I

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.

Lets 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

Patients name: D. W.Address: #13 Dona Consolacion, ,Manila. Birthday: October 4, 1952

Age: 54 years old

Birthplace: Cebu CitySex: Male

Citizenship: Filipino

Religion: Roman Catholic

Status: MarriedEducational Attainment: College Graduate

Occupation: Teacher

Admitting Diagnosis: Diabetes Type 2

Final Diagnosis: Diabetes Type 2

III. HISTORY OF PRESENT ILLNESS

Twenty days prior to admission, patient noted onset of wound 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, decided to transfer to UERM for further management.

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 had undergone Below the Knee Amputation at UERM.

VI. FAMILY, PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY

A. MEMBERS OF IMMEDIATE FAMILYName AgePosition in the familyEducational attainmentOccupationGeneral Health status

Benito Sotto54 yrs oldFather2nd yr H.S.NoneUnhealthy

Diomedes Sotto66 yrs oldMotherCollege of Education

graduateTeacherHealthy

Vincent Sotto31 yrs oldEldest child2nd yr CollegeN/AHealthy

Debbie Sotto30 yrs old2nd childCollege of Education graduateTeacherHealthy

Larrafe Sotto27 yrs old3rd child2nd yr CollegeN/AHealthy

Disebel Sotto25 yrs old4th child3rd yr CollegeN/AHealthy

Adelfa Sotto23 yrs old5th childCollege of Education graduateTeacherHealthy

Domagit Sotto22 yrs oldYoungest childCollege of Marine Trans. graduate SeamanHealthy

C. ENVIRONMENTAL HISTORY

They lived in Dona Consolacion, Manila 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 Metro ManilaD. HEREDO-FAMILIAL HISTORY

He verbalized that his father is diagnosed with mild hypertension. And his mother is also a diabetic. he has no food and drug allergies.

VIII. DEVELOPMENTAL DATA

AgeDevelopmentPatients Behavior

Infancy

(birth to 18 months)Trust vs. MistrustReported that he grew up normally as a young kid, demonstrated a normal steady growth. Nourished with breast milk for a year and a half.

Toddler

(18 months to 3 years)Autonomy vs. Shame and DoubtCan fully walk alone without holding onto support bars at the age of 1 year and 8 months. Was claimed to be very anxious about many things and enjoys playing alone. Very negativistic about many things.

Preschooler

(4 to 5 years old)Initiative vs. GuiltPlay was the most important activity of the day. Started to go along with peers and look for adventures. At this age, she can manage to wash himself alone and toilet training was established.

School Age

(6 to 12 years old)Industry vs. InferiorityStarted grade 1 at the age of 6 years old. He enjoyed the company of his friends and also loves to study. Shows interest in studying and playing.

Adolescent

(12 to 18 years old)

Self-Identity vs. Role confusionThis was marked as the most memorable time of the patients life especially that at this stage, she had already experienced boy to girl relationship.

Early adult

(20 to 40 years old)Intimacy vs. IsolationAlready go married at the age of 22 years old. And he had 6 children; some were already professional and some got married and have children too.

At PresentIntegrity vs. despairNow, its his concern to have more grandchildren and his children would raise them properly. He is ever glad that his family has been very supportive in these times.

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.

2 HAIR Variable, no infestation, slightly dry hair, evenly distributed hair.

3 NAILS Has smooth texture, highly vascular and pink in color, and intact epidermis

4 HEAD Normocephalic and smooth skull contour, absence of nodules, symmetric facial features, symmetric facial movements

5 EYES Eyebrows symmetrically aligned and equal movement, skin intact, no discharge, no discoloration, lids closed symmetrically, approximately 15 to 20 involuntary blinks per minute, sclera appears white, shiny, smooth and pink conjunctiva, pupils black in color, equal in size, positive reaction to light and accommodation able to read at a regular distance

6 EARS Color is same as facial skin, symmetric position, mobile, firm and not tender, able to hear ticking sounds on both ears, has smooth texture and no signs of discharges

7 NOSE Symmetric and straight, no discharge but manifests slight flaring due to post- operative pain, has uniform color, not tender and has no lesions, nasal septum intact and in the midline, breaths freely and regularly

8 MOUTH AND BUCCAL CAVITY Uniform pink color, ability to purse lips, no retraction of gums, pink gums, smooth, white, shiny tooth enamel, lips were red, soft and symmetrical in shape, no lesions, no bleeding noted on gums, tongue is in central position, pink color, smooth lateral margins, moves freely and has no lesions.

9 NECK Muscles equal in size, head centered, coordinated, smooth movements with no discomfort, has equal strength, lymph nodes not palpable.

10 LUNGS AND THORAX Chest is symmetrical, skin intact, uniform temperature, full symmetric chest expansion, clear breath sounds, respiratory rate is 25 cycles/min.

