ST.

PAUL UNIVERSITY DUMAGUETE

Graduate School MAN/MSN Program

HEALTH ASSESSMENT
A CASE OF PATIENT WITH DIABETES MELLITUS TYPE 2

Prepared by:
Joralyn A. Pacres R.N

INTRODUCTION

The incidence of diabetes is growing around the world. It is in the top ten leading
causes of deaths. Filipinos are not an exemption to this incidence as more and more Filipinos
are affected by the disease. Diabetes is a chronic metabolic disease that occurs when the
human body is not able to produce enough of the hormone insulin or because cells do not
respond to the insulin that is produced. With type 2 diabetes, it is a chronic condition that
affects the way your body metabolizes sugar.
In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for
their body's needs, particularly in the face of insulin resistance. In many cases this actually
means the pancreas produces larger than normal quantities of insulin. A major feature of type
2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle
cells).
In 2010, there were 309,000 deaths related to non-communicable chronic diseases,
including diabetes. Approximately a quarter of these deaths were people of working age
(younger than 60 years). The Philippines is one of the worlds emerging diabetes hotspots.
Ranked in the top 15 in the world for diabetes prevalence, Philippines is home to more than 4
million people diagnosed with the disease and a worryingly large unknown number who are
unaware they have diabetes. In 2014, 9% of adults 18 years and older had diabetes. In 2012
diabetes was the direct cause of 1.5 million deaths. More than 80% of diabetes deaths occur in
low- and middle-income countries.

Source: http://www.who.int/mediacentre/factsheets/fs312/en/
http://www.allaboutdiabetes.net/philippine-diabetes-statistics/
The study that is to be presented features a patient who has a type 2 diabetes mellitus.
As a nurse I am involved in what nursing intervention I am going to apply to this kind of patient.
And in order to help my patient in his current health status the first basic step to do as a nurse
is to gather information or data from your patient in accordance with your health assessment.

ANATOMY AND PHYSIOLOGY

Fig. 1

Fig. 2

Pancreas
The pancreas is both an endocrine and exocrine gland. It is a wedge shaped elongated
gland which lies in the abdominal cavity. Structurally, the pancreas can be divided into three
(3) regions: the head, which lies over the vena cava in the C-shaped curve of the duodenum;
the body, which lies behind the duodenum; and the tail, which is situated under the spleen.
The pancreas is composed of two types of cell; exocrine and endocrine cells.
Exocrine Functions:
Pyramidal acinar cells are exocrine cells that compose the bulk of pancreatic tissue.
Groups of acinar cells form an acinus, and groups of acini form grapelike lobules. The acini
secrete the digestive enzymes of the pancreatic juice.

Pancreatic enzymes - these enzymes are released from the pancreatic acinar cells and are
involved in the digestion of foodstuffs.
There are three main types of enzyme present in pancreatic juice:
1. Amylases, which break down carbohydrates into glucose and maltose.
2. Lipases, which are important in the early stages of fat breakdown.
3. Proteases, including trypsinogen, the precursor of proteolytic trypsin.

Endocrine Function
Endocrine cells, or the islets of Langerhan, make up 1% of the pancreatic cells. They
are most numerous in the tail region of the pancreas. They consist of clusters of cells
surrounded by pancreatic acini. The major endocrine cells of the pancreas are alpha, beta and
delta cells, which secrete glucagons, insulin and somatostatin, respectively.
When the blood sugar level falls below normal levels, the alpha cells are stimulated to
secrete glucagon, which accelerates the conversion of glycogen to glucose in the liver. When
the blood sugar level is above normal, the beta cells secrete insulin, which promotes both the
metabolism of glucose by tissue cells and the conversion of glucose to glycogen, which is then
stored in the liver.

Insulin
Beta cells have channels in their plasma membrane that serve as glucose detectors.
Beta cells secrete insulin in response to a rising level of circulating glucose ("blood sugar").

Physiological effects
The actions of insulin on the global human metabolism level include:
- Control of cellular intake of certain substances, most prominently glucose in muscle and
adipose tissue (about of body cells).

