LCP Case Study

HOLY TRINITY UNIVERSITY
Puerto Princesa City, 5300 Palawan

Philippines
In Partial Fulfillment of the Requirements in

Related Learning Experience
SUMMER AFFILIATION 2010
LUNG CENTER OF THE PHILIPPINES
A CASE STUDY
“Diabetes Mellitus Type II/PTB”

Presented to:
Ms. Elma Jazz E. Macrohon, R.N., M.A.N.

Clinical Instructor
Presented by:
Eduard L. Alcantara
BSN 3rd Year – Group C
April 23, 2010
Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB Page 1
APPROVAL SHEET
This case study entitled “Diabetes Mellitus/PTB” serves as partial fulfillment of the requirements
in Related Learning Experience, Lung Centre of the Philippines. It was examined and approved with the
grade of _______%.
Clinical Instructor
____________________________________________
Ms. Elma Jazz E. Macrohon, R.N., M.A.N
ACKNOWLEDGEMENT
The researcher would like to extend their sincere appreciation and heartfelt thanks to the
following respectable persons who shared their time and effort for the success of this study.
To the nurses and other staff of the Lung Center of the Philippines for being the place of
exposure and for the learning endowed which is essential to give effective and ideal nursing care.
To my dear patient and her husband for their valuable time, cooperation, and willingness to
share significance information; their contributions for the enhancement of our skills in the assessment
of knowledge on the disease process that are the lifeblood of this case study.
To our clinical instructor for her unwavering support and guidance to us, Ms. Elma Jazz Elma-
Macrohon, R.N., M.A.N.
To my parents, who have always been our inspirations and the force within each one of us for
their constant support in achieving and reaching our goals in our chosen career.
And most of all, to our Savior and Dear Almighty God for His Divine providence and His most
precious gift of wisdom and good health.
DEDICATION
I would like to dedicate this case study to my parents and
to our clinical instructor, who had inspired us in making this case study possible,
for what has been imparted;
for my friends who gave me their unending support;
knowledge, skills and technically know-how
in the field of nursing with patience
and without limitation and above all,
to our Almighty God
for His never-ending blessings,
guidance and enlightenment.
E.L.A.
TABLE OF CONTENTS
Title Page------------------------------------------------------------------------------------------------------------------
----------1
Approval Sheet ----------------------------------------------------------------------------------------------------------

----------2
Acknowledgement -----------------------------------------------------------------------------------------------------
----------3
Dedication ----------------------------------------------------------------------------------------------------------------
----------4
Table of Contents-------------------------------------------------------------------------------------------------------
------- 5-6
Chapter I
Introduction--------------------------------------------------------------------------------------------------------------
----------7
Significance of the Study ----------------------------------------------------------------------------------------------

----------8
Statement of the problem --------------------------------------------------------------------------------------------

----------8
Scope and Delimitation -----------------------------------------------------------------------------------------------

----------8
Definition of Terms-----------------------------------------------------------------------------------------------------
----------9
Chapter II
Personal Data------------------------------------------------------------------------------------------------------------
----10-16
• Biographical Information
• Clinical and Family History
• Past Health History
• Present Medical History
• Present Condition
• Physical Assessment
• Summary of Findings
• Psychological Development (Erik Erikson)
Chapter III
Laboratory Examination and Results-------------------------------------------------------------------------------

----17-19
• Urinalysis
• Blood Glucose Test
Chapter IV
Schematic Pathophysiology-------------------------------------------------------------------------------------------
----
Narrative Pathophysiology--------------------------------------------------------------------------------------------
----20-21
Chapter V
Medical Management--------------------------------------------------------------------------------------------------
--------22
• Diet Therapy
Chapter VI
Prioritization of the Problems----------------------------------------------------------------------------------------

--------23
Concept Map-------------------------------------------------------------------------------------------------------------
--------24
Nursing Care Plans------------------------------------------------------------------------------------------------------

----25-35
Discharge Plan-----------------------------------------------------------------------------------------------------------
----36-37
Chapter VI
Prognosis------------------------------------------------------------------------------------------------------------------
--------38
Conclusion----------------------------------------------------------------------------------------------------------------
---------39
Bibliography--------------------------------------------------------------------------------------------------------------
---------40
INTRODUCTION
Diabetes Mellitus Type II or formerly referred as non-insulin dependent Diabetes

Mellitus (NIDDM) usually occurs after the age of 40, the pancreas retains some ability to
produce insulin but this is inadequate for the body’s needs: patients may require treatment
with oral hypoglycemic drugs.
Diabetes Mellitus (DM) or simply 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. This is the reason why diabetics need an insulin
injection if the disease is already severe.1
The incidence of type 2 diabetes is rising, especially in urbanized parts of the world
where sedentary lifestyles and obesity abound. In addition to weight and inactivity, race puts
some people at increased risk for developing type 2 diabetes. The incidence of diabetes is
rapidly increasing globally, and Asian Indians have the highest prevalence.2
The cause of continues to be a mystery, although both genetics and environmental

factors such as obesity and lack of exercise appear to play roles.3 The most common chronic
complications are cardiovascular disease, peripheral vascular disease, eye disease
(Retinopathy), kidney disease, skin disease (Diabetic Dermopathy) and peripheral and
autonomic neuropathy.4
Dr. Tommy Ty Willing, President of the Philippine Diabetes Association (PDA), during
World Diabetes day in November 2008 said that DM is prevails not only on middle-aged
persons but it is now more common among elementary and highschool students.
Pediatric endocrinologist Chan-Cua said the Philippines is still low on this score
compared with other countries, especially Scandinavian nations like Finland, Sweden, and
Norway, but we are also seeing an increase every year. My perception on this is simple –
Filipinos love sweets and fatty foods. Also, our staple food is rice, which is a starchy food item.
This makes diet as the primary risk factor to diabetes in the Philippines in my view.5
The researcher studied this case to identify the etiology, causes, Pathophysiology and
nursing care management needed to reduce risks and other complications that might arise in
the condition of the client.
SIGNIFICANCE OF THE STUDY
1
http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-philippines-and-
worldwide/
2
http://www.sciencedaily.com/releases/2008/02/080229112210.htm March 3, 2008
3
worldwide/
4 rd
Pathophysiology made Incredibly Easy! 3 Edition
5
worldwide/
This case study will serve as baseline information and future references for the nursing
students and other workforce in the medicine field. This case study is important to all the
researchers involved developing skills and knowledge with regards to the case. It will aid in
learning more about the possible nursing care management that are necessary and other
essentials. Furthermore as the case is presented it could share information to other nursing
students and will be useful reference with regards to the care of Diabetes Mellitus and to the
management care done to the patient with this condition.
STATEMENT OF THE PROBLEM
Generally, this case study entitled “Diabetes Mellitus Type II/PTB” seeks to find answers to the
following queries:
1. What is Diabetes Mellitus (DM)?