11 PERIPHERAL VASCULAR SYSTEM Full pulsations, symmetric pulse volumes, blood pressure is noted to be 140/80; extremities show no sign of redness, tenderness and edema.

12 BREAST AND AXILLAE Skin is uniform in color, it is also smooth and intact, no lesions and absence of discharges. No presence of tenderness and masses on the axillae.

13 ABDOMENUnblemished skin, uniform in color, symmetric contour, flabby and soft, no rashes or skin lesions, no appearance of bulges.

14 MUSCOSKELETEL SYSTEM UPPER EXTREMITIES Has an equal size on both sides of the body, no contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each bodys side.

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.15 NEUROLOGIC SYSTEM Conscious and coherent, no language deficiency, well oriented to time and place, coordinated body movements, smooth and steady

MALE GENITALS AND REPRODUCTIVE TRACT Even distribution of pubic hair, pubic skin intact and has no lesionsX. MEDICAL MANAGEMENTA. TREATMENT AND PROCEDURESDate: 11 12 06

Ward: Surgery wardPreoperative 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. MEDICATIONSTramadol 50mg/amp 1 amp IVTT q 6 hrs RTC

Clindamycin 300mg/cap 1 cap q 6 hrs

Humulin 70/30 35 u SQ ACBF 15u SQ AC supper

Cataflam 50mg/tab 1 tab BID

C. DIAGNOSTIC PROCEDURELABORATORY RESULTSTESTRESULTUNITREFERENCE

WBC25.810^3/ul4.8-10.8

NEU4240-73

LYM3420-45

MONO32-8%

EOS .0200-4%

BASO.0830-1%

RBC4.910^6/ulM 4.7-6.1; F 4.2-5.4

HGB16.7g/dlM 14.0-18.0; F 12.0-16.0

HCT33.6%M 42.0-52.0; F 37.0-47.0

MCV84.2FlM 80-94; F 81-99

MCH29.4Pg27.0-31.0

MCHC34.9g/dl33.0-37.0

Platelet15010^3/ul130-400

FBS: 256 URINALYSIS

MACROSCOPIC

Color

=

amber

- within the normal range

Character

=

cloudy

- within the normal range

pH

=

6.0

- within the normal range

Sp Gravity

=

1.020

- within the normal range

Glucose

=

+2

- not normal

Protein

=

+1

- not normalMICROSCOPE(per test) WBC

=

0-2/hpf - within the normal range

RBC

=

1-3/hpf

- within the normal range

Epithelial cells

=

moderate- within the normal range

Bacteria

=

few

- not normalD. DIETBreakfast: Full Diabetic Diet

Lunch: Full Diabetic Diet

Dinner: Full Diabetic Diet

DRUGMECHANISM OF ACTIONINDICATIONCONTRAINDICATIONADVERSE EFFECTNURSING RESPONSIBILITY

Diclofenac K

(Cataflam)

50mg/tab

Po

TID

After meals

Classification:Anti-inflammatory,NSAIDDiclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme, cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors.. Acute or long-term treatment of mild to moderate pain, including dysmenorrhea

Rheumatoid arthritis

Osteoarthritis

Ankylosing spondylitis

Treatment of actinic keratosis in conjunction with sun avoidance

Ophthalmic: Postoperative inflammation from cataract extraction

Active peptic ulcer; hypersensitivity to diclofenac or other NSAIDs. Treatment of perioperative pain in CABG surgery. 3rd trimester of pregnancy. Topical: Not to be applied onto damaged or nonintact skin. GI disturbances; headache, dizziness, rash; GI bleeding, peptic ulceration; abnormalities of kidney function. Pain and tissue damage at Inj site (IM); local irritation (rectal); transient burning and stinging (ophthalmic). Take drug with food or meals if GI upset occurs. Take only the prescribed dosage.

You may experience these side effects: Dizziness, drowsiness (avoid driving or using dangerous machinery while using this drug).

Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision; black, tarry stools.

Name of drugGeneral ActionSpecific ActionAdverse Effects IndicationContraindicationNursing Responsibilities

ClindamycinANTIBIOTIC;

Anti- infectives- inhibits bacterial protein synthesis by binding to 50S subunit of ribosome.

- hinders or kills susceptible bacteria.CNS: headache

CV: Thrombophlebitis

EENT: pharyngitis

GI: abdominal pain,

Anorexia, bloody or tarry stools, constipation, diarrhea, dysphagia, esophagitis, flatulence, nausea, psuedomembranus colitis, unpleasant or bitter taste, vomiting.

