Case study on diabetes mallitus

Objectives of Case study PresentationObjectives of Case study Presentation

• To share experience and knowledge with friends and supervisors.

• To get feedback from the supervisors and friends for further improvement. 

• To develop confidence in facing the mass and presenting skills

selection of case study • DM is commonly seen disease condition in

our country.• I selected this case as to learn in depth

about the disease condition. • Providing nursing care by applying nursing

process.

 

To provide holistic nursing care to the patient

using the nursing process.

To gain knowledge about the disease condition. To identify the major complication of diabetes . .

contd

Methodology• History taking • Observation • Physical examination • Discussion with teachers, senior staffs and

doctors • Using various text books and• Related internet search technology

• Name of client: Purna Bahadur BK• Age: 63 year • sex: Male• IPNO: 26308• Address : Jutpani 2 Chitwan • Diagnosis :- DM with HTN• Ward :- Male medicine• Bed No. :-15 • Date of admission :-• Date of interview :-• Date of discharge :- • Attending physician :-• Informants :- Patients and his wife

Bio-profile

Chief complain

• Dizziness for 3 days• Weakness for 3 days

History of present health

• Patient has history of HTN for 6 months, under medication (Amlodipine 5 mg OD)

• Diabetes under insulin therapy • Feeling of weakness, difficult to walk for 3 days

1. Patient was a known case of hypertension for 6 month

2. He had CVA before 6 month He got weakness of right limbs after CVA3. No history of COPD 4. No history of any surgical illness.5.No history of food and drugs allergy.

history of Past health

ENVIRONMENTAL HISTORY

• Type of family :- Single Family• No. of family:- 2 members • Type of house:- Cemented house • NO. of rooms :- 4• Kitchen :- Separated•  Fuel used :- Firewood , Gas• Drinking Water - Tap water• Toilet - Water seal • Drainage System :- Closed drainage

Contd

Family history • No history of Hypertension, Diabetes, TB

or asthma in family.

Socio economic history • Middle class family.

Smoking :- NO historyAlcohol : - No Food habit :- 3 times a day/ non vegetarianBowel and bladder :- Regular bowel and

bladder habitSleeping Pattern :- 8 hours at night

PERSONAL HISTORY

Family tree5

58 s 66yrs

28 yrs

Expired male

Expired female

Patient

Male

Female

65yrs

32yrs

Developmental task In book My patient

Adjusting to retirement and reduced or fixed income

He had been retired, he is getting pension,so he is adjusted to that

Adjusting to decreasing health and physical strength.

He was adjusted to that,as he verbalize that he could not hear properly, has vision problem due to aging process

Adjusting to the death of the spouse

He has two children,no loss of spouse

Finding way to maintaining quality of life

Not involved in social work

Accepting self as ageing He had accepted the ageing process, as he verbalizes it is natural

Maintaining satisfactory living arrangements

He had maintained the satisfactory living arrangements

Redefining the relationship with the adult children

He had no good relationship with son,but in good relationship with his daughter

General Inspection:Gait : Uncoordinated Body Build : GeneralConsciousness : Conscious and alert Facial expression : Anxious Vital signs Temperature : 980 f Pulse : 80b/minute and regular ,normal

volume and character. Respiration : 24 /minute, regular Blood Pressure : 140/90 mm Hg in both arms

(supine) Weight : 68kg

P HYSICAL EXAMINATION

General examination

• Pallor Absent• Icterus absent• Lymph node not palpable• Clubbing, cyanosis absent• Edema Not present• Dehydration absent.• Skin normal

Physical examination cont• Examination of head ,face and neck 1.HeadHair colors and texture normal, clean hair no any injury2.EyesNo discharge and redness of the eye lid, Blurred vision3. EarsNo discharge but difficulty in hearing

contd4. NoseNo discharge , bleeding and smelling problem. 5.Mouth Missing teeth and dental carries

6. NeckNo enlarged lymph node and thyroid gland .normal neck mobility is present

Respiratory examination• Inspection • Normal • Palpation

Non tender • Percussion• Resonant in all side of the chest. • Auscultation• Normal vesicular breath sound in both site

Cardiovascular system Inspection: normal shape Palpation• Non tender. Auscultation • No murmur in all areas.

Inspection- no distension ,moving symmetrically with respiration,

no dilated superficial veins, no scar marks Palpation- Non tender, liver- normal, spleen- normal Percussion- Dullness presentAuscultation- Bowel sounds present (normal)

Abdominal problem

CNS examination• Higher mental function is adequate• Motor examination eg position of limbs

normal ,no atrophy, no ulcer, uncoordinated gait

• No abnormal movement.• Weak muscle power in right limb.• Sensory normal

Comfort sleep ,rest

• Patient was anxious• No properly sleep at night.