2. What are the factors that precipitate and contributed to the development of DM?
3. What are the medical management for a patient with Diabetes Mellitus?
4. What are the nursing assessments, diagnoses, plans, interventions, evaluations inclusive
to a patient with the said case?
SCOPE AND DELIMITATION OF THE STUDY

This study is delimited in terms of problem, source of data or population, locale and
time frame.
Problem:
This study focuses on “Diabetes Mellitus” together with the manifestations, treatment
modalities of the disease and possible nursing care plans.
Source of Data/ Population:

The population being referred in this study is the patient, significant others, patient’s
chart and admitting physician.
Locale:
The study was conducted on the 3-C Ward, Room Number 3301 of the Lung Center of
the Philippines.
Time Frame:
The study was performed on April 16-18, 2010 at 7:00-11:00 am; though the
interventions were limited for just four hours at the Ward 3-C of Room 3301 of the Lung Center
of the Philippines.
DEFINITION OF TERMS
DIABETIC MELLITUS- the disease where the body cannot control sugar absorption because the
pancreas does not secrete enough insulin.
DIABETIC DIET- a prescribed diet which is low in carbohydrates and sugar.
GLUCOSE METER-is a medical device for determining the approximate concentration of glucose
in the blood.
GLYCOGEN – is the stored glucose in the liver and muscle.
HYPERGLYCEMIA- is the excess of glucose in the blood.
HYPOGLYCEMIA- low concentration of glucose in the blood.
HYPOTHERMIA- a condition in which core temperature drops below that required for normal
metabolism and body functions which is defined as 35.0 °C (95.0 °F).
INSULIN- hormone produced by Islets of Langerhans in the pancreas that serves as precursors
for glucose to provide bodily energies.
POLYDIPSIA- the condition where the patient is abnormally thirst.
POLYURIA- the condition where a patient passes a large quantity of urine, usually as a result of
diabetes insipidus.
PULMONARY TUBERCULOSIS – the infectious disease in the lungs where pulmonary infiltrates
accumulate, cavities develop, and masses of granulated tissues form within the lungs.
DIABETIC COMA- a state of unconsciousness caused by untreated diabetes.
DIABETIC NEPHROPATHY- is the progressive damage to the kidneys seen in some people with
long-standing diabetes. It is manifested as an excessive leakage of protein into the urine
followed by gradual decline of the kidney function and even kidney failure.
PANCREAS – The largest pure endocrine gland in the body. It is both an endocrine gland
producing several important hormones, including insulin, glucagon, and somatostatin, as well
as an exocrine gland, secreting pancreatic juice containing digestive enzymes that pass to the
small intestine.
TOXAEMIA – Condition produced by the presence of bacterial toxins in the blood, usually with
tissue or organ damage, fever, and severe intestinal upset.
CHAPTER II
PERSONAL DATA
A. Biographical Information
Name: Mrs. Constellation
Age: 54 years old, 4 months, 55 days
Sex: Female
Address: 59 Mercury St., Constellation Homes, Novaliches, Caloocan
Educational Background: College Graduate (BS Commerce)
Religion: Roman Catholic
Civil Status: Married
Occupation: Self-employed/Dependent/Housewife
Usual Source of Medical Care: Doctor/Health Care Professional
Date & Time of Admission: April 12, 2009; 7:00 AM
Admitting Diagnosis: DM/PTB?
Chief Complaints: Increased blood Sugar
Attending Physician: Newell R. Nacpil, MD
Sources of Data: Patient’s Subjective and Objectives Cues, Chart, SO
B. Clinical and Family History

Name of Father: Papa Star
Disease within the Family: Diabetes Mellitus, Cardiac Arrest, Bronchial Asthma
Name of Mother: Mama Starry
Disease within the family: Pulmonary Tuberculosis, Hypertension
Number of children in the family: 4
Death in the family: 1st and 4th Child
Cause: Toxaemia
Immunization status: Unrecalled
C. Past Medical History
She was born on December 5, 1955 via normal spontaneous delivery. Her childhood
illnesses are cough, colds, and influenza. She experienced having Caesarean delivery five
times.
She experienced having Hysterectomy when she was 46 years old because of Myoma.
She doesn’t have any allergy on food, medications or pollens.
She admitted that her father had died due to Cardiac Arrest (Stroke CVA) and her
mother has pulmonary tuberculosis. She said that some of her relatives had Diabetes
Mellitus.
She was once admitted on February 2009 at Novaliches Hospital for 3-4 days because of
the increased on her blood sugar.
D. Present Medical History
Two weeks prior to admission she finished washing their clothes and found a blood stain
on the floor. She suspected but unsure that it came from her mouth and got worried. After
that incident she immediately got the idea of having a check-up.
After days, she forgot the planned check-up. On April 11, 2010 she checked her blood
sugar through glucose meter and it showed increased in her blood sugar. She immediately went
to a clinic under the service of Dr. Cheng, but the said doctor was absent during that time so
she went on the clinic of Dr. Nacpil. On the said clicnic, she was confirmed having an increased
blood sugar. In addition to that, through the use of X-ray it was confirmed that she has
pulmonary tuberculosis and was given appropriated medications. Dr. Nacpil referred her to the
Lung Center of the Philippines. She was admitted on April 12, 2010 at 7 o’clock in the morning.
She is confined at Ward 3-C Private Room 3301 and administered insulin and Fixcom for
her PTB.
She is ordered to have strict Diabetic Diet.
E. Present Condition
a. Perception and expectation of illness/hospitalization
The client came to the hospital because of the significant change in her blood
sugar and her worry about the unconfirmed PTB. She expects that she’ll be home after 2
days of confinement. She still lives with her mother and her husband and children who
she considers important persons in her life.
She spends her time by watching the television and cross-stitching.
After hospitalization she expects to have a general strictness on her lifestyle.
b. Specific Basic Needs
i. Comfort / Rest needs