Increase of DNA replication and protein synthesis via control of amino acid uptake.
Modification of the activity of numerous enzymes.
The actions of insulin on cells include:
1. Increased glycogen synthesis
2. Increased fatty acid synthesis
3. Increased esterification of fatty acids
4. Decreased proteolysis
5. Decreased lipolysis
6. Decreased gluconeogenesis
7. Decreased autophagy
8. Increased amino acid uptake
9. Increased potassium uptake
10. Arterial muscle tone Increase in the secretion of HCl by Parietal cells in the stomach

REVIEW OF SYSTEM

Fig. 3

A: Demographic Data
Patients name: Patient LV
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Address: Balangay 11 Pob. Quezon Bukidnon

Birthday: October 8, 1963
Age: 51
Sex: Female
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Married
Occupation: Housewife

B. HEALTH PATTERNS ASSESSMENT

1. Health perception and Management Pattern
Reason for hospitalization/ chief complaint: fever associated with cough, LBM, loss of
appetite

History of present illness: 2 weeks prior to admission patient experienced on and off onset of
fever for 3 days associated with cough. Taking mefenamic acid and apply body ointment and
felt relieved after but fever came back. Loss of appetite noted after 3 days of fever and decided
to seek bisaya treatment or manhihilot, then good appetite back and patient eat whatever she
crave. A night after she complain of abdominal pain and voided 4 times with bloody stool noted
hence decided to seek medical advice then admitted.

Previous Hospitalizations/surgeries:

 10 years ago admitted at Bukidnon Provincial Hospital Maramag due to 8 months

pregnant. She lost her baby and she discovered that she has a high blood
pressure.
2000-2001: admitted at BPH Maramag and undergo Ceasarian Section with her
youngest daughter
2007-2008 admitted 18 weeks pregnant and end up to miscarriage and undergo
Dilation and Curettage (raspa).

Family Health History:

What other health problems have you had? ___________________________________

Things done to manage health: ____________________________________________

V: NURSING REVIEW OF SYSTEM

1. General appearance

Patient is conscious, coherent and responsive when being asked. Not restless
and calm, not having fever or any unusualities.

2. Skin
Has cold skin, brown in color, decrease of skin elasticity noted due to age. There
are no signs of skin lesions and sores but scars on lower extremities noted.
There is absence of rashes and itchiness and no change in skin color.

3. Head
Patient is normocephalic and head is proportion to the body. On and off onset of
headache experienced 2 days prior to admission and relieved by taking
mefenamic acid, but there is absence of headache upon admission. Thin hair
noted and evenly distributed, slightly dry and presence of flakes noted. Facial
movement is symmetrical and closed fontanels noted.

4. Eyes
She has pale conjunctiva, blurry vision noted and wear eyeglasses. There is no
eye infection noted. Normal pupil reaction. Peripheral vision is intact.

5. Ears
There is normal gross hearing, tympanic membrane is intact and there is no foul
smell or any discharges noted in external canal.

6. Nose
Nose is at midline of the face, the mucosa is pinkish. No discharges noted and
both are patent. Normal gross smell and no tenderness noted upon palpation of
sinuses.

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7.

7. Mouth
Lips are pale but no lesions. Mucosa is pale, tongue is in midline. Does not wear
any dentures, but oral cavity is noted. Missing teeth is noted and gums are pale.
Tonsils are not inflamed and uvula is in midline.

8. Neck
There was no presence of neck stiffness or pain. Can turned head side to side.
Thyroids are non-palpable and trachea is in midline.

9. Abdomen
Straie noted with protuberant configuration of the abdomen. Bowel sounds is
hyperactive with 37 clicks in a minute with loud prolonged gurgles. Abdomen is
non-tender and soft, there is no guarding noted.
10. Cardiovascular/Respiratory status
No complaint of chest pain, precordial area is flat. Heart sound is normal.
Symmetrical peripheral pulses noted. Capillary refill of <3 seconds. Nonproductive cough noted and with regular breathing pattern. Lung expansion and
tactile fremitus is symmetrical. Patient was not in oxygen support and with o2
saturation of 97%.
11. Upper and Lower Extremities
She can hold things properly and can walk without assistance.

