I.

INTRODUCTION

Diabetes mellitus is a condition in which the pancreas no longer produces enough

insulin or cells stop responding to the insulin that is produced, so that glucose in the

blood cannot be absorbed into the cells of the body. Symptoms include frequent

urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet,

oral medications, and in some cases, daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-

onset diabetes, and this form of diabetes occurs most often in people who are overweight

and who do not exercise. Type II is considered a milder form of diabetes because of its

slow onset (sometimes developing over the course of several years) and because it

usually can be controlled with diet and oral medication. The consequences of

uncontrolled and untreated Type II diabetes, however, are the just as serious as those for

Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat

misleading. Many people with Type II diabetes can control the condition with diet and

oral medications, however, insulin injections are sometimes necessary if treatment with

diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both hereditary

(genetic factors passed on in families) and environmental factors involved. Research has

shown that some people who develop diabetes have common genetic markers. In Type I

diabetes, the immune system, the body’s defense system against infection, is believed to

be triggered by a virus or another microorganism that destroys cells in the pancreas that
produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a

role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells

have become resistant to the insulin produced and it may not work as effectively.

Symptoms of Type II diabetes can begin so gradually that a person may not know that he

or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other

symptoms may include sudden weight loss, slow wound healing, urinary tract infections,

gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while

a patient is seeing a doctor about another health concern that is actually being caused by

the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include people

who:

• are obese (more than 20% above their ideal body weight)

• have a relative with diabetes mellitus

• belong to a high-risk ethnic population (African-American, Native American,

Hispanic, or Native Hawaiian)

• have been diagnosed with gestational diabetes or have delivered a baby weighing

more than 9 lbs (4 kg)

• have high blood pressure (140/90 mmHg or above)

• have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL

and/or a triglyceride level greater than or equal to 250 mg/dL

 • have had impaired glucose tolerance or impaired fasting glucose on previous

testing

MORBIDITY

Ten Leading Causes of Morbidity

Number, Rate/100,000 Population & Percentage

Philippines, 2002
MORTALITY

Ten Leading Causes of Mortality by Sex

Number, Rate/100,000 Population & Percentage

Philippines, 2002

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and

lifestyle changes. It is best managed with a team approach to empower the client to

successfully manage the disease. As part of the team the, the nurse plans, organizes, and

coordinates care among the various health disciplines involved; provides care and

education and promotes the client’s health and well being. Diabetes is a major public

health worldwide. Its complications cause many devastating health problems.

II. PATIENT PROFILE

Ward: 6th Main

Date of Admission: July 18, 2009

Patient Name: R. R

Address: Sampaloc Manila

Age: 54

Gender: Male

Birth Date: November 13,1954

Educational Status: High School Undergraduate (3rd year)

Religion: Roman Catholic

Nationality: Filipino

Civil Status: Married

Occupation: Tricycle Driver

Health Care Financing: SSS

Informant: Patient, Wife and the Daughter

Reliability: 100 %

Admission Data

1. Chief Complaint: Wound right big toe

2. Initial Diagnosis: Gangrene big toe right foot related to Diabetes

mellitus type II

3. Final Diagnosis: Gangrene big toe right foot related to Diabetes

mellitus type II

4. Attending Physician: Dr. Fuentes and Dr. Sison

III. PATIENT HISTORY/ NURSING HISTORY
a. History of Present Illness

Eight months prior to admission patient noticed blisters of his right

big toe ventral surface area. Patient self medicate metformin 500 mg/tab

and glimeperamide 2mg/tab. No consultation done.

One week and 6 days prior to admission, patient noticed swelling

of the right foot no other associated signs and symptoms were noted.

Patient