Before Hospitalization:
• Her usual length of sleep is 6-7 hours a day, usually from 10pm to 4 or 5
am; stated that at times he takes a nap in the afternoon; able to take a
bath daily; able to routinely perform oral care, brushes her teeth three
times daily after meal.
• She also takes a bath every day after breakfast.
At the course of illness and during Hospitalization:

• She experienced headache and consulted the physician immediately and
cannot do her ADL’s.
ii. Safety needs

• The client doesn’t experience difficulty in moving about. She wears
eyeglasses and don’t have hearing difficulty.
During hospitalization:
• She is confined in a bed with side rails and SO’s at her side –mother, her
husband and her children. They are the most important persons in her
life. She also wears eyeglasses and said she cannot see clearly when she
is far as 2-3 feet away.
iii. Fluids and Nutrition

• Prior to admission, her usual meal is composed of ½ to 1 cup of rice, 1
piece of medium-sized fried fish, a cup of coffee with sweetener in the
morning; ½ to 1 cup of rice with viand of vegetables at lunch time; ½ to 1
cup of rice with 2 medium-sized pork adobo at dinner time; she prefers
vegetables and fruits. She drinks 9-11 glasses of water in a day
approximately 2,640cc (240cc x 11).
• As verbalized, “Mahilig ako sa gulay at prutas… nagdidiyeta na rin ako…”
During hospitalization:
• The Doctor ordered a Diabetic diet with calorie intake of approximately
2000cal/day; consumes approximately 3,000cc oral fluids/day.
Breakfast Lunch Dinner Snacks Total
Kcal
Intake
per
day
1 cup rice 1 cup rice 1 cup rice 2 glass juice 1,627.6
(200 Kcal) (200 Kcal) (200 Kcal) (120 Kcal) KCal
1 cup 1 serving 1 serving Beef 2 slice bread

coffee fish stew Steak (200 Kcal)
with sugar (89 Kcal) (118Kcal)
alternative 8 pcs
(20.6Kcal) 1 1 glass (30g/4pcs)
medium- lemonade (60 Crackers 280
1 slice sized Kcal) Kcal (140Kcal
Papaya (40 banana x 2)
Kcal) (40 Kcal)
Calamansi
juice (60
Kcal)
iv. Elimination
• Usually defecates once every 2 to 3 days, usually in the morning, to a
hard formed stool, yellowish - brownish in color; nocturia noted, urinates
about 12-15 times a day with no difficulty reported. Urine is slightly hazy
in color and approximately 70cc/hour.
During Hospitalization:
• Defecates once a day, with no definite time, to a soft formed stool,
yellowish in color approx. 220cc a day; urinates about 11-12 times
approximately 60-70cc/urination day with no difficulty reported. Urine is
slightly (yellow to orange).
v. Oxygenation
• Prior to admission no reports of DOB and SOB; home described as
surrounded with trees; She doesn’t smoke but her husband smokes as a
way of hobby at least once a month or nothing at all.
During Hospitalization:
• Upon admission at the 3-C Ward, revealing a normal RR ranging from 20-
22 cpm; (-) DOB; (-) SOB (April 13 to 15, 2009);
vi. Others
i. Sexuality:
o Generally Feminine in the way he acts, speaks and dress.
ii. Allergies:
o Reported (-) drug allergy; (-) asthma; (-) food; (-) dust.
iii. Communication:
o He communicates using Tagalog as their dialect. Responsive to the
questions asked and able to comprehend. She is also able to speak
Ilocano dialect and English.
F. Physical Assessment
MENTAL STATUS Conscious and coherent with fast response to external stimuli; GCS
of 15/15 (E=4; V=5; M=6) as of April 13-15, 2010.
o Impression: Congruent affect and happy mood, and with good
feminine appearance and grooming.
o Speech: Speaks clearly and speaks logically.
o LOC: Alert and understands written and spoken language and
responds appropriately.
o Orientation: Oriented on the person near, place, and time.
Hair Approximately 3-4 inches in length with minimal white hair strands;
dry; well distributed in the scalp
Head Normocephalic; (-) pediculosis capitis; (-) mass; (-) lesion or
Face tenderness.
Symmetrical facial structures; CNV Trigeminal nerve tested using
cotton functioning well; CNVII facial functions tested through food
functioning well.
Eyes Eyebrows and eyelids are intact, arched along bony prominences
above orbits; lashes present on upper and lower lids; (-) swelling of
lacrimal gland or duct; with pale palpebral conjunctivae noted; with
symmetrical pupils equally round and reactive to light
accommodation; with pupillary size of 3 mm on both eyes; (+)
medial movement of both eyes, symmetric movement of eyelids; (+)
blurring of vision in both eyes wearing no glasses when reading.
Ears Same color with the facial skin; top of pinna in line with the outer
canthus of the eye; (+) moderate amount of cerumen on both ears;
responsive to sound stimuli (CN VIII – Vestibulocochlear intact)
Nose Symmetrical; with patent nares, (-) nasal flaring noted; septum at
midline, straight and intact; mucosa is dry and pale pink in color;
able to distinguish odor (CN I – Olfactory Intact)
Throat/Mouth able to stick out tongue and; (+) white curd like patches at the
tongue surface; (+) gag and swallowing reflexes, able to speak and
cough, able to distinguish taste ( CN IX – Glossopharyngeal intact
Heart: and CN X – Vagus intact)
Chest and Lungs: (-) palpable lifts and heaves; (-) murmurs; Cardiac rate 72-78 bpm.
Inspection: With symmetrical lung expansion during respiration;

diaphragmatic breathing noted, RR-20-22 cpm with regular rhythm;
spine vertically aligned; spinal column is straight; right and left
shoulder are at the same height.
Palpation:
o posterior – skin intact; (-) palpable masses; full symmetric

lung expansion noted; bilateral symmetry of tactile fremitus
is noted; most palpated at the apex of the lungs
o anterior – uniform temperature on the anterior thorax noted;

skin intact; (-) palpable mass on all quadrants of the breasts
including the axilla; with full and symmetric lung expansion
noted
Percussion: Resonant sound heard on anterior and posterior

intercostals spaces upon percussion
Auscultation: (-) bronchial sound heard on both lung apex is noted; (-

)bronchovesicular sound heard on the mid-line of the lungs is noted;
Abdomen: (-)vesicular breath sounds heard on both lung bases is noted upon
auscultation.
I – flat abdomen noted; (+) symmetric movement during respiration.