Tobacco use:

Yes

No

Used to smoke ________packs/day for_________ years

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Alcohol use:

Yes

No

Coffee/Cola/Tea Intake:

Amount:______________ Frequency: ___________

Yes

Recreational/ Illicit Drug use:

Allergies:

Yes

No Amount:_______ Frequency: __________

Yes

No Specify: __________

No

Food: _____________________ Medication: _________________________

Others: ____________________
2. Nutrition and Metabolic Pattern
Special Diet? __________________________ Supplements: ___________________
Pattern of daily food/fluid intake: __________________________________________
Appetite: ____________________________

wt. loss/gain? ____________________

Nausea/vomiting: ______________________
Food/eating discomforts: _________________________________________________
Nutritional state:

well-nourished

poorly nourished

obesity

cachexia

3. Elimination Pattern
Usual bowel pattern (characteristic of stool, frequency, discomforts) _______________

Date of last BM: ____________________

Any problems with hemorrhoids/incontinence? ________________________________
Use of anything to manage bowels (e.g. laxatives, enema, suppositories, anti-diarheals)
__________________________________________________________________

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Usual urinary pattern (describe frequency, character, amount, problem in control, etc.)
______________________________________________________________________
Dysuria

hematuria

nocturia

retention

flank pain

polyuria

oliguria

4. Activity-Exercise Pattern
Exercise Pattern (type/regularity): __________________________________________
Leisure Activities? _______________________________________________________
Activities of Daily Living/ Mobility Status:
0 total independence
1 assist with device
2 assist with person
3 assist with device and person
4 total dependence
Feeding ____

Meal Preparation ______

Bed mobility ________

Bathing ____

Cleaning ______

Chair/toilet transfer _____

Dressing ____

Laundry ______

Ambulation _______

Grooming ____

Toileting ______

R.O.M _______

5. Cognitive-Perceptual Pattern
Level of Consciousness:

conscious

alert

confused

drowsy

stuporous

comatose
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Orientation:

oriented

Emotional state:

calm

disoriented to: time/ person/ place

worried/anxious

restless

others:________

Cognition: Primary language __________________________

Speech Deficit ___________________________
Educational attainment ______________________

6. Sleep-Rest Pattern
Usual sleep/rest pattern: ________________________________________________
Adequate:

yes

no

Factors affecting sleep pattern: ____________________________________

Methods to promote sleep: ______________________________________________
History of sleep disturbances: ____________________________________________

7. Self-perception And Self-concept Pattern

How do you describe yourself? __________________________________________
Are there any ways you feel differently about yourself since youve been
ill/hospitalized?: _____________________________________________________________
Description of non-verbal behaviors: ______________________________________

8. Role-Relationship Pattern
Marital status: ________
Age and Health of significant others: _____________________________________________
Illnesses in the family: ________________________________________________________
Live

alone

family

others: _________________

Family feelings regarding hospitalization:___________________________________

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Who are the people that will help you most at this time? ______________________________
Occupation: ______________________
Financial support system: ____________________

9. Sexuality-Reproductive Pattern
Menstrual Pattern: ______________________ Problem/changes: __________________
Date of LMP: __________________________ Pregnancy history: _____________________
Uses of birth control measure
Monthly breast exam
Breast:

equal

yes

unequal

Tenderness

yes

no Type: ________________________________

no
Surfaces:

smooth

retraction

masses at: ___________________

dimpling

edema

others: ______________

10. Coping-Stress Tolerance Pattern

Have you experienced any recent stressful situations in addition to your
illness/hospitalization? _________________________________________________________
Is there any ways we can be of assistance? __________________________________
How do you usually manage stresses? ______________________________________
What do you do for relaxation? _____________________________________________

11. Value-Belief Pattern

Religion: ________________ Is it important in your life? How? __________________
Religious Practices ___________________________________________________________

EENT
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 Impaired Vision Blind

Pain Reddened Drainage
Gums Hard on hearing Deaf
Burning Edema Lesion Teeth
No problem

RESP
Asymmetric Tachypnea
Apnea Rales Cough Barrel Chest
Bradypnea Shallow Rhonchi Crackles
Diminished Dyspnea
Orthopnea Labored Wheezing
Pain Cyanotic No problem

CARDIO VASCULAR
Arrhythmia Tachycardia Numbness
Diminished pulses Edema Fatigue
Irregular Bradycardia Murmur
Tingling Absent pulse Pain
No problem
GASTRO INTESTINAL TRACT
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 Obese Distention Mass

