Westminster College

School of Nursing and Health Sciences

Nursing 309
I.

Patient Information
Student Name
Clayton Jensen
Patients Initials (No Names):B.D.

Date of Care: 01/28/2014

Age: 15
Gender: Male Source of

Information:
Admitting Diagnosis and date of admission: Type 1 Diabetes 01/27/2014 Date
of health history: 01/27/2014
Surgery, if applicable and date: NONE_
Vital signs: Temperature:

36.4

Respirations:

B/P:

16

Pulse: 88__
114/68

Wt & Percentile: 76.8 kg 93%

Height & Percentile: 161 cm 10%

OFC & Percentile: N/A
Current Medications, Frequency & Dose:
Drug Name
(pharm)

Insulin
Glargine
(Lantus)

Dose/Route/Frequ
ency/
other possible
routes (total
amount received
per dose/per day)
0.5 units / kg / day
SubQ
At dinner time

Show calculations
for safety range

Classification &
why patient
receiving (specific)

Major Side
Effects

Nursing
Implications &
Special
Precautions

Administer 5075%
of daily insulin
requirements once
daily
(range 2100
units/day)

Pharmacologic:
pancreatics

Assess patient for

signs and
symptoms of
hypoglycemia and
hyperglycemia
periodically
during therapy.

safe: Y

Patient is receiving this

for control of his type 1
diabetes mellitus

Endo:
HYPOGLYCEMIA.
Local:
lipodystrophy,
pruritis, erythema,
swelling.
Misc: allergic
reactions including
ANAPHYLAXIS.

Total insulin dose

determined by
needs of patient;
generally 0.5 1
unit/kg/day; 50
70% of this dose
may be given as
meal-related
boluses of rapidacting insulin

Pharmacologic:
pancreatics

Endo:
HYPOGLYCEMIA.
Local:
lipodystrophy,
pruritis, erythema,
swelling.
Misc: allergic
reactions including
ANAPHYLAXIS.

Assess patient for

signs and
symptoms of
hypoglycemia and
hyperglycemia
periodically
during therapy.

Total amount: 30
units per day
received / 24 hours:
30 units

Insulin
1 unit per 10 grams
Aspart
carbohydrates
(novoLOG)
For elevated premeal blood glucose
give insulin SQ 1
unit per every 50
mg/dl over 150 mg/dl
blood glucose
For elevated prebedtime glucose
(obtained before

Control of hyperglycemia
in patients with type 1 or
type 2 diabetes mellitus.

Control of hyperglycemia
in patients with type 1 or
type 2 diabetes mellitus.
Patient is receiving this
for control of his type 1
diabetes mellitus

Page 1

bedtime snack) give

insulin SQ 1 unit per
every 50 mg/dl over
200mg/dl blood
glucose

safe: Y

Total amount: Varies

with meals
received / 24 hours:
Varies with meals

II.

Nursing Assessment

A. Health Perception Health Management Pattern

Patient is a 15 year old with a history of asthma, depression and ADD who presented
with polydipsia, polyuria, nocturia, and elevated glucose on self-monitored measurement. Mom
began noticing on Tuesday (3/11/2014) that Patient was drinking a lot and peeing every 20
minutes. Patient noted that he was also waking up at night to urinate. He has a great aunt that
has DM2 with a glucometer and so he began checking his blood sugar levels, which averaged in
the 400's. This morning he went to his PCP at St. Marks where an A1C and blood glucose was
taken and the PCP recommended he come to PCMC for admission so that he could receive the
proper classes and training to best help him manage his sugars. His appetite has not changed.
He reports not having restful sleep recently despite sleeping 10-12 hrs a night. Looking back
they feel like he has been affected for about 3-4 months. Over the past 3-4 months Patient has
had N/V, stomachaches, and intermittent diarrhea. He missed the last couple of days of school
due to vomited and feeling poorly. Which is a rarity in itself since his mother spoke of him never
missing school. She said that he is generally pretty healthy. He never even gets the cold or flu
and if he does it isnt bad enough to effect him all that much. This is when they though it would
be a good idea to take him to the hospital. He was then admitted to the Primary Childrens
hospital on 01/27/2014 for care.
Upon arrival Patient we diagnosed with Type 1 Diabetes Mellitus. They spoke of having
an aunt that has Diabetes Mellitus type 2 but not type 1. Their family history doesnt look to
have neither any trace of the disease in it nor any other real significant diseases.

Page 2

Diagram Legend
Male family member

Female family member

Deceased family members

(Cause of death is shown initalics).