A – with 2-3 borborygmic sound/min in all quadrants.
Genito-urinary:
P – dull sound heard at the first quadrant; tympanic sound
Skin and percussed in 3rd and 4th quadrants.
P – soft to touch, non-tender, with smooth, consistent contour.
Extremities:
Unable to assess.
Cool skin; With body temperature of 33.1⁰C. Capillary refill of 2-3
seconds; fair in complexion; good skin turgor; muscle grade of 5/5 on
upper extremities; muscle grade of 5/5 on lower extremities.
Cranial Nerves Assessment
I. Olfactory Nerve - Unable to smell mild smells

II. Optic Nerve - Blurry vision when not
wearing eyeglasses.
III. Oculomotor - Normal
IV. Trochlear - Normal
V. Abducens - Normal
VI. Trigeminal - Normal
VII. Facial - Normal
VIII. Acoustic - Normal
IX. Glossopharyngeal - Normal
X. Vagus - Normal
XI. Spinal Accessory - Normal
XII. Hypoglossal - Normal
General condition:
Conscious and coherent; with stable vital signs
SUMMARY OF FINDINGS SIGNIFICANT TO NURSING CARE
1. S: None
O: Cool skin; with body temperature of 33.1⁰C.
Nursing Diagnosis: Hypothermia R/T decreased metabolic rate
2. S : None
O: Fluctuating blood glucose level.
Nursing Diagnosis: Unstable blood Glucose R/T Diabetes Mellitus
3. S: As verbalized, “Mahilig ako sa gulay at prutas… nagdidiyeta na rin ako…”
O: Prior to admission, her usual meal is composed of ½ to 1 cup of rice, 1 piece of medium-
sized fried fish, cup of coffee with sweeter in the morning; ½ to 1 cup of rice with viand of
vegetables at lunch time; ½ to 1 cup of rice with 2 medium-sized pork adobo at dinner time; she
prefers vegetables and fruits.
Nursing Diagnosis: Imbalanced nutrition: less than body requirements R/T Insulin
deficiency
4. S: “Medyo may kalabuan ang paningin ko...” as verbalized.

O: (+) blurring of vision in both eyes wearing no glasses when reading.
Nursing Diagnosis: Disturbed Sensory Perception R/T Diabetes Mellitus
5. S: NONE
O: presence of DM and PTB; exposed to visitors
Nursing Diagnosis: Risk for infection R/T chronic disease (DM and PTB?)
PSYCHOSOCIAL THEORY BY ERIK ERIKSON
Age Book Profile Life Profile Remarks

Middle Adulthood: Erikson states that the significant The client was She
task is to perpetuate culture and able to establish successfully

35 to 55 or 65
transmit values of the culture her own family accomplished
Ego Development through the family (taming the and nurtured her this stage.
kids) and working to establish a own children

Outcome:
stable environment. Strength according to their
Generativity vs. Self-
comes through care of others and needs.
absorption or
production of something that
Stagnation
contributes to the betterment of
Basic Strengths: society, which Erikson calls
Production and Care generativity, so when we're in this
stage we often fear inactivity and
meaninglessness. If we don't get
through this stage successfully, we
can become self-absorbed and
stagnate.
CHAPTER III
Laboratory Examinations and Results
DIAGNOSTIC PROCEDURES
1. Urinalysis
Definition: An array of tests performed on urine and one of the most common methods of
medical diagnosis.
Rationale: To determine urine compositions and possible abnormal components (such as

protein, glucose and/or infection).
Date ordered: April 12, 2010
DIAGNOSTIC RESULT NORMAL INTERPRETATION RATIONALE

PROCEDURE VALUES
Colour Light Yellow Pale to Within normal The intensity of the
amber limitations. color generally
indicates
concentration of
urine. Pale or
colourless urine
indicates dilute and
yellow indicates
urine is
concentrated.
Transparency Slightly Hazy Clear Abnormal; (+) Determines the
clouding in the urine clouding of urine;
output. also called opacity or
turbidity.
Glucose (+1) (-) Above normal. Determine presence
Indicates presence of of glucose ion urine
glucose ion in urine that may indicate
and indicates DM, kidney damage.
presence of DM and
kidney damage.
pH 6.5 4.5 – 8.0 Normal; Indicative of To measure or
adequate defense determine the acidity
mechanism against or alkalinity of urine.
possible pathogens in
the genitor-urinary
infection.
Specific gravity 1.012 1.005-1.035 Indicative of negative To measure the
existing dehydration amount of substance
dissolved in the
urine. These tests
also determine how
well the kidneys are
able to adjust the
amount of water in
the urine.
Protein (-) (-) Within normal Protein is normally
limitations. not found in the
urine. Fever, hard
exercise, pregnancy,
and some diseases,
especially kidney
disease, may cause
protein to be in the
urine.
Nitrite (-) (-) Within normal Bacteria that cause a
limitations. urinary tract
infection (UTI) make
an enzyme that
changes urinary
nitrates to nitrites.
Nitrites in urine show
a UTI is present.
RBC 0-2/HPF 2-3/HPF Below normal result To determine the
which means amount of oxygen
insufficient being transported in
haemoglobin supply the body
in the body.
Epithelial Few None Presence of It is normal not to
contamination. have any epithelial
cells present in a
urine sample or to
have occasional
numbers of any of
the three cell types.
Large numbers of
squamous cells may
indicate
contamination of the
urine specimen, but
large numbers of
either the
transitional or renal
tubular cells may
indicate a serious
disease process.
Bacteria Moderate None Presence of bacterial Bacteria are common
infection. in urine specimens
because of the
abundant normal
microbial flora of the
vagina or external
urethral meatus and
because of their
ability to rapidly
multiply in urine
standing at room
temperature.
Mucus Thread Few None Normal This is a common
finding in urine since
the entire urine
system is filled with
mucus.
5. Blood Glucose Test