Investigations2067-5-28Hematological• BSR-210mg/dl• Sodium-139mg/dl• Potassium-4. 6mmol/dl• Createnine-1.0mg/dl• Blood urea-30mg/dlgm

Investigation contd

Urine analysis• Color-light yellow• Reaction-Acidic• Albumin- Nil• Sugar-Trace• Transparency -Clear• Pus cells-0-2/HPF• Epithelial cells-0-2/HPF

Contd

2067/5/29• FBS-170mg/dl5/30• FBS-167mg/dl5/31• FBS- 150

Treatment

• Inj human insulin – 3o.7ou BD continue• Amlod – 5mg OD continue

Informal health teaching

• Diabetic diet • Foot care • Exercise • Regular check up of eye, BP, blood sugar• Adequate fluid• Different site of injection • Physical care

Discharge teaching

Diabetes mellitus• Diabetes mellitus, often simply referred

to as diabetes—is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced.

Incidence

• Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed. In the United States, approximately 800,000 new cases of diabetes are diagnosed yearly (Mokdad et al., 2000).

Incidence continue

Diabetes is especially prevalent in the elderly, with up to 50% of people older than 65 suffering some degree of glucose intolerance. Among adults in the United States, diagnosed cases of diabetes increased 49% from 1990 to 2000, and similar increases are expected to continue (Centers for Disease Control and Prevention [CDC], 2002).

Types of diabetes

• Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.)

• Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency.

Gestational diabetes

• Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.

Secondary diabetes • Accompanied by conditions known or

suspected to cause the disease: pancreatic diseases, hormonal abnormalities, medications such as corticosteroids and estrogen-containing preparations.

• Depending on the ability of the pancreas to produce insulin, the patient may require treatment with oral antidiabetic agents or insulin.

Etiology

• Hereditary• Autoimmune• Viral • Environmental factorPredisposing factors• Diagnosed over the age of 40 years• Overweight/obesity• Pancreatic infection

Clinical manifestation

• Polyuria (frequent urination),• Polydipsia (increased thirst) and• Polyphagia (increased hunger)• Visual blurring• Fatigue• Weight loss• Coma

Clinical feature

In my patient

• Polyuria • Polydipsia • Polyphagia • Visual blurring• Fatigue

Investigation

Condition 2 hour glucose Fasting glucose

Normal <7.8 (<140) <6.1 (<110)

Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126)

Contd Diabetes is diagnosed by examining glucose levels in blood

samples using one or more of the following tests: • Random glucose test — a glucose level above

11.1mmol/L taken at a random time on two occasions is a diagnosis of diabetes.

• Fasting glucose test — a glucose level above 7.8mmol/L measured without anything to eat and on two different days is a diagnosis of diabetes.

• Glucose tolerance test — a blood glucose test is taken two hours after a glucose drink is given to the patient. A level above 11.1mmol/L is a diagnosis of diabetes, while a level below 7.8 is normal.

Treatment

Management • Complete history taking and physical

examination• Blood test-FBS, RBS, PP,glycocylated,

hemoglobin,• Urine analysis • Insulin therapy • Diabetic Diet• Medicine

Management of my patient

• Diabetic diet

Management1)PREVENTION There is no know way to prevent diabetes except

it resulting from secondary cause following environmental factors can be modified in

• prevention of obesity• Prevention of illness• Reduction of environmental stressor• Prevention and control of hypertension• Exercise

Management continue• 2)EMERGENCY CAREA)Deabetic ketoacidosis• Goal of the treatment for this acute condition

are rehydration, restoration of electrolyte balance and reduction of blood glucose level

• Administer regular insulin• Administer IV fluid • Blood glucose level should not be lowered

• B) hyperglycemic hyperosmolar non ketotic syndrome• Is characterized by extreme hyperglycaemia, profound

dehydration, mild or undectable urea and the absence of Acidosis.Hyperosmolarity of plasma and elevated blood urea nitrogen

• Is treated with vigorous fluid replacement and administration of insulin and electrolyte

• infusion N/S over 2 hrs period followed by hypotonic saline solution

• Insulin is given infusion pump, if blood glucose levels decreases rapidly about 250 mg/dl dextrose saline is added to prevent hypoglycemia

C)hypoglacemia

Nursing care planASSESSMENTA. Subjective data• Polyuria • Polydipsia • Polyphagia • Visual blurring• Fatigue• Weight loss• Un-coordinated gait

B. Objective data• Hypertension• Right hand and right leg weakness• Unco-ordinate gait• Color of injected site• Anxiety

Orem’s self-care theory

Theory of self care

Theory of self care deficit

Theory of Nursing system Wholly compensatory Partially compensatory Supportive educative system

Theory apply for my case

Goal: to achieve optimal levels of knowledge regarding diabetes and its consequence

Objectives:• Patient will state the importance of maintaining a

diabetic diet.  • List the food items less in carbohydrate and fat • Patients will state the importance of foot care,

regular check up of eye, glucose level blood, blood pressure,

APPLYING THE OREM’S THEORY

SELF-CARE DEFICIT1 . Therapeutic self care demand: Deficient area: fluid volume

Adequacy of self care agency: inadequate

NURSING DIAGNOSIS • Fluid volume deficit related to inadequate intake

Goal: To achieve optimal levels of fluids

Objectives:• Patient will state the importance of maintaining a

fluid balance.  

