA at Ormoc Hospital, decided to transfer to VCMC for further
management.
One day prior to admission, admitted at VCMC for further management. Estimated date of
confinement was on November 12, 2006.
Vital signs taken: BP – 130/80 mmHg, HR – 117 beats / minute, RR – 19 cycles / minute and
temp. – 36.7 0C.
IV. PAST HEALTH HISTORY
Diabetic for 14 years with poor compliance to medications for diabetes like humulin and
claims no compliance for 5 years. Claim to be an alcoholic beverage and a smoker for 1 year. He
was also diagnosed with Hypertension. He has been operated for wound suturing at the left foot
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dorsum last 2001 at CCMC. And on June 2002, he had undergone Below the Knee Amputation
at VCMC.
V. NURSING REVIEW OF SYSTEMS
1 General Appearance Patient is not having fever, conscious, coherent, responsive
when being asked. He has a slender body type; voice is clear when he talks and appears
relaxed and comfortable upon my visit.
2 Skin Patient has cool and has good skin turgor. There are no signs of skin lesions and
sores; there is absence of rashes and itchiness and no change in skin color.
3 Head Patient is normocephalic, proportion to the body. Sometimes he experienced
headache but was relieved by taking OTC medications. There is even distribution of hair and
has slightly dry hair but has no presence of flakes.
4 Eyes He has pinkish, palpable conjunctiva, does not wear glasses and has clear vision
with absence of eye infection.
5 Ears Symmetrical, non-tender and smooth texture.
6 Nose The nose is at the midline of the face, palpable, with no presence of swelling. He
also experienced colds due to weather conditions.
7 Mouth He does not wear any dentures but experiences toothaches sometimes due to
lack of oral care.
8 Neck There was no presence of neck stiffness or pain. It can move regularly and there
is no sign of swelling.
9 Upper Extremities Warm and has good skin turgor, smooth texture, and non-tender.
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10 Breast There was absence of lumps, nipple discharge, scales or cracks around the
nipples.
11 Lungs He has no cough, his not wheezing or having any lung disease.
12 Abdomen Flabby, soft and non-tender
13 Lower Extremities He had undergone Above the Knee Amputation at the left and
Below the Knee Amputation at the right due to Diabetes Mellitus. He has impaired mobility
thus he really needs assistance upon movement
14 GENITOURINARY SYSTEM No presence of sexually transmitted disease. Foreskin
retracts easily. The left sacral sac is lower than the right. Testicles are sensitive to pressure,
firm, smooth and equal in size. No swelling, lesions, itching noted in the reproductive area..
15 NEUROLOGIC SYSTEM Has clear thinking and has slight changes in emotional
state such as changes in mood and sometimes being irritable because of his health condition.
Has a good sense of memory and shows no signs of speech problems.
16 ENDOCRINE SYSTEM He is able to tolerate cold and hot temperature; he is above
the normal appropriate body mass index and has a history of diabetes.
VI. FAMILY, PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY
A. MEMBERS OF IMMEDIATE FAMILY
Name Age Position in the family
Educational attainment
Occupation General Health status
Benito Sotto 54 yrs old Father 2nd yr H.S. None Unhealthy
Diomedes Sotto
66 yrs old Mother College of Educationgraduate
Teacher Healthy
Vincent Sotto 31 yrs old Eldest child 2nd yr College N/A Healthy
Debbie Sotto 30 yrs old 2nd child College of Teacher Healthy
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Education graduate
Larrafe Sotto 27 yrs old 3rd child 2nd yr College N/A Healthy
Disebel Sotto 25 yrs old 4th child 3rd yr College N/A Healthy
Adelfa Sotto 23 yrs old 5th child College of Education graduate
Teacher Healthy
Domagit Sotto
22 yrs old Youngest child
College of Marine Trans. graduate
Seaman Healthy
B. PERSONAL AND SOCIAL HISTORY
Date of birth: October 04, 1952
Place of Birth: Poro, Camotes
Nationality: Filipino
Civil Status: Married
Home address: GBA Pitogo Consolacion, Cebu
Name of Father: Bienvinido Sotto
Name of Mother: Julia Sotto
Personal Habits: Driving
Dialects Spoken: Cebuano, Tagalog, English
C. ENVIRONMENTAL HISTORY
They once lived in Poro, Camotes where the patient’s parents lived but transferred in
Consolacion, Cebu together with his eldest son and family. He described his neighborhood as a
clean place and peaceful. Garbage disposal are properly taken cared of by government garbage
collectors. They secure water by means of the faucet from MCWD
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D. HEREDO-FAMILIAL HISTORY
He verbalized that his father is diagnosed with mild hypertension. And his mother is also
a diabetic. She has no food and drug allergies.
VII. PHYSICAL ASSESSMENT
The patient was observed lying on bed, able to tolerate light movements, afebrile,
comfortable and no headache. Vital signs were noted to be; BP – 130/90 mmHg, HR – 96 bpm,
RR – 25 cpm and temp. – 35.90C.
1 SKIN Shows no signs of erythema, jaundice or cyanosis. Generally has uniform
pigmentation except in areas around the neck and areas exposed to the
sun. No signs of skin interruptions. Have warm and good skin turgor.