Definition: A blood glucose test measures the amount of sugar (glucose) in a sample of your
blood.
Rationale: Your doctor may order this test if you have signs of diabetes. It is also used to
monitor patients who have the disease.
Date Time Glucose Result

April 12, 2010 12 pm Patient ate
2 pm 334 mg/dL
6 pm 210 mg/dL
April 13, 2010 12 midnight 223 mg/dL
6 am 186 mg/dL
11 am 260 mg/dL
6 pm 147 mg/dL
6 am 169 mg/dL
12 midnight 193 mg/dL
6 am 186 mg/dL
CHAPTER IV
Schematic Pathophysiology and Narrative Pathophysiology
NARRATIVE PATHOPHYSIOLOGY
This section narrates the disease process of Diabetes Mellitus Type II/PTB.
Mrs. Constellation’s condition is affected by predisposing factors such as family history
and of old age of 54 years old. The highest incidence of DM Type II occurs in those persons with
family history and in individuals ages 40 and above. Her diet also contributes to the illness
process.
When there is increased glucose in the blood, there will be increased absorption of
glucose which will result to increase of its absorption in the GI tract, specifically in the colon.
The stimulation of the production of glucose happens when the pancreas specifically the
A cell, B cell, and D cell works together. The A cell increases the secretion of glucagon, B cell
decreases the production of insulin which the D cells inhibits A cell and B cell processes.
When there is increased absorption of glucose insulin deficit happens. Insulin deficits
happen when there is the decreased secretion of insulin and there is insulin resistance. This will
result to increased basal hepatic glucose production mainly in the liver resulting to decreased
glucose metabolism and decreased insulin-stimulated glucose uptake.
When there is decreased glucose metabolism there will be decreased in the flow of
blood in the lymphatic system (perfusion) resulting in decreased immune system functioning
which then increases the risk for infection. M. tuberculosis can be spread or transmitted
through cough or sneezes of other people. Because of the lowered immune system response
the process of invasion and proliferation of bacteria happens. The PTB is asymptomatic because
of its early stage.
The decreased of insulin-stimulated glucose uptake results to the abnormal metabolism
of Carbohydrates, Protein and Fats thus affecting the lipid metabolism. If there is a problem in
the lipid metabolism hypoglycemia happens which will result to hypothermia because of the
decreased energy production or metabolism.
Another, if there abnormal metabolism of Carbohydrates, Protein and Fats thus
affecting the lipid metabolism which results to unstable blood glucose.
When hyperglycemia occurs it will result to thickening of the capillary basement
membrane resulting to capillary closure, demyelinization of the optic nerve, and aberrations of
myelin sheath which affects the eyesight causing impaired visual perception specifically
disturbed visual perception.
When there is increased glucose in the blood stream meaning that there is decreased
glucose in the cell/s which will cell starvation. When these happens polyphagia or excessive
eating occurs because of the stimulation of the hypothalamus which is the satiety center
causing excessive thirst and hunger which will result to increased food and water intake.
When there is cell starvation there will be negative feedback mechanism which
decreases the fat and protein in the body which caused imbalanced nutrition.
When there is hyperglycemia, there will be glucosuria or the excess glucose spills in the
urine resulting polyuria which result to flushing of excess glucose and ketones in the blood
stream resulting to polydipsia and polyphagia.
CHAPTER V
Medical Management
A. Diet
Type of Diet Date Ordered Rationale
NPO April 12, 2010 To prevent any alterations in

diagnostic test done to the
patient.
Diabetic Diet April 13, 2010 To eat specific portions of

Carbohydrates and Proteins at
specific times throughout the
day by a diabetic person to
make sure that the diet is
stabilizing blood sugar levels.
CHAPTER VI
PRIORITIZATION OF NURSING PROBLEMS/NURSING CARE PLANS
ACTUAL OR ACTIVE PROBLEM:
Problem No. Problem Date Identified Date Resolved Remarks
The temperature
1 Hypothermia R/T
April 13, 2010 April 14, 2010 increased but not in
decreased
metabolic rate its normal level.
With latest blood

Unstable blood
2 Glucose R/T April 13, 2010 April 15, 2010 sugar level of 186
Diabetes
mg/dL.
Mellitus
The client can’t

Disturbed Visual
3 clearly see an
Perception R/T
Diabetes April 13, 2010 April 14, 2010
object 2-3 feet
Mellitus
away.
Imbalanced
The client
nutrition: less
than body experiences
April 14, 2010 April 15, 2010
4 requirements fluctuation of blood
R/T Insulin sugar level.
deficiency
HIGH RISK OR POTENTIAL:
Problem No. Problem Date Identified
1 Risk for infection R/T chronic April 13, 2010

disease (DM and PTB?)
Demographic Profile
Name: Mrs. Constellation
Gender: Female
Age: 54 years old
1. Marital status: Married 3. Disturbed Visual
Religion: Catholic Perception R/T
Hypothermia R/T decreased Occupation: Self- Diabetes Mellitus
metabolic rate employed/Dependent/Housewife
Educational Background: College
Graduate (BS Commerce)
Vital Signs:
BP: 120/80 mmHg

