I. INTRODUCTION Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term
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I. INTRODUCTION
Diabetes mellitus is a condition in which the pancreas no longer produces enough
insulin or cells stop responding to the insulin that is produced, so that glucose in the
blood cannot be absorbed into the cells of the body. Symptoms include frequent
urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet,
oral medications, and in some cases, daily injections of insulin.
The most common form of diabetes is Type II, It is sometimes called age-onset or adult-
onset diabetes, and this form of diabetes occurs most often in people who are overweight
and who do not exercise. Type II is considered a milder form of diabetes because of its
slow onset (sometimes developing over the course of several years) and because it
usually can be controlled with diet and oral medication. The consequences of
uncontrolled and untreated Type II diabetes, however, are the just as serious as those for
Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat
misleading. Many people with Type II diabetes can control the condition with diet and
oral medications, however, insulin injections are sometimes necessary if treatment with
diet and oral medication is not working.
The causes of diabetes mellitus are unclear, however, there seem to be both hereditary
(genetic factors passed on in families) and environmental factors involved. Research has
shown that some people who develop diabetes have common genetic markers. In Type I
diabetes, the immune system, the body’s defense system against infection, is believed to
be triggered by a virus or another microorganism that destroys cells in the pancreas that
produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a
role.
In Type II diabetes, the pancreas may produce enough insulin, however, cells
have become resistant to the insulin produced and it may not work as effectively.
Symptoms of Type II diabetes can begin so gradually that a person may not know that he
or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other
symptoms may include sudden weight loss, slow wound healing, urinary tract infections,
gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while
a patient is seeing a doctor about another health concern that is actually being caused by
the yet undiagnosed diabetes.
Individuals who are at high risk of developing Type II diabetes mellitus include people
who:
are obese (more than 20% above their ideal body weight)
have a relative with diabetes mellitus
belong to a high-risk ethnic population (African-American, Native American,
Hispanic, or Native Hawaiian)
have been diagnosed with gestational diabetes or have delivered a baby weighing
more than 9 lbs (4 kg)
have high blood pressure (140/90 mmHg or above)
have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL
and/or a triglyceride level greater than or equal to 250 mg/dL
have had impaired glucose tolerance or impaired fasting glucose on previous
testing
MORBIDITY
Ten Leading Causes of Morbidity
Number, Rate/100,000 Population & Percentage
Philippines, 2002
MORTALITY
Ten Leading Causes of Mortality by Sex
Number, Rate/100,000 Population & Percentage
Philippines, 2002
Diabetes mellitus is a common chronic disease requiring lifelong behavioral and
lifestyle changes. It is best managed with a team approach to empower the client to
successfully manage the disease. As part of the team the, the nurse plans, organizes, and
coordinates care among the various health disciplines involved; provides care and
education and promotes the client’s health and well being. Diabetes is a major public
health worldwide. Its complications cause many devastating health problems.
II. PATIENT PROFILE Ward: 6th Main
Date of Admission: July 18, 2009
Patient Name: R. R
Address: Sampaloc Manila
Age: 54
Gender: Male
Birth Date: November 13,1954
Educational Status: High School Undergraduate (3rd year)
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Married
Occupation: Tricycle Driver
Health Care Financing: SSS
Informant: Patient, Wife and the Daughter
Reliability: 100 %
Admission Data
1. Chief Complaint: Wound right big toe
2. Initial Diagnosis: Gangrene big toe right foot related to Diabetes
mellitus type II
3. Final Diagnosis: Gangrene big toe right foot related to Diabetes
mellitus type II
4. Attending Physician: Dr. Fuentes and Dr. Sison
III. PATIENT HISTORY/ NURSING HISTORY
a. History of Present Illness
Eight months prior to admission patient noticed blisters of his right
big toe ventral surface area. Patient self medicate metformin 500 mg/tab
and glimeperamide 2mg/tab. No consultation done.
One week and 6 days prior to admission, patient noticed swelling
of the right foot no other associated signs and symptoms were noted.
Patient sought consult in Rizal Medical Center, and then patient referred to
our institution private physician. Patient advised to continue the
medication that he takes.
Three days prior to admission, patient noticed that his right big toe
become black, the wound become bigger, patient sought consult at our
institution at out patient department. Patient was advised for surgical
procedure hence admission.
b. Past Medical History
No previous hospitalization. No known food and drug allergies.
Patient diagnosed last April 28, 2008, Diabetes Mellitus type II,
maintenance medication metformin 500 mg TID and Diclofenac 500 mg.
c. Family Health History
The patient’s father has a cyst on his breast. And his mother is
hypertensive. Most of his siblings are hypertensive which is a risk factor
of diabetes mellitus. But our patient is not hypertensive.
d. Personal and Social History
Patient is a highschool undergraduate. He is a tricycle driver since
2000. He started smoking and drinking alcoholic beverages when he was
15 years old and stopped 20 years ago.