BreER = Breast Cancer

TypES = Type 2 Diabetes

AstMA = Asthma

TypES1 = Type 1
Diabetes

AngNA = Angina

HypON = Hypertension

HeaCK = Heart Attack

DepON = Depression

Patient lives with both his mother and father and two siblings, an older bother and a younger
sister. Both parents work but the mother only works about 1 or 2 days a week just for some extra
fun money. The father is in the military and works at Hill Air force Base up near Ogden. Neither
of the parents smoke or drink. Both of Patients siblings dont show any signs or symptoms of
any illness like his. Also both parents are free from ailments as well. The only thing they
mentioned, and did so sarcastically, would be that of old age. Due to Patients age he is very
capable in understanding what is happening to him and how it is going to change his life. He also
understands that none of this issue is his fault or anyones fault in anyway. Even thought this is
his first visit to a hospital he is taking everything pretty well. I of course was not at the hospital
when he first arrived but as of 01/28/2014 he was taking things rather well.
Patient, prior to his visit, has not taken any medication even for his asthma and
depression. They said it was never serious enough that they felt he needed to take anything for it.
Although now that he is a newly diagnosed Type 1 Diabetic he will have to not just take a
medication but completely manage his glucose levels throughout each and every day. His mother
spoke of it possibly being a hard transition for him due to being without medication completely
Page 3

to being 100% dependent on it. Either way they both seemed optimistic in his future care and
management.
The CDC recommends 15 yrs olds get any catch up vaccines they had not received
previously as well as a yearly influenza vaccine and a meningococcal (MCV4) booster or if child
is getting their first dose a booster is not needed. Patient is fully up to date on all of his
childhood and yearly immunizations besides his influenza vaccine for the year of which he will
receive during his current hospital visit before he goes home.
*Immunizations children 1-15 should be caught up on or receive: Hep B, DTaP, Hib, PCV, HPV, Influenza, MMR,
Varicella, Hep A, Meningococcal conjugate vaccine, IVP series

In general the family seems very healthy. They practice good hygiene and practice good
safety habits like seat belts are a must and they even have a fire escape plan in their home of
which they have even practiced. None of the family members have allergies other than a little
hayfever at times. They promote a great lifestyle. They do a lot of family activities revolving
around motocross and swimming. And their eating habbits are close to that of a diabetic anyway.
The mother said We do our best to keep a good diet because I know first hand the complications
of bad eating with my parents and sister. All three have suffered from it.
Patient is a 15Y 1M Male who presents with labs and symptoms consistent with insulin
dependent diabetes mellitus. At this time he is stable and not in DKA. While his age and
presentation are most consistent with type 1 diabetes, type 2 is still a remote possibility. He will
need to be admitted for initiation of his insulin therapy and diabetes teaching.
Pt is alert and oriented to time, place, person and situation. He is interactive, calm, and
pleasant, personal hygiene is clean and well groomed, body is proportional.

Basic Metabolic Panel

Test
Status
Last Reference
Range:

Cl

CO2

Anion Gap (Na Cl

CO2)

137-146 3.4-4.7 98-109 17-25

Units:

03/17/14.16:42

Na

Final

mmol/L

mmol/ mmol/ mmol/

L
L
L

* 129
L

4.1

96 L

CO2

19

Glucos BU Creatinin
e
N
e

Ca

3-16

60-115

8-21

0.42-0.90

8.810.7

mmol/L

mg/dL

mg/dL

mg/dL

mg/dL

14

* 650 H

14

0.76

9.8

Point of Care, Blood Testing

Test
Status
Last Reference
Range:

137146

Units:

03/17/14.12:43

Na

3.4-4.7 17-25

mmol/L mmol/L mmol/L

Final

132 L

4.5

21

Glucos
e

Calcium, Ionized (Whole

Blood)

Hematocrit

Hgb,
Calc

60-115

1.09-1.33

37.0-49.0

13.0-16.0

mg/dL

mmol/L

g/dL

505 H

1.27

43.0

14.6

Point of Care, Blood Gas Testing

Test Status

Specimen Source

Last Reference Range:

Units:

03/17/14.12:43

Final

Capillary

pH

pCO2

PO2

HCO3

BaseDef

7.37-7.43

24-37
mmHg

47-96
mmHg

15.9-22.4
mmol/L

0.2-7.5
mmol/L

7.39

34

70

20.1

Whole Blood Glucose

Test Status

Glu, Whole Bld

Last Reference Range:

60-115

Units:

mg/dL

Page 4

03/18/14.08:10
03/18/14.02:00
03/17/14.21:06
03/17/14.15:42

Final
Final
Final
Final

Page 5

* 220 H
* 232 H
296 H
* >600 H

Nursing Diagnoses:

B. Nutritional-Metabolic Patterns
The family of Patient typically sits down together to eat a family meal for dinner around
6 or 6:30pm. They make sure this happens every nigh and if it cant they make a point to not let
it happen consecutively. They said coming from a military style of living by having the father of
the house in the military they know how important not only family but discipline is. Some of the
main foods that are prepared for their dinner times are dishes with rice and chicken. They will
have the occasional steak dish just because the family loves steak but it doesnt happen all that
often. They mentioned that the only thing that they might be able to do better is control the
portion size of which they consume. Often times they go back for seconds and at times for thirds
even though they know they would have been fine with a single serving. They family doesnt
really have any foods they dont like. They seemed to really like anything and everything.
Patient did mention that he really enjoys being around his family at dinnertime and always love
a hot meal.
From the get go Patients mother said that he was an eater. She said that when he was
born he would breast feed enough for two babies. She said her other children never ate like he
did. Patient was born via vaginal birth on 12/06/1999. He weighed 6lbs 14oz. There were no
complications with his birth or with his mothers pregnancy. He wasnt a big baby, in fact he was
just about average. Regardless his mother kept reiterating that he was quiet the eater. He
currently weighs almost 173 pounds and is only 52. He didnt appear to be out of sharp or a
lazy teen. In fact, Patient is an avid motocross rider and says he practices every weekend and as
much as he can during the week.
Upon assessment of this area of the functional health patterns Patient seemed to be
within normal limits. His skin condition was pink and warm with elastic turgor, no edema, no
lesions, and no masses or deformities. His mouth and lips are pink and dry, no erythema, no
tonsils, and moist mucous membranes. He did have a few places where he had cavities worked
on and filled in but what teen doesnt have them. His hair is expected for his age and was evenly
distributed. His height of 161 cm puts him in the 10%-ile and his weight of 76.8Kg puts him in
the 93%-ile. Knowing this data indicates that he is within the defined limits for his age in both
height and weight but he is approaching being outside the ranges in both categories. His
temperature was roughly 98.6 during the whole time I was there with him and he was eating PO
with ease without any nausea or vomiting. See lab values above.
In this section I want to touch on what will be Patients new diet and insulin regimen that
he will have for the rest of his life. As for his fluid requirements, he follow the same lines as any
other food with carbs. If the beverage contains carbs they will need to be counted and calculated
towards how much insulin he will need to process the sugars correctly. If anything, water is the
only recommendation for him to drink and he is recommended to drink a lot of it (3 liters a day).
When it comes to food he is to regulate his insulin each time he eats as well.
He is to give himself 0.5 units/kg/day of insulin glargine (Lantus) at dinnertime
subcutaneously. This is his long acting insulin. Based on his weight he would give himself 38
units every night at dinner.
With his short acting insulin it is a little trickier. He is to subcutaneously take insulin
aspart (novoLOG) with meals 1 unit per 10 grams carbohydrates. In addition to the 1 unit insulin
per 10 grams carbs, give the following as a correction dose:
- For elevated pre-meal blood glucose give insulin aspart (novoLOG) SQ 1 unit
per every 50 mg/dL over 150 mg/dL blood glucose.

For elevated pre-bedtime glucose (obtain before bedtime snack) give insulin
aspart (novoLOG) SQ 1 unit per every 50 mg/dL over 200 mg/dL blood glucose.
o (pharmacy to enter on MAR range = 1 18 units for total novoLOG
dose.)

3. Nursing Diagnoses
C. Elimination Patterns
Patient has regular toileting habits, and as might be expected he is capable of controlling
how regular he is. His is 100% continent. He said that he has a bowel movement every day if not
twice a day. He spoke of some slight constipation a while back but he didnt have to do anything
for it to resolve. He simply just had to wait for his body to handle it. His mother said that he
doesnt have night sweats at all. While at the hospital he said that he has had regular bowel
movement and has had no problems there. He did have some serious nausea and vomiting before
arriving to Primary Childrens due to his high blood glucose level. Upon arrival his blood sugar
was averaging in the 400s confirming his hyperglycemia and therefore Type 1 Diabetes
Mellitus. After his diagnosis they took both him and his mother to be taught how to better
manage his sugar levels. I will further explain later in the teaching section what was taught to
him and his mother to manage his diabetes.
Upon observation of drainage the color and consistency was a clear amber with no odor.
He was urinating roughly 250 300 mls every 3 hours, which is right on target with the 1
ml/kg/hr ratio. His bowel and bladder elimination was regular and without effort or strain. They
did not do any urine tests on him.