Contd

Implementation• provided adequate fluid to the patient • Teach Patient and his wife about liquid and

liquid diet.Evaluation • Patient was taken liquid diet

APPLYING THE OREM’S THEORY

SELF-CARE DEFICIT1 . Therapeutic self care demand: Deficient area: diabetic

food adequacy of self care agency: not maintain

NURSING DIAGNOSIS • Alteration in diet pattern related to knowledge deficit

regarding importance of diabetes diet

b. Nursing Goals and objectives Goal: To achieve optimal level of diabetic diet and

minimize the risk of complication of diabetes.Objectives:• Patient will state the importance of diabetic diet.

• Take diabetes diet  

Contd

Implementation• Encourage the patient to take low carbohydrate

and fat containing diet• Teach Patient about amount and timing of the

food.

EVALUATION • Patient and his wife understood the importance of

maintaining diabetic diet.   • in terms of food will be decreased with the

initiation of the nutritional intake. • The supportive educative system was useful .

contdDesign of the nursing system supportive educative. Method of helping:• Guidance • Support • Teaching • Providing developmental environment

Knowledge gained through the case study

• I got comprehensive knowledge about the individualized care

• I got knowledge about diabetic diet.• I got knowledge to care the diabetic client• I got knowledge about holistic care of patient• I got knowledge about possible complication of this

disease

Daily Progress reportDaily Progress report

Date :- 2067/5/ 28Admission day A patient was came in medical OPD with history

of dizziness and weakness . On admission patient’s vitals sign were: B.P=140/90 mm of hg, R.R=32/min, Pulse=88/min, Temp.=98ºf according to nursing

report. RBS-210mg/dl Insulin-30.70 u BD Sc

Date :- 2067/5/ 29 2nd day of admission • Vitals signs: B.P= 140/80, pulse= 90/min,

R.R=24/min, Temp.=98.6ºf, • FBS-170mg/dl

Date :- 2067/5/ 30 3nd day of admission• Vitals signs: B.P- 140/80, pulse-70b/min, R.R-22/min,

Temp.-98ºfFBS. • Sleeping pattern good• Bowel and bladder normal

Date :- 2067/5/314th day of admission• Vitals signs:

B.P- 130/90, pulse-70b/min, R.R-32/min, Temp.-98ºf, • Patient condition was normal • Patient was discharge on request.

Complication • Low blood sugar levels leading to weakness,

confusion and sometimes seizures and loss of consciousness.

• Susceptibility to infections. • Ulcers and infections of the feet. • Arteriosclerosis (hardening of the arteries),

particularly in smokers and those with high blood pressure.

• Diabetic nephropathy (kidney disease). • Diabetic retinopathy (diabetes-related eye disease). • Diabetic neuropathy (nerve damage).

• Exercise • Exercise is very important both type 1 and type 2 diabetes. A

good exercise programme can help to control your blood sugar level. However, you may need to adjust your insulin dose according to the amount of exercise you take, as too much insulin and exercise may lower your blood sugar level.

• Oral medications• Oral medications lower the blood sugar by increasing the

amount of insulin secreted by the pancreas or by increasing the action of insulin in the body or by delaying the absorption of glucose. These drugs are called hypoglycemic tablets. They will not be effective unless they are combined with dietary restrictions.

Insulin therapy• Insulin therapy is the main treatment for type 1 diabetes. It may

also be required by some people with type 2 diabetes., • The aim of insulin therapy is to control the amount of insulin in

the bloodstream so that glucose levels are normal or near normal. You will be put on insulin and begin to regulate your diet as soon as the diagnosis is confirmed.

• As well as self-injections of insulin every day, you should also check your blood sugar level every day to ensure you get the right dosage of insulin — if you have too much or too little sugar in your blood, you will need to change your diet or the amount of insulin you are taking to keep your blood sugar at a healthy level.

• Diet • Diet is important in both type 1 and type 2 diabetes, but in type

2 diabetes effective dietary management may be sufficient to control the disorder. The main aim is to maintain a normal blood sugar level.

• Your doctor will advise you about which foods you should eat and how to space your meals to avoid going too long without food. The number of calories you are allowed is determined by whether you need to maintain, lose or gain weight.

• Your doctor may refer you to a dietician to help you plan a diet that includes a lot of carbohydrates and high-fibre food, and minimises the intake of sugar-rich foods. If you are overweight, you will be advised to lose weight — losing as little as a few pounds can reduce your need to take medication.