Type 2 diabetes almost always has a slow onset (often years), but in Type 1, particularly
in children, onset may be quite fast (weeks or months). Early symptoms of Type 1 diabetes are
often polyuria (frequent urination) and polydipsia (increased thirst and consequent increased
fluid intake). There may also be weight loss (despite normal or increased eating), increased
appetite, and unreduceable fatigue. These symptoms may also manifest in Type 2 diabetes,
though this seldom happens for some years, and sometimes not at all. Clincally, it is most
common in Type 2 patients who appear at the doctor with frank poorly controlled diabetes.
Another common presenting symptom is altered vision. Prolonged high blood glucose
causes changes in the shape of the lens in the eye, leading to blurred vision and, perhaps. All
unexplained quick changes in eyesight should force a fasting blood glucose test.
Especially dangerous symptoms in diabetics include the smell of acetone on the patient's
breath (a sign of ketoacidosis), Kussmaul breathing (a rapid, deep breathing), and any altered
state of consciousness or arousal (hostility and mania are both possible, as is confusion and
lethargy). The most dangerous form of altered consciousness is the so-called "diabetic coma"
which produces unconsciousness. Early symptoms of impending diabetic coma include polyuria,
nausea, vomiting and abdominal pain, with lethargy and somnolence a later development,
progressing to unconsciousness and death if untreated.
Signs and symptoms of diabetes mellitus are due to the high amounts of sugar in the
body. The signs and symptoms of Type 1 diabetes develop quicker and become more severe than
those of Type 2 diabetes. However, the symptoms of Type 2 diabetes may not be noticed until a
regular medical checkup. The more severe the diabetes is, the more sugar is in the blood and the
longer high blood sugar levels last. The high amount of sugar in the blood means that more urine
is needed to carry it out of the body. As a result, people with diabetes usually experience a strong
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urge to pee, high amounts of urination (peeing), and constant thirst. The strong urge to pee can
occur at night and lead to low amounts of sleep. A high amount of peeing also leads to high
amounts of water and electrolyte loss. Electrolytes are chemical substances that are able to
conduct electricity after they are melted or dissolved in water.
For people with diabetes mellitus, the urine smells sweet because the extra sugar comes
out in the urine flow. Weakness and tiredness occur because the cells in the body are not able to
store or use the sugar that they need for energy. Thus, the body is being starved of one its main
energy sources. The body still gets some energy, however, from breaking down stored fat. The
breaking down of stored fat, in turn, leads to weight loss.
Although people with diabetes mellitus can break down stored fat for energy, the body
has a difficult time doing so. People with diabetes mellitus also have a difficult time breaking
down proteins. The difficulty in breaking down fats, especially when the body does not produce
insulin, can lead to the production of acids and poisonous chemical substances called ketones.
This condition is known as ketoacidosis. Ketoacidosis is a medical emergency because it can
cause coma, severe loss of body fluids, and even death. A coma is a state of deep
unconsciousness in which there are no voluntary movements, no responses to pain, and no verbal
speech. The signs and symptoms of ketoacidosis are nausea, vomiting, abdominal pain,
confusion, deep breathing, and foul-smelling breath. The foul-smelling breath smells like nail
polish remover.
Emergency treatment for ketoacidosis includes giving the person fluids to correct for
fluid loss and to bring back a normal chemical balance in the blood. Insulin injections are also
given to allow cells to better absorb glucose from the blood. Ketoacidosis can occur in people
with Type 1 and Type 2 diabetes. The difficulty with breaking down fats is especially true for
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people with Type 1 diabetes (see two sections down for a description) if they miss several doses
of insulin or develop another disease. The reason for this is that developing another disease
increases the body's use of insulin. Other symptoms of diabetes mellitus are blurry vision,
increased hunger, boils, as well as tingling and loss of sensation in the feet and hands. Boils are
inflamed, pus-filled areas of the skin. Pus is a yellow or green creamy substance sometimes
found at the site of infections.
X. MEDICAL MANAGEMENT
A. TREATMENT AND PROCEDURES
Name: Sotto Benito Z., 54 years old, Filipino
Hospital no: N98361
Date: 11 – 12 – 06
Ward: Surgical Ward, MS-04
Preoperative diagnosis: Diabetic Foot Gangrene at the left
Operation: Below the Knee Amputation
Post-operative diagnosis: Diabetic Foot Gangrene at the left
Anesthetic: Spinal/ Saddle Analgesia
Anesthetic started: 1:15 pm
Operation started: 1:40 pm Ended: 3:08 pm
B. MEDICATIONS
Atenolol 50mg/tab 1 tab OD q 8am
Tramadol 50mg/amp 1 amp IVTT q 6 hrs RTC
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Clindamycin 300mg/cap 1 cap q 6 hrs
Humulin 70/30 35 ‘u’ SQ ACBF 15’u’ SQ AC supper
Cataflam 50mg/tab 1 tab BID
C. DIAGNOSTIC PROCEDURES
HEMATOLOGY
Patient: Benito Z. Sotto Room: MS-04
Physician: Dr. Luis Carlos Fanlo November 12, 2006
LABORATORY RESULTS
TEST RESULT UNIT REFERENCEWBC 25.8 10^3/ul 4.8-10.8NEU 23.2LYM 1.65MONO .857EOS .020BASO .083
RBC 3.99 10^6/ul M 4.7-6.1; F 4.2-5.4HGB 11.7 g/dl M 14.0-18.0; F 12.0-16.0HCT 33.6 % M 42.0-52.0; F 37.0-47.0MCV 84.2 Fl M 80-94; F 81-99MCH 29.4 Pg 27.0-31.0MCHC 34.9 g/dl 33.0-37.0Platelet 612 10^3/ul 130-400