3. Nursing Diagnoses

D. Activity-Exercise Pattern
Patient is a very active kid. Not only does he go to school Monday through Friday from
7:00a.m. to 3:00 p.m. but he also participates in a lot of extra curricular activities. I will mention
that Patient currently has a GPA of 3.84 and his mother made sure I knew it. She is very proud
of him for that. As for the extra curricular, he is on the football team and ROTC, he is also very
in to motocross and practices every day he can, he likes to play video games, be with friends and
family, and he is even apart of a band playing the bass. All in all, he seems to be a very well
rounded kid, having a foot in just about everything. He mentioned that he hardly ever watches
TV and if he does it is usually to watch a movie with friends, family, or on a date. He said he
didnt have a favorite program or show but if he had to say he like one in particular he would say
Game of Thrones, not only because it is good but because he has read the books a few times.
At his age his mother said she doesnt feel she needs to give him any restrictions so he doesnt
have any. Only until the past while Patient hasnt had any restrictions when it came to his
activity level. When he started to feel ill due to his high blood sugar he has been unable to do
most of the things he has committed to and loves. He is currently just playing video games and
trying his best to keep up in school from home. That being said he is very eager to get back out
there even with his insulin
Functional Level Codes
dependency and continue to
Level 0
Full self care
progress academically and in his
Level I
Requires use of equipment or device
extracurricular activities.
Level II
Requires assistance or supervision
Patient mentioned that
from another person
bathing for him is like brushing his
Level III
Requires assistance or supervision
teeth; it should be done before you
from another person and equipment or
leave the house at all costs. He said
device
if he had to give up one or the other
Level IV
Is dependent and does not participate
it would be bathing for the day
because brushing his teeth is
something he wouldnt be able to get away with, unlike not taking a shower for one day. He said
he prefers a shower of a bath, using a sponge/loofa instead of a bar of soap, and both shampoo
and conditioner because he has longer hair. He said he could floss more but he make sure that he
brushes his teeth two and sometimes three times a day. He said he either gets up and showers in
the morning and brushes his teeth in the shower or does the same thing at night, whichever ends
up being easier. He is more than capable of taking care of himself and doesnt need aid with his
grooming other than his mother cuts his hair. He does not need any help with eyeglasses, contact
lenses, hearing aid, orthopedic appliances, artificial elimination appliances, and orthopedic
devices.
Feeding
Bathing/hygiene
Dressing

0
0
0

Toileting: ______0__
General mobility _ 0__
Grooming
____0__

At this point Patient is a very independent person and seems to want to stay that way
very much. He currently does not have any issues of shortness of breath, murmurs, orthopnea,
cyanosis, dizziness, pacemaker, anemia, blood transfusion, hypertension, edema, hemoptysis,
sputum, SOB, wheezing, coughing, asthma, dyspnea, choking, lack of coordination, pain,
swelling, fractures, aches, cramps, arthritis, decreased range of motion, or muscle atrophy.
Now I would make sure to teach both Patient and his mother are taught about how the
long-term complications of Type 1 Diabetes develop gradually, over years. The earlier you
develop diabetes, and the less controlled your blood sugar, the higher the risk of complications.
Eventually, diabetes complications may be disabling or even life threatening. So issues that can
arise are:
Heart and blood vessel disease. Diabetes dramatically increases your risk of various
cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack,
stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.
Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels
(capillaries) that nourish your nerves, especially in the legs. This can cause tingling, numbness,
burning or pain that usually begins at the tips of the toes or fingers and gradually spreads
upward. Poorly controlled blood sugar could cause you to eventually lose all sense of feeling in
the affected limbs. Damage to the nerves that affect the gastrointestinal tract can cause problems
with nausea, vomiting, diarrhea or constipation. For men, erectile dysfunction may be an issue.
Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters that
filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage
can lead to kidney failure or irreversible end-stage kidney disease, which requires dialysis or a
kidney transplant.
Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy),
potentially leading to blindness. Diabetes also increases the risk of other serious vision
conditions, such as cataracts and glaucoma. So a yearly eye exam is a must.
Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of
various foot complications. Left untreated, cuts and blisters can become serious infections.
Severe damage might require toe, foot or even leg amputation.
Skin and mouth conditions. Diabetes may leave you more susceptible to skin problems,
including bacterial and fungal infections. Gum infections also may be a concern, especially if
you have a history of poor dental hygiene.
Osteoporosis. Diabetes may lead to lower than normal bone mineral density, increasing your
risk of osteoporosis.
Pregnancy complications. High blood sugar levels can be dangerous for both the mother and
the baby. The risk of miscarriage, stillbirth and birth defects are increased when diabetes isn't
well controlled. For the mother, diabetes increases the risk of diabetic ketoacidosis, diabetic eye
problems (retinopathy), pregnancy-induced high blood pressure and preeclampsia.
Hearing problems. Hearing impairments occur more often in people with diabetes.

Upon examination Patient had a BP of 114/68, a respiration rate of 18 with a regular

oscillating cycle of inspirations and expirations while having clear breath sounds, and a heart rate
of 88.
He was alert and oriented to time, place, person and situation. He is interactive, calm, and
pleasant, personal hygiene is clean and well groomed, and his body was proportional. See
appendix A for labs.
Due to his hospitalization he and his family have suffered in a few ways but probably
most in their exercise/activity level. They are very active people to begin with and to have
Patient in the hospital it has slowed them down a lot. Even leading up to his hospitalization he
was bed ridden which slowed him down even more. At least now his blood sugar is back into
normal range and is feeling 100 times better. That being said he is up an moving around the
hospital a lot. He was scheduled to go home the day after my visit with him. He was very excited
to get back to life again as was his mother.