IV. LEVEL OF HEALTH FUNCTIONING
LEVEL OF
FUNCTIONING
a. health perception
and management
c. elimination pattern
BEFORE
HOSPITALIZATION
“The client defined
health as an important
thing that you should
take care of. Even
though he has diabetes
mellitus he still
considered himself as a
healthy person because
he can still do his daily
activity.”
The patient urinates 4-5
times a day.
The color of the urine
is light yellow.
The patient defecates
regularly.
DURING
HOSPITALIZATION
He considers himself as a
healthy person despite of
what happened to him
The client urinate 2x a
day.
The color of the urine is
yellowish.
The patient can’t manage
to go to Comfort Room
by himself alone that’s
ANALYSIS/
INFERENCE
Based from the
gathered
According to the data
collected, the patient
having difficulty in
elimination due to the
operation conducted.
d. activity exercise
pattern
e. sleep rest pattern
“araw araw akong
namamasada simula
6am-12nn ang tulog ko
ay 4 hours
lang.pagkagising ko ng
4am nag-eexercise ako
hanggang 5 ng
umaga,tapos 6 ng
umaga balik pasada na
ulit.”
He usually wakes up
around 4:00 in the
morning to prepare for
his work. The client
also stated that he
doesn’t have enough
sleep everyday because
of his work.
why his wife assists him
to defecate.
“.nahihirapan akong
gumalaw-galaw dahil sa
pagkakaputol ng paa ko.
Ngayon tinutulungan ako
ng asawa ko para
makakilos papunta sa
C.R at bumangon. Hindi
ko na rin mkuha pang
mag-exercise ngayon.” as
vervalized by our client.
“paputol-putol ang tulog
ko,3 hours lang
pinakamatagal kong
tulog ditto”
The client wasn’t able
to do things
independently.
Before
hospitalixation the
patient can only
acquire a little time
for rest and sleep
because of his work.
During
hospitalization the
patient can’t sleep
f. Cognitive
perceptual pattern
g. self perception
pattern and self
concept pattern
“Malabo na ang mata
ko at gumagamit na rin
ako ng salamin sa mata
kapag ako ay may
babasahin” as
verbalized by the client
-Impaired vision
-comprehension is still
at best
-nothing wrong with
his sense of hearing
High self esteem
believes in facts and
believes in what she
believe is right
-Impaired vision
-comprehension is still at
best
-nothing wrong with his
sense of hearing
He believes in facts and
believes in what he
believe is right
well because of the
pain brought by his
amputated leg.
Having a poor sense
of sight could cause
delay of what he
does. It is really
important for us to
have a good sense of
sight especially when
driving and reading.
Adjusted because of
the discomfort caused
by the pain of the
amputation
Has irritations and set
of boundaries for
himself
Intakes medications
and vitamins
Pushes himself to the
limits by working
overtime and doing
extra activities
Sees himself as a
strong individual,
competitive type of
person and is confident
regarding him self
Has irritations and
boundaries hor himself
Intakes medications and
vitamins
Pushes himself to the
limits by working
overtime
and doing extra
activities
Sees himself as a strong
individual, competitive
type of person and is
confident regarding
himself
Changed due to the
operation happened
Gained additional for
fast recovery
Adjusted because of
the immobility
Increased due to the
operation
h. role relationship
pattern
They are all living
together in the same
house. And they have a
good relationship with
each other.
Their major problem is
that if how can they pay
his hospital bills. And he
feels that he is not
capable of doing because
V. PHYSICAL ASSESSMENT
Biographic data:
Name: R. R Weight:
Address: Sampaloc Manila Height:
B.P.:
Age: 54 Temperatures: 36.8
Sex: Male Pulse Rate:72
Race/Ethnic Origin: None Respiratory Rate: 21
Marital Status: married Reason from admission: Wound of his right big toe
Occupation: Tricycle Driver
Religious orientation: Roman Catholic IBM:
Educational Attainment: High School Undergraduate
Health care financing and usual source of medical care: SSS
Areas to be Asses Actual Findings Normal findings Interpretation/ Analysis
Body built, height &
weight
>proprtionate, varie with
lifestyle
Proportionate & varies
with life style
Posture & Gait > not relaxed and erect
posture and no
coordinated movements
Relax, erect posture &
coordinated movements
Hygiene Not neat and clean Clean & Neat
Body/breath Odor No body odor and no
breath odor
No body odor or minor
body odor relative to
work of exercise; no
breath odor
Facial Expression Distress noted No distress noted
Signs of health/illness Unhealthy appearance Healthy appearance
Client’s attitude Cooperative, able to
follow instructions
Cooperative, able to
follow instructions
Client’s Response Understandable & clear
tone
Understandable & clear
tone
Quantity of speech Associated with the
thoughts
Associated with the
thoughts
Organization of thoughts Logical sequence, has a
sense of reality
Logical sequence, has a
sense of reality
SKIN
Skin color Varies from light to deep
brown; from ruddy pink
to light pink; from
yellow overtones to
olive.