GU: UTI

HEMATOLOGIC:

Eosinophilia, thrombocytopenia, transient leukopenia

SKIN: maculopapular rash, urticaria

OTHER: anaphylaxis, erythema, pain (I.V. use), induration, pain; sterile abcess (I.M. use)- infections caused by sensitive staphylococci, streptococci, pneumococci, bacteroides, fusibacterium, clostridium perfringens, and other sensitive aerobic and anaerobic organisms.

-endocarditis prophylaxis for dental procedures in patients allergic to penicillin

-acne vulgaris

-bacterial vaginosis

- pneumocystis jiroveci (carinii) pneumonia

-toxoplasmosis (cerebral or ocular) immunocompromised patients-contraindicated in patients hypersensitive to drug or lincomycin

-use cautiously in patients with renal or hepatic disease, asthma, history of GI disease, or significant allergies.-assess patients infection before and regularly throughout therapy

-before giving first dose, obtain specimen for culture and sensitivity test, begin therapy pending results.

-monitor renal, hepatic, and hematopoetic functions during prolonged therapy.

-be alert for adverse reactions and drug interactions

-if adverse GI reactions occurs, monitor patients hydration.

-teach patient how to store oral solution.

-tell patient to take entire amount prescribed even after he feels better.

-warn patient that I.M. injection may be painful

-instruct patient to report diarrhea and to avoid self-threatening psudomembranus colitis

-tell patient receiving drug I.V. to report discomfort at infusion site.

GENERIC NAMETHERAPEUTIC ACTIONSINDICATIONSCONTRA-

INDICATIONSADVERSE EFFECTSNURSING CONSIDERATION

Insulin

Insulin injection:

Humulin R, Humulin R Regular U-500 (concentrated), Novolin ge Toronto (CAN), Novolin R, Novolin R PenFill, Regular Iletin II, Velosulin Human BR

Insulin is a hormone secreted by the beta cells of the pancreas that, by receptor-mediated effects, promotes the storage of the body's fuels, facilitating the transport of metabolites and ions (potassium) through cell membranes and stimulating the synthesis of glycogen from glucose, of fats from lipids, and proteins from amino acids.

Treatment of type 2 (noninsulin-dependent) diabetes that cannot be controlled by diet or oral agents

Contraindicated with allergy to pork products (varies with preparations; human insulin not contraindicated with pork allergy).

Use cautiously with pregnancy (keep patients under close supervision; rigid control is desired; following delivery, requirements may drop for 2472 hr, rising to normal levels during next 6 wk); lactation (monitor mother carefully; insulin requirements may decrease during lactation).

Hypersensitivity:Rash,anaphylaxis orangioedema Local:Allergylocal reactions at injection siteredness, swelling, itching; usually resolves in a few days to a few weeks; a change in type or species source of insulin may be tried; lipodystrophy; pruritus

Metabolic:Hypoglycemia;ketoacidosis

Assessment

History:Allergy to pork products; pregnancy; lactation

Physical:Skin color, lesions; eyeballturgor; orientation, reflexes, peripheral sensation; P, BP, adventitious sounds; R, adventitious sounds; urinalysis, blood glucose

Interventions

Ensure uniform dispersion of insulin suspensions by rolling the vial gently between hands; avoid vigorous shaking. Give maintenance doses subcutaneously, rotating injection sites regularly to decrease incidence oflipodystrophy; give regular insulin IV or IM in severeketoacidosisor diabetic coma. Monitor patients receiving insulin IV carefully; plastic IV infusion sets have been reported to remove 20%80% of the insulin; dosage delivered to the patient will vary. Do not give insulin injection concentrated IV; severe anaphylactic reactions can occur. Use caution when mixing two types of insulin; always draw the regular insulin into the syringe first; if mixing with insulinlispro, draw thelisprofirst; use mixtures of regular and NPH or regular andLenteinsulinswithin 515 min of combining them;Lantusinsulin (insulinglargine) cannot be mixed in solution with any other drug, including otherinsulins.

CuesProblemPlanningNursing InterventionRationaleEvaluation

Subjective:

Kaninang umaga lang ako naoperahan; as verbalized by the patient.

Objective:

T-36.3C

Weak in appearance

Clean and intact abdominal dressing

Risk for infection R/t Short term: After Hours of nursing intervention the client will be able to demonstate ways on how to prevent infection

Long term: After 3 days of nursing intervention the client will be able to have no infection . Assess signs and symptoms of infection especially temperature.

Emphasize the importance of handwashing technique.

Maintain aseptic technique when changing dressing/caring wound.

Keep area around wound clean and dry.

Emphasized necessity of taking antibiotics as ordered.

Fever may indicate infection.

It serves as a first line of defense against infection.

Regular wound dressing promotes fast healing and drying of wounds.

Wet area can be lodge area of bacteria

Premature discontinuation of treatment when client begins to feel well may result in return of infection.

Goal met:

Patient was free from any signs and symptoms of infections as manifested by absence of fever.

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