RR: 20 cpm
PR: 72 bpm
Temperature: 33.1 ⁰C
CONCEPT MAP
2. 4. Imbalanced nutrition: less

than body requirements R/T
Unstable blood Glucose R/T 5. Risk for infection Insulin deficiency
Diabetes Mellitus R/T chronic disease
(DM and PTB?)
NURSING CARE PLAN
PROBLEM #1
Assessment Statement of Problem Planning Nursing Intervention Outcome
SC: “Ayos naman ang Hypothermia R/T STG: INDEPENDENT Unable to measure
pakiramdam ko pero decreased metabolic At the end of 2 hours, temperature due to the
parang sa bawat oras ng rate will be able to 1) Established trust and end of duty.
pagkuha sa temperatura demonstrate measures rapport.
ko nasa 33 hanggang NANDA Definition: that will enhance ®To gain trust and STG: partially met
35⁰C.” Body temperature below normothermia. rapport for effective (April 14, 2010: 8:00 am
normal range. assessment and 33.4⁰C then at 10:00 am
LTG: intervention. 34.1⁰C)
OC: Etiology: At the end of 3 days, will 2) Monitored vital signs LTG: partially met
Body The cause of lower body be able to continually especially the
temperature temperature is because demonstrate measures temperature.
below normal of the decreased that will manage normal (R) For baseline data
range metabolic rate range of temperature. and to plan effective
Cool skin secondary to DM. interventions.
Temperature: 3) Provided warm
35.4⁰C (April 13, Background Theory: liquids.
2010), According to Virginia (R) To enhance warming
33.1⁰C (April 14, Henderson the unique effect on the body and
2010: 8:00am) function of the nurse to promote good
34.1⁰C (April 14, assist the individual, sick circulation.
2010: 10:00 am), or well, in the 4) Encouraged to have
moderate movement or
33.1⁰C (April 15, performance of those exercise.
2010) activities contributing to ® To increase the body
the health or its temperature because it
recovery (or to a helps in metabolism.
peaceful death); that he 5) Measured urine
would perform unaided output.
if he has the necessary ® Oliguria/renal failure
strength, will or can occur due to low
knowledge, and to do flow state and/or
this in such a way as to following hypothermic
help him gain osmotic diuresis.
independence as rapidly 5.) Monitored
as possible. laboratory studies, such
as ABGs (respiratory and
metabolic acidosis);
electrolytes; CBC
(increased hematocrit,
decreased white blood
cell count); cardiac
enzymes (myocardial
infarct may occur owing
to electrolyte
imbalance, cold stress
catecholamine release,
hypoxia, or acidosis);
coagulation profile;
glucose;
pharmacological profile
(for possible cumulative
drug effects).
® To measure or identify
alterations.
6.) Provided well-
balanced, high-calorie
diet/feedings.
® To replenish glycogen
stores and nutritional
balance.
7.) Discussed
signs/symptoms of early
hypothermia.
® To facilitate
recognition of problem
and timely intervention.
PROBLEM #2
S: Unstable blood Glucose STG: at the end of 2 1.) Determined STG: met
(none) R/T Diabetes Mellitus hours nursing nutritional status With latest blood sugar
intervention, will be and potential for glucose of 186 mg/dL.
O: NANDA Definition: able to participate to delayed healing LTG: partially met
o Weakness Variation of blood normalize blood sugar or tissue injury
o Diabetes glucose/sugar levels level. exacerbated by
Mellitus from the normal range. malnutrition.
o Fluctuating LTG: at the end of 3 ® To plan for
blood sugar Etiology: days will be able to appropriate
levels: Unstable blood sugar maintain optimal well- nursing care
334 mg/dL; 210 occurs because of DM. being. plan.
mg/dL, 223 2.) Determined
mg/dL, 186 Background Theory: individual factors
mg/dL, 260 According to Lydia Hall’s that may
mh/dL, 147 Key Concepts of Three contribute to
mg/dL, 169 Interlocking Circles unstable
mg/dL, 169 Theory “Nursing is Glucose.
mg/dL, 160 participation in care, ® To know the
mg/dL, 193 core and cure aspects of mere cause.
mg/dL, patient care, where 3.) Provided
CARE is the sole function information on
of nurses, whereas the balancing food
CORE and CURE are intake,
shared with other antidiabetic
members of the health agents, and
team.” energy
expenditure.
® To facilitate
client’s
understanding.
4.) Reviewed client’s
diet, especially
carbohydrate
intake. ® Glucose
balance is
determined by
the amount of
carbohydrates
consumed,
which should be
determined in
needed
grams/day.
5.) Emphasized
importance of
checking
expiration dates
of medication,
inspecting insulin
for cloudiness if
it is normally
clear, and
monitoring
proper storage
and preparation
(when mixing
required).
® Affects insulin
absorbability.
6.) Checked
injection sites
periodically.
® Insulin
absorption can
vary from day to
day in healthy
sites and is less
absorbable
in
lypohypertrophic
(lumpy) tissues.
COLLABORATIVE
1.) Consulted with

dietitian about
specific dietary
needs based on
individual
situation (e.g.,
growth spurt,
pregnancy,
change in activity
level following
injury).
® To have
adequate intake.
PROBLEM #3
Assessment Statement of problem Planning Nursing Intervention Outcome
SC: (none) Imbalanced nutrition: less STG: At the end of 1 hour INDEPENDENT STG: “Naiintindihan ko na ang
than body requirements R/T nursing intervention will be kalagayan at kondisyon ng
OC: Insulin deficiency able to verbalize the 1.) Ascertained patient’s pangangatawan ko ngayon.”
dietary program and usual
causative factors.
o Pale conjunctiva NANDA Definition: The state pattern; compare with Was met
noted recent intake.
in which an individual is LTG: At the end of 3 days will
o Weakness ® Identifies deficits and LTG: The goal was met with
o Fluctuating blood experiencing an intake of be able to normalize eating
deviations from latest blood sugar level of 186
sugar levels: nutrients insufficient to meet habits and laboratory values.
therapeutic needs. mg/dL.
metabolic needs.
334 mg/dL; 210 2.) Identified food
mg/dL, 223 mg/dL, Etiology: The client is
preferences, including
186 mg/dL, 260 experiencing imbalanced
ethnic/cultural needs.
mh/dL, 147 mg/dL, nutrition because of the
169 mg/dL, 169 alterations of insulin ® If patient’s food
mg/dL, 160 mg/dL, production. preferences can be
incorporated into the
193 mg/dL,
Background Theory: meal plan, cooperation
According to Dorothy with dietary requirements
o Weight = 60.7 kg
Johnson “each individual has may be facilitated after
patterned, purposeful, discharge.
repetitive ways of acting that
comprises a behavioral 3.) Observed for signs of
system specific to that hypoglycemia, e.g.,
individual.” changes in level of
consciousness,
cool/clammy skin, rapid
pulse, hunger, irritability,
anxiety, headache,
lightheadedness,
shakiness.
® To make appropriate
nursing intervention.
4.) Health teaching about