Varies from light to dark
brown
Uniformity of skin color Generally, uniform
except for areas expose
to the sun
Generally, uniform
except for areas expose
to the sun
Edema No edema No edema
Skin lesion No edema Freckles, birth marks,
some flat and raised
abrasions or other lesion
Skin moisture Moisture in skin folds
and the axillae
Moisture in skin folds
and the axillae
Skin turgor When pinched, skin
brings back to previos
state
When pinched, skin
brings back to previous
state
HAIR
Evenness of growth Evenly distributed hair Evenly distributed hair
Hair thickness or
thinness
Thick hair Thick hair
Texture and oiliness Silky resilient hair Silky resilient hair
Upon admission patient was scheduled for disarticulation of right big toe with debridement. The surgical procedure was done on the same day. Capillary blood glucose monitoring.
On the second day post operatively patient was on diabetic diet medication was given. Capillary Blood Glucose monitoring was done. Capillary blood glucose monitoring.
On the third day diet medication was given and also Capillary Blood Glucose monitoring was done.
Fourth hospital day patient was scheduled for repeat debridement of right foot, where wound exudates was sent for Culture and Sensitivity test was given. Capillary blood glucose monitoring.
On the fifth day debridement of foot was done. Capillary blood glucose monitoring.
On the 6th hospital day patient complaint pain on the wound site but tolerable and patient was advised for below knee amputation where Cardio Pulmonary clearance was requested and done. Capillary blood glucose monitoring.
On the 7th day Vital signs monitoring was done. Capillary blood glucose monitoring.
On the 8th day Capillary Blood Glucose monitoring and vital signs was done. On the 9th day wound cleaning was done. Capillary blood glucose
monitoring. On the 10th day intravenous fluid of PNSS 1L was started. Capillary blood
glucose monitoring. Intravenous fluid of PNSS was continued and was operated on the 11th
hospital day for below knee amputation patient tolerated the procedure well with no subjective complaint, medication was continued. Capillary blood glucose monitoring.
Surgical procedure and date performed, July 29- below the right knee amputation. Capillary blood glucose monitoring.
X. NURSING CARE PLAN
CUES
Subjective:“hindi gumagaling ang sugat ko” (my wounds are not healing) as verbalized by the patient
Objective:Wound at the right big toe
INFERENCE/ANALYSISMINI-PATHOPHYSIOLOGY
Increased in blood sugar level.
Poor circulation
Poor wound healing
NURSING DIAGNOSIS
Poor wound healing related to
GOAL/PLAN
INTERVENTION/ IMPLEMENTATION
Independent:Observe for sign of infections and inflammations.
Promote good hand washing by nurse and patient
Maintain aseptic technique for IV insertion procedure, administration of medication, and providing maintenance and side care.Rotate IV sites as indicated.
provide conscientious skin care, gently massage bony areas. Keep the skin dry, linens dry
RATIONALE
Patient may be admitted with infection, which could have. precipitated ketoacidotic state, or may develop a nosocomial infection.
Reduces the risk of cross contamination
high glucose in the blood creates an excellent medium
EVALUATIONt
After 8 hours of nursing interventions, the patient was able to identify interventions to prevent or reduce risk of infection.
and wrinkle free.
Place in semi fowler’s positions.
Encourage adequate dietary and fluid intake of 3000 ml per day.
Collaborative:Obtain specimen for culture and sensitivities as indicated
forfection.
Minimizes the risk in bacterial growth.
Peripheral circulation may be impared, placing patient at increased risk for skin irritation or breakdown and infection.
Facilitates lung expansion and reduces risk of aspiration
Decrease susceptibility to infection.Identifies organisms so
the most appropriate drug therapy can be instituted.
XI. DISCHARGE PLANNINGMEDICATION
Amlodipine 10mg 1tab (morning)
Glimeperide 2mg 1tab OD
Metformin 500mg 1tab TID
Tramadol + Paracetamol 1tab TID
EXERCISEPractice bending the amputated leg
TREATMENTCBG monitoring TID a.c
HEALTH TEACHING
OUT-PATIENT FOLLOW UPFollow- up at IM OPD 1 week after discharge
1 slice toasted whole wheat bread with 1 teaspoon margarine1/4 cup egg substitute or cottage cheese1/2 cup oatmeal1/2 cup skim milk1/2 small banana
Snack: (Each has 60 calories or 15 grams carbohydrate. Pick two per day.)16 fat-free tortilla chips with salsa1/2 cup artificially sweetened chocolate pudding1 ounce string cheese plus one small piece of fruit3 cups "lite" popcorn
Lunch: (535 calories, 75 grams carbohydrate)
1 cup vegetable soup with 4-6 crackers1 turkey sandwich (2 slices whole wheat bread, 1 ounce turkey and 1 ounce low-fat cheese, 1 teaspoon mayonnaise)1 small apple
Dinner: (635 calories, 65 grams carbohydrate)4 ounces broiled chicken breast with basil and oregano sprinkled on top2/3 cup cooked brown rice1/2 cup cooked carrots1 small whole grain dinner roll with 1 teaspoon margarineTossed salad with 2 tablespoons low-fat salad dressing4 unsweetened canned apricot halves or 1 small slice of angel food cake