4. Nursing Diagnoses
E. Sleep-Rest Pattern
Patient said that usually goes to bed around 11:00 12:00p.m. and wakes up for school
during the week at 7:00a.m. and on the weekends at 10:00a.m. He said that he would be capable
of sleeping in until 12:00 1:00a.m. if he allowed himself, his mother then interjected by saying
if I let you, you mean.. He replied with a smirk on his face and a nod of his head. He
apparently never takes naps, which make his time at the hospital a little weird for him
considering how many naps he is taking. He said, In a way it is kind of nice being here just for
that one reason. He said that he doesnt really have a routine prior to bed. He said he will
shower if time allows it and of course brush his teeth but that was it. The past few nights prior to
the hospital he would have to get up one or two times in the night to urinate but that was due to
his blood sugar issue. He normally sleeps through the night soundly. He doesnt share and room
with anyone and never has in his life. In fact he is in the basement bedroom of his home so there
isnt even anyone else down there with him. He has his whole basement to himself most of the
time. He has never had any sleeping problems other than recently with the brief nocturia. He said
the only problem he has with his awakening is just awakening. He says he struggle to get up in
the morning. Maybe earlier to bed would help but he doesnt care regardless. He enjoys stay up
late.
There was a period of about 2 hours during my visit that he sleep. Other than that time of
rest he was up and moving around.
Being at the hospital has help his sleeping in comparison to how horrible it was before
his glucose levels were handled. Even still he was getting much less sleep than he normally does.
This was largely due to him being a light sleeper and being in an unfamiliar place. He said just
hearing people outside his door or hearing people close doors on the pod would wake him up
through the night making it difficult to get a good nights rest.

4. Nursing Diagnoses
F. Cognitive Perceptual Patterns

Patient does not have a history of hearing issues. He does wear glasses most of the time
and contacts when he is going to play a sport or do something that could break his glasses. He is
near sited and has a prescription of 3.00 in both eyes. He is a very smart and has now learning
disabilities. He does not have any speech or communication problems, memory problems,
history of seizures, headaches, or dizziness. His two grandfathers both have some hearing loss
and use hearing aids but those are the only two that need hearing assistance. Lastly he has never
taken any ototoxic medications.
He is oriented to time, place, person and situation. He is interactive, calm, and pleasant,
personal hygiene is clean and well groomed, body is proportional. Hearing is intact with a
positive whisper test, no discharge, and ears are symmetric. He is perfectly capable of grasping
ideas and questions on an abstract and concrete stand point. He speaks English as his dominant
language. He has a vocabulary level of that of a 15 year old and a bit of a short attention span
unless entertained. For labs see appendix A.
Since his hospitalization his perception of himself has changed a little bit considering he
is now a Diabetic and will be for the rest of his life. This mean he will be different from most of
the teens in this world. Since he is in that stage of identity vs. role confusion he might have a
little harder time figuring out where he fits in now with his diabetic issue. This is a critical time
for young adolescents. They are beginning to find who they are and are becoming their own
person. Knowing he is a diabetic during this stage of his life will most definitely affect him. He
will have to constantly worry about what amount of insulin is needed for any activity or any
meal. This could possibly hinder his desire to play sports or other activities due to having to
figure out the proper amount of insulin and injected it into himself. This could also swing his
peers views of him in a different direction (both good and bad) than if he didnt have his
diagnosis.

4. Nursing Diagnoses
G. Self Perception/Self Concept Pattern
Upon discussing Patients temperament with his mother she was quick to respond by
saying how easy going her is. She says that he rarely ever fits her about anything let alone
anyone else like his bother or sister. She said he is generally very positive and cheerful and a
blessing in her life. She said that he of course has buttons that can be press which make him
annoyed or angry. These would be things like busy work from school or feeling he has been
treated unfairly but generally he is not this way. He is capable of letting things pass him by
without getting mad or annoyed by it. Things that would help him relax and subdue his angry
would just to leave him to go and do one of his many hobbies. She said if he can distract himself
from the issue at hand he is capable of forgetting all about it quickly. When he does get annoyed
or upset all he really does is he gets quiet, which is very unlike him. This also means he doesnt
talk to anyone about his issue, which could be an issue in itself, in the long run, as he might
bottle things away until a later date. Since his mother has been with him this whole time and his
father tends to be away until late at night he really hasnt noticed an impact in the lack of his
mother or father being with or around him. In fact he said he is ready for his mom to go do
something else instead of being so focused on him all the time. His mother worried that he would
end up looking at himself differently. She knows how great of a kind he is and the confidence he
already has but something like this could potentially rock anyones world for the worse. She said
she can only hope for the best and support him as much as she can.

Patient is a very social person, even with strangers like myself. He had no problem
keeping eye contact. As we spoke we got off topic a lot of times just talking about random things
which might be a result of some difficulty with his attention span or distractibility, but not
enough that I would think it would ever hinder him. He was always loud enough even for the
people outside the room to laugh at his jokes. As for his posture, he was mostly in the bed when I
spoke with him but as he walked around the pod and hospital he seemed to carry himself in a
positive way. Being the confident teen he seems to be I would definitely give him a 1 on the 1
5 scale of relaxation or anxiety (anxious (5) or relaxed (1)).
Again this is a period of time in Patients where he is trying to figure himself out and
throwing diabetes in the mix could potentially hurt him or help him do just that. As of what I saw
I feel he can handle it. Im sure he will probably doubt himself at some point but he shows the
confidence needed to pull through.