the Diabetic Diet.
® To gain cooperation and
appropriate plan of nursing
care.
COLLABORATIVE
1.) Performed fingerstick
glucose testing.
® For monitoring.
2.) Performed other
laboratory diagnostic
procedures as ordered by
AP.
® For monitoring and
accurate diagnosis of the
client’s case.
3.) Consulted with dietitian
for initiation of resumption
of oral intake.
® Useful in calculating and
adjusting diet to meet
patient’s
needs; answer questions
and assist patient/SO in
developing meal plans.
PROBLEM # 4
Assessment Statement of the problem Planning Nursing intervention Outcome
SC: Medyo may kalabuan ang Disturbed Visual Perception STG: At the end of 1 hour 1.) Identified client with STG: met
paningin ko...” R/T Diabetes Mellitus nursing intervention, will be condition that can LTG: partially met.
able to regain usual level of affect sensing,
NANDA Definition: interpreting,
cognition.
Change in the amount or and communicating stimuli.
OC: patterning of incoming
stimuli accompanied by a (R) To plan for an
o Wears eyeglasses diminished, exaggerated, LTG: At the end of 3 days appropriate nursing care
o Blurry vision distorted, or impaired plan.
nursing intervention will be
response to such stimuli.
able to be free of injury.
2.) Monitored drug regimen.
Etiology: ® To identify medications
The client experiences blurry with effects or drug
vision because of the interactions that may
presence of Diabetes cause/exacerbate sensory/
Mellitus. perceptual problems.
Background theory: 3.) Evaluated sensory

awareness: Stimulus of
According to Dorothea Orem hot/cold, dull/sharp,
“Nursing is a service of smell, taste, visual acuity and
deliberately selected and hearing; gait/mobility, and
performed actions to assists location/function of body
individuals or groups to parts.
® To evaluate client’s
maintain self care including
response.
structural integrity,
functioning and 4.) Explained
development." procedures/activities,
expected sensations, and
outcomes.
® For cooperation.
5.) Placed call bell/other
communication device within
reach and be sure client
knows where it is/how to use
it.
® For immediate response of
the health care provider.
6.) Assisted client/SO(s) to

learn effective ways of
coping with and managing
sensory disturbances,
anticipating safety needs
according to client’s sensory
deficits and developmental
level.
® To facilitate client’s
effective response.
PROBLEM #5
SC: (none) Risk for infection R/T chronic STG: At the end of 1 hour Independent Demonstrated and verbalized
disease (DM and PTB?) nursing intervention will be 1) Provided clean understanding of the
able to verbalize and environment by regimen; performed hand
NANDA Definition: demonstrate ways of performing hygienic washing before and after
OC: The state in which an preventing infection. measures such as meals; ate orange during
individual is at increased risk bedside care. lunch.
a. Presence of illnesses for being invaded by LTG: At the end of 2 days, will ® This promotes
b. Presence of daily be able maintain in cleanliness and lessens “Kailangan kong
pathogenic organisms. pangalagaang mabuti ang
visitors demonstrating measures in harboring of
c. Administration of preventing infection. microorganism from the kalusugan ko lalo na dahil
Etiology: may sakit ako, kailangan ko
medications (subcutaneous) client’s environment.
ng pag-iingat para maiwasan
Client is at risk because of the
2) Demonstrated ang iba’t ibang mga
presence of Diabetes Mellitus inpeksyon.”
proper hand washing
and Pulmonary Tuberculosis. technique.
® To see how proper way STG: met
Background theory: of hand washing is done.
According to Florence LTG: met
Nightingale “Nursing is the 3) Educated on the
act of utilizing the importance of
environment of the patient to regular hand
assist him in his recovery.” washing procedure.
®Hand washing
procedure is a first line
defence to prevent
transfer of
microorganism.
4) Instructed to eat
foods rich in Vit. C
such as calamansi,
bayabas, and citrus;
protein-rich foods
such as milk and
other milk products,
chicken meat, egg
white, etc.
®Vit. C rich foods
enhance strong immune
system making the body
résistance. Protein rich
foods promote tissue
and wound healing
through collagen
formation.
Dependent
1.) Antibiotic and Anti-TB
administered by NOD, as
indicated.
® A prophylaxis against
susceptible and possible
pathogenic organism.
® To prevent the
development of MDR-TB.
DISCHARGE PLAN
Assessment
Statement of problem Planning Nursing Intervention Expected Outcome
S: “Ano pa ba ang pwedeng Readiness for enhanced STG: At the end of 1 hour will To demonstrate activities
makatulong sa akin paglabas Therapeutic Regimen be able to verbalized See separate page for that could promote health.
ko rito?” as verbalized. Management R/T (to be understanding about intervention.
developed) treatment regimen.
O: Frequent questioning
regarding treatment Definition: A pattern of LTG: At the end of 3 days will
modalities. regulating and integrating be able to demonstrate
into daily living a program for activities that will aid in
treatment of illness and its health promotion.
sequelae that is sufficient for
meeting health-related goals
and can be strengthened.
Background Theory:
Imogene King’s Nursing as a
helping profession that assist
individual and groups to
attain, maintain and restore
health.
INTERVENTION
Nursing Intervention Rationale
Medication:
Continue taking prescribed home medication if any. ® To ensure that the patient will achieve the desired effect of
the medications.
® To stimulate endogenous insulin production and increase
insulin production and insulin sensitivity.
Exercise
Perform breathing and other appropriate exercise. ®To promote oxygen supply thereby relaxes muscle and
relieves anxiety.
® To increase insulin sensitivity, improve glucose tolerance,
and promote weight loss.
Treatment ® To meet nutritional needs, to control blood glucose levels,

Meal Plan for Diabetes Mellitus. and to help the patient reach and maintain his ideal body
weight.
Health Teaching
Practice proper Hand washing. ® To prevent transfer of microorganisms and spread of
infection.
OPD ® To further evaluate clients health status after discharge and
Advised to have follow-up check after discharge to monitor progress.
Diet ® To provide positive nitrogen balance to aid in healing

Eat foods rich in vitamin C such as citrus fruits, proteins process and boosts resistance against infection.
such as eggs and meat products ®To regain strength.
Instruct the patient to follow special diet as ordered. ® To maintain appropriate sugar level.
Spiritual
Encouraged to pray and always seek God’s help, ® To strengthen faith that will help in healing process.
always have faith that everything has a purpose and it
happens according to God’s will
CHAPTER VI
PROGNOSIS
The patient has shown signs of improvement through the medications, interventions given. There is a
good prognosis.
SUMMARY AND CONCLUSION
This study focused intensively on the case of my patient, Mrs. Constellation received a good nursing care.
She had been monitored especially in her glucose levels. She was given medications and maintenance medication
for her Diabetes and PTB.
Several risk factors were confirmed and evaluated which contributed to the said problem. In our patient’s
case the predisposing and contributing factors were age (54 years old) and genetics (maternal and paternal), diet
(increase carbohydrates and sugar intake).
The problems identified were Hypothermia R/T decreased metabolic rate, unstable blood Glucose R/T
Diabetes Mellitus, Disturbed Sensory Perception R/T Diabetes Mellitus, Imbalanced nutrition: less than body
requirements R/T Insulin deficiency, Risk for infection R/T chronic disease (DM and PTB?). Specific interventions
were given for each identified nursing problems and evaluated accordingly.
BIBLIOGRAPHY
Doenges, Marilyn E.,Moorhouse,Mary Frances and Geissler-Murr, Alice C. Nurse’s Pocket Guide, Eleventh Edition
Davis Company,2008.
th
Nursing Drug Handbook, 28 Ed. Philippines: Lippincot Williams and Wilkins © 2008
th
Suzanne Smeltzer, et.al., Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, Vol. 1, 11 edition (
Lippincott Williams and Wilkins, reprinted in the Philippines, © 2008),
nd
Mary Brambilla McFarland, RN, MSN, et.al. Nursing Implications of Laboratory Tests, 2 edition (Delmar Publishers
Inc., New York, USA, © 1988)
th
Elaine Marrieb et. al. Principles of Anatomy and Physiology 8 Edition © 2007
Gould, B. E. (2007). Pathophysiology for the Health Professions. Singapore: Elsevier (Singapore) Pte Ltd.
Wilkins, L. W. (2005). Pathophysiology made Incredibly Easy! Philadilphea et. al.: Lippincott Williams and
Wilkins.

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HOLY TRINITY UNIVERSITY

Puerto Princesa City, 5300 Palawan

In Partial Fulfillment of the Requirements in

“Diabetes Mellitus Type II/PTB”

Ms. Elma Jazz E. Macrohon, R.N., M.A.N.

April 23, 2010

Ms. Elma Jazz E. Macrohon, R.N., M.A.N

I would like to dedicate this case study to my parents and

for what has been imparted;

for my friends who gave me their unending support;

knowledge, skills and technically know-how

in the field of nursing with patience

and without limitation and above all,

to our Almighty God

for His never-ending blessings,

guidance and enlightenment.

Approval Sheet ----------------------------------------------------------------------------------------------------------

Significance of the Study ----------------------------------------------------------------------------------------------

Statement of the problem --------------------------------------------------------------------------------------------

Scope and Delimitation -----------------------------------------------------------------------------------------------

• Clinical and Family History

• Past Health History

• Present Medical History

• Psychological Development (Erik Erikson)

Laboratory Examination and Results-------------------------------------------------------------------------------

• Blood Glucose Test

Prioritization of the Problems----------------------------------------------------------------------------------------

Nursing Care Plans------------------------------------------------------------------------------------------------------

Diabetes Mellitus Type II or formerly referred as non-insulin dependent Diabetes

The cause of continues to be a mystery, although both genetics and environmental

SIGNIFICANCE OF THE STUDY

STATEMENT OF THE PROBLEM

1. What is Diabetes Mellitus (DM)?

SCOPE AND DELIMITATION OF THE STUDY

Source of Data/ Population:

DIABETIC DIET- a prescribed diet which is low in carbohydrates and sugar.

GLYCOGEN – is the stored glucose in the liver and muscle.

HYPERGLYCEMIA- is the excess of glucose in the blood.

HYPOGLYCEMIA- low concentration of glucose in the blood.

POLYDIPSIA- the condition where the patient is abnormally thirst.

DIABETIC COMA- a state of unconsciousness caused by untreated diabetes.

B. Clinical and Family History

C. Past Medical History

D. Present Medical History

a. Perception and expectation of illness/hospitalization

She spends her time by watching the television and cross-stitching.

After hospitalization she expects to have a general strictness on her lifestyle.

i. Comfort / Rest needs

At the course of illness and during Hospitalization:

ii. Safety needs

iii. Fluids and Nutrition

• As verbalized, “Mahilig ako sa gulay at prutas… nagdidiyeta na rin ako…”

1 cup 1 serving 1 serving Beef 2 slice bread

Inspection: With symmetrical lung expansion during respiration;

o posterior – skin intact; (-) palpable masses; full symmetric

o anterior – uniform temperature on the anterior thorax noted;

Percussion: Resonant sound heard on anterior and posterior

Auscultation: (-) bronchial sound heard on both lung apex is noted; (-

I – flat abdomen noted; (+) symmetric movement during respiration.

Cranial Nerves Assessment

I. Olfactory Nerve - Unable to smell mild smells

SUMMARY OF FINDINGS SIGNIFICANT TO NURSING CARE

3. S: As verbalized, “Mahilig ako sa gulay at prutas… nagdidiyeta na rin ako…”

4. S: “Medyo may kalabuan ang paningin ko...” as verbalized.