Dysphagia Rigidly Pain

GENITO-URINARY and GYNE

Pain Urine color Vaginal bleeding
Hematuria Discharge Nocturia
No problem

NEURO
Paralysis Stuporous Unsteady Seizures
Lethargic Comatose Vertigo Tremors
Confused Vision Grip No problem
MUSCULOSKELETAL and SKIN
Appliauce Stiffness Itching Petechiae
Hot Drainage Prosthesis Swelling
Lesion Poor turgor Warm Deformity
Wound Rash Skin color Flushed
Atrophy Pain Ecchymosis
Disphoretic Moist Scar
Legend: - area with abnormality

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PHYSICAL ASSESSMENT
SKIN
General color:

pinkish

pallor

Texture:

smooth

rough

Turgor:

supple

firm

Temperature:
Moisture:
Others:

warm
dry

jaundice

cyanotic

flushed

mottled

others
dehydrated

cool

others:

moist/clammy

petechiae

dusky

oily

ecchymosis

hematoma

lesions/rashes

Edema: __pitting ___non-pitting ___pedal: R/L ___bipedal Grading: _____

HEAD
Normocephalic
Facial movements:
Fontanels:
Hair:
Scalp:

symmetrical

closed

fine

assymetrical

clean

assymetrical

sunken

coarse

bulging

dry

dandruff

enlarged

masses:_____
lag at R/L

open: specify_____

normal/even distribution
lice

others:________

alopecia

wound/scars/lesions: specify_______________

EYES
Lids:

symmetrical

Periorbital Region:
Conjunctiva:

R/L edema/swelling
edema

pink

pale

Sclera:

anicteric

Pupils:

equal: size____mm

Reaction to light: R=

subicteric

brisk

sunken
lesion
icteric

R/L ptosis

lesions:_____________

discoloration
discharges
hemorrhages

unequal: R=____mm L=____mm

sluggish

fixed

L=

brisk

sluggish

fixed
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Reaction to accommodation:

Visual acuity:

uniform constriction

grossly normal

farsighted

unequal constriction

nearsighted

Wears eyeglasses /contact lenses

Peripheral vision:

intact/full

decreased/limited: _________________

EARS
External Pinnae:

normoset

External canal:

discharge: ___foul smelling ___serous ___purulent ___mucoid

Tympanic membrane:
Gross hearing:

symmetrical

tenderness

lesions

intact

normal

decreased

symmetrical

R/L deafness

NOSE
Alar flaring
Septum:

midline

deviated

Mucosa:

pinkish

pale

Discharge:
Patency:

serous

Sinuses:

reddish

mucoid

both patent

Gross smell:

perforated

purulent

R/L obstruction

normal/symmetrical

bloody
masses/lessions: describe__________

R/L olfactory deficiency

tenderness: ____maxillary

____frontal

MOUTH
Lips:

pinkish

Mucosa:
Tongue:
Teeth:

pallor

pinkish
midline
complete

cyanosis

pallor

dryness/cracks

lesions:_______________

cyanosis

R/L deviation
missing teeth

atrophy
carries

dentures
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Gums:

pinkish

pallor

bleeding

tendernesss

PHARYNX
Uvula:

midline

R/L deviation

Mucosa:

pinkish

pallor

Tonsils:

not inflamed

reddish
R/L inflamed

R/L exudate

NECK
Trachea:

midline

R/L deviation

Cervical lymph nodes:

Thyroids:

lymphadenopathy

non-palpable

tenderness

enlarged

CARDIOVASCULAR STATUS
Chest pain/radiation: _________
Orthopnea

paroxysmal nocturnal dyspnea

Precordial area:
Heart sounds:

palpitations

flat

bulging

distinct

Peripheral pulses:

regular

symmetrical

Capillary refill ______

tenderness
faint

jugular vein distention

heave

irregular

regular

dyspnea on exertion

absent

thrill

Murmurs best heard at _______

weak

bounding

clubbing

ABDOMEN
General:

superficial veins

Configuration:
Bowel Sounds:
Percussion:

straie

symmetrical

asymmetrical

normoactive
tympanic

scars/lessions: ______

hyperactive

hypertympanitic

flat

globular
hypoactive

protuberant

scaphoid

absent

dullness at: ___________

Fluid wave
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Palpation:

muscle guarding

direct tenderness

Organomegaly: ____liver ____spleen

rebound tenderness

bladder distention

masses at: ________

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