4. Nursing Diagnoses
H. Role Relationship Pattern
Patient does not have any other name he goes by than his birth name. Since he is of 15
years of age he is pretty capable of taking care of himself for the most part. He said if there is
any one person that would be considered someone that takes care of him that would be either his
mother or father. His father is the only one that works full time and he does so for the military.
He tends to go to work early in the morning and get home late in the afternoon (6am 8pm)
Monday through Friday. He does have the weekends off of which he utilizes for his family.
Patients mother just works part time maybe one or two days a week to pull in some extra cash
where she can. There are no special family considerations like adoption, fostering children,
stepparents, divorce, or single parenting. As of now Patients mother said that this issue with
him has been the first happening in a long time. She even said that no one in her family have
died or have had many problems, so he hasnt even experienced anything like that in his life
other than his current issue.
Patient said he has 2 main friends he hangs out with most of the time. They pretty much
do everything together and his mother said that they are both great kids. The three of them more
often than not go up to tracks made for motocross and the practice most of the day. He does have
his older brother hang out with them if he is not out with his friends already. In general though
Patient said he is a friend with everyone and anyone that wants to be friends with him. He said
this is partly why he loves to go to school as much as he does because he enjoys being around all
his friends and peers. He also enjoys the learning aspect of school but he believes he will like it
better when he gets to college and can study what he has an interest in. so it sounds like things
go pretty well for Patient at school both amongst his friends and academics.
Patient does not have any type of security object of any kind. If anything just having
people with him is what provides him with comfort, being such a people person.
In their household they do practice a number of methods of discipline that seem to work
very well with them. His mother did say though that her kids dont get in trouble all the often. So
they never really have to practice that much discipline on their kids. What they will do is simply
just progressively take more and more privileges away with how severe the problem at hand is.
When their kids were younger they did spank them when they needed it.
The mother said that the only way her other kids are affected is by not having her there at
the home as much as she normally is and of course not having their brother at home. She said
that he kids understand what is happening and know that their brother needs her at this time

more than them. The only concern she said she had was just getting his diet right and making
sure he takes the right amount of insulin. She said she was sure more would arise and she gets to
know more about the disease from a first hand point of view, but until then she is just going to
figure out how to feed her child.
From an objective stand point Patient seems to have a very good and close relationship
with his mother and father. I didnt get to se him interact with him father during my visit but the
way he and his mother spoke of him made him sound like a great dad.
As stated before Patient is in the identity vs. role confusion stage of Ericksons stages of
development. This is a critical time for young adolescents. They are beginning to find who they
are and are becoming their own person. Being a newly diagnosed Type 1 Diabetic he now knows
that he will have this issue for the rest of his life. Knowing this during this stage of his life will
most definitely affect him. He will have to constantly worry about what amount of insulin
needed for any activity or any meal. This could possibly hinder his desire to play sports or other
activities due to having to figure out the proper amount of insulin and injected it into himself.
This could also swing his peers views of him in a different direction than if he didnt have his
diagnosis. (Hockenberry & Wilson, 2007). See appendix A for labs.

4. Nursing Diagnose

I. Sexuality/Reproductive Pattern
Patient has definitely begun or possibly completed puberty being a 15 year old. These
events usually occur between 91/2 and 14 years of age (Hockenberry & Wilson, 2007 pg.743).
speaking with his mother she said that he has never come to her about puberty issue. That is
something that his father dealt with more than her. Knowing what she does through her husband
Patient hasnt really had any concerns or issue with puberty. She said he asked a few questions
here and there but nothing of significance. She said he husband spoke with both her boys at the
some time about how sexuality works around the age of 10. Patient and his mother didnt have
any concerns about issues related to sexuality or maturation.
Patient was uncomfortable when I brought up sexuality for the first time. I think I did a
good job of making light talk of the topic but it still was hard for him to answer questions and do
so with being nervous. His hospital stay has not had any effect on sexuality or reproductive
issues. I did not do physical assessment in this area and all labs are in appendix A.

4. Nursing Diagnoses
J. Coping-Stress Tolerance/Values-Belief Patterns
Having such a good head on his shoulders Patient doesnt get upset all that often but he
does get stress just like anyone. To relieve that stress he will go hang out with friends or go do
one of his many hobbies. His mother said he never really had or has temper tantrums. At this
moment he faked one in his bed like a baby and almost kick everything of his bed table. It was
funny. Continuing she explained if he ever has an issue he is open to talk about it but usually it
will take someone else to come ask him about it. He wont be the first one to express his feelings
when upset. This especially happens when he is disappointed about something. He just gets quite
and goes off by himself to usually occupy his mind with something else like a hobby.
They mentioned there havent been any big changes recently in their lives. I asked about
the potential for moving since the father of the house is in the military and they said the last time
they moved was when he was a 5 year old and they dont plan on moving for a long time. At
least until he and his siblings are out of high school. Patient said he has never tried drugs before
and tried a couple times some alcohol and was disappointed each time. He has also never thought
of suicide as an option.
He mother love this question about being accident prone. She laughed and then said It is
a miracle he hasnt come home with broken bones or something worse up to this point. His
hobbies arent exactly the safest ones. Luckily though he hasnt injured himself beyond the
scrapes and bruises.
The religion they practice is that of the LDS religion. They said they go to church just
about every Sunday and have family night every Monday if they can. I asked them if they would
like to have any type of religious practice continued in the hospital setting and they said that their
bishop already cam by when Patient first got there and gave him a blessing of healing and
comfort.
Their desires in life at this point is just to stay health and manage this new diabetes
diagnosis to the best of their ability. Other than that just the usual of graduating high school and
college, getting a career and family started and just living a good life, they want to just be happy
and play as much as possible. He mentioned that he doesnt know yet what he would major in
but he wants to make a lot of money in his future career. He was a little concerned with how

being a diabetic might hinder him in life but I reassured him of those I know with the some
disease that are very successful in all fields and if they can he can.
There was no stress test or depression scale performed on B.D.

4. Nursing Diagnoses
K. Other

1. Are there any other issues you would like to talk about?
How can we be most helpful?

III.

Pathophysiology (5 pts)

**TYPE ONE DIABETES MELITUS:

Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a
chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow
sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs
when the body becomes resistant to the effects of insulin or doesn't make enough insulin. Various
factors may contribute to type 1 diabetes, including genetics and exposure to certain viruses.
Although type 1 diabetes typically appears during childhood or adolescence, it also can develop
in adults. Despite active research, type 1 diabetes has no cure, although it can be managed. With
proper treatment, people who have type 1 diabetes can expect to live longer, healthier lives than
they did in the past.
Signs and symptoms of Type 1 Diabetes Mellitus usually are a result of either high or low
blood sugar. High blood sugar usually results in being very thirsty, feeling hungry, feeling tired
all the time, having blurry eyesight, feeling numbness or feeling tingling in your feet, losing
weight without trying, and urinating more often. If blood gets even higher symptoms might be
deep raping breathing, dry skin and mouth, flushed face, fruity breath odor, nausea or vomiting,
inability to down fluids, and stomach pain. These more serious sign and symptoms are a result of
diabetic ketoacidosis. With low blood sugar the symptoms would present with headache, hunger,
nervousness, rapid heartbeat (palpitations), shaking, sweating, and weakness.
TREATMENT:
Because type 1 diabetes can start quickly and the symptoms can be severe, people who
have just been diagnosed may need to stay in the hospital. If you have just been diagnosed with
type 1 diabetes, you may need to have a checkup each week until you have good control over
your blood sugar. Your health care provider will review the results of your home blood sugar
monitoring and urine testing. Your provider will also look at your diary of meals, snacks, and
insulin injections. It may take a few weeks to match the insulin doses to your meal and activity
schedule. As the disease gets more stable, you will have fewer follow-up visits. Visiting your
health care provider is very important so you can monitor any long-term problems from diabetes.
You are the most important person in managing your diabetes. You should know the basic steps
to diabetes management: how to recognize and treat low blood sugar (hypoglycemia), how to
recognize and treat high blood sugar (hyperglycemia), diabetes meal planning, how to give
insulin, how to check blood glucose and urine ketones, how to adjust insulin and food when you
exercise, how to handle sick days, where to buy diabetes supplies and how to store them.

INSULIN:
Insulin lowers blood sugar by allowing it to leave the bloodstream and enter cells.
Everyone with type 1 diabetes must take insulin every day. Insulin must be injected under the
skin using a syringe, insulin pen or pump. It cannot be taken by mouth because the acid in the
stomach destroys insulin. Insulin types differ in how fast they start to work and how long they
last. The health care provider will choose the best type of insulin for you and will tell you at what
time of day to use it. Some types of insulin may be mixed together in an injection to get the best
blood glucose control. Other types of insulin should never be mixed. You may need insulin shots
from one to four times a day. Your health care provider or diabetes nurse educator will teach you
how to give insulin injections. At first, a parent or other adult may give a childs injections. By
age 14, most children can give their own injections. People with diabetes need to know how to
adjust the amount of insulin they are taking like when they are going to exercise, when they are
sick, when they will be eating more or less food and calories and when they are traveling.
DIET AND EXERCISE:
By testing their blood sugar level, people with type 1 diabetes learn which foods and
activities raise or lower their sugar level most. This helps them adjust their insulin doses to
specific meals or activities to prevent blood sugar from becoming too high or low. The American
Diabetes Association and the American Dietetic Association have information for planning
healthy, balanced meals. It can help to talk with a registered dietitian or nutrition counselor.
Regular exercise helps control the amount of sugar in the blood. It also helps burn extra calories
and fat to reach a healthy weight. Talk to your health care provider before starting any exercise
program. People with type 1 diabetes must take special steps before, during, and after physical
activity or exercise.
MANAGING YOUR BLOOD SUGAR:
Checking your blood sugar level yourself and writing down the results tells you how well
you are managing your diabetes. Talk to your doctor and diabetes educator about how often to
check. To check your blood sugar level, you use a device called a glucose meter. Usually, you
prick your finger with a small needle called a lancet to get a tiny drop of blood. You place the
blood on a test strip and put the strip into the meter. The meter gives you a reading that tells you
the level of your blood sugar. Keep a record of your blood sugar for yourself and your doctor or
nurse. The numbers will help if you have problems managing your diabetes. You and your doctor
should set a target goal for your blood sugar level at different times during the day. You should
also plan what to do when your blood sugar is too low or high. Low blood sugar is called
hypoglycemia. Blood sugar levels below 70 mg/dL are too low and can harm you.
FOOT CARE:
People with diabetes are more likely than those without diabetes to have foot problems.
Diabetes damages the nerves. This can make you less able to feel pressure on the foot. You may
not notice a foot injury until you get a severe infection. Diabetes can also damage blood vessels.
Small sores or breaks in the skin may become deeper skin sores (ulcers). The affected limb may
need to be amputated if these skin ulcers do not heal or become larger, deeper, or infected. To
prevent problems with your feet stop smoking if you smoke, improve control of your blood
sugar, get a foot exam by your health care provider at least twice a year and learn whether you
have nerve damage check and care for your feet every day. This is very important when you

already have nerve or blood vessel damage or foot problems and make sure you wear the right
kind of shoes. Ask your health care provider what is right for you.
COMPLICATIONS:
After many years, diabetes can lead to other serious problems. You could have eye
problems, including trouble seeing (especially at night) and sensitivity to light. You could
become blind. Your feet and skin could develop sores and infections. If you have these sores for
too long, your foot or leg may need to be amputated. Infection can also cause pain and itching.
Diabetes may make it harder to control your blood pressure and cholesterol. This can lead to
heart attack, stroke, and other problems. It can become harder for blood to flow to the legs and
feet. Nerves in the body can become damaged, causing pain, tingling, and numbness. Because of
nerve damage, you could have problems digesting the food you eat. You could feel weakness or
have trouble going to the bathroom. Nerve damage can also make it harder for men to have an
erection. High blood sugar and other problems can lead to kidney damage. The kidneys may not
work as well as they used to. They may even stop working so that you need dialysis or a kidney
transplant.

IV.

Physical Assessment (10 pts)

ASSESSMENT: Brett is a 15Y 1M Male who presents with labs and symptoms consistent
with insulin dependent diabetes mellitus. At this time he is stable and not in DKA. While his age
and presentation are most consistent with type 1 diabetes, type 2 is still a remote possibility. He
will need to be admitted for initiation of his insulin therapy and diabetes teaching.
GENERAL: Pt is alert and oriented to time, place, person and situation. He is interactive, calm,
and pleasant, personal hygiene is clean and well groomed, body is proportional.
HEAD: Head is smooth and round, face is symmetrical, hair is expected for age and even
distributed, fontanelles are closed, no overriding suture lines.
EYES: Pupils round and reactive to light, anisocoria (left pupil smaller than right which has been
this way since birth). Conjuctiva is pink and sclera is white, Pt does wear glasses and had them
off during the examination.
EARS: Hearing is intact, no discharge, ears are symmetric.
NOSE: Patency is intact, no drainage or discharge
OROPHARYNX: Lips are pink and dry, no erythema, no tonsils, moist mucous membranes.
NECK: Full ROM, no tenderness upon palpation, lymph nodes soft and non-tender.
CHEST: Skin is pink and warm, turgor is elastic, no lesions, masses, or deformities.
CARDIOVASCULAR: RRR, no noticeable murmurs, rubs, gallops. Normal S1 and S2.

LUNGS: Clear lung sounds bilaterally, no increased work of breathing, no wheezing or crackles.
ABDOMEN: Abdomen is soft, flat, non-distended and non-tender; bowel sounds are present in
all four quadrants, no masses palpated
UPPER EXTREMITIES: 5/5 muscle strength, skin is pink, warm to touch, no cyanosis, or
clubbing noted, nails smooth and healthy, no edema present, CRT <3 sec.
LOWER EXTERMITIES: 5/5 Muscle strength, skin pink and uniform in color, warm to touch,
no cyanosis, or clubbing noted, nails smooth and healthy, no edema present, CRT <3 sec.
GENITOURINARY: Did not examine.
NEUROLOGIC: NAD, CN II-XII grossly intact.
SKIN: no skin rashes.

V.

Nursing Care Plan (60 pts)

Utilizing the data gathered in the database, prioritize the five highest priority nursing
diagnoses, state why these nursing diagnoses were selected and process them out.
Include one Psychosocial Nursing Diagnosis. Identify the subjective and objective
data, short-term and long-term goals, nursing interventions (including all
assessments, treatments, medications), rationale and evaluation of goal achievement.
Rationale for the nursing interventions is to be scholarly and documented using the
APA format. Each nursing pattern is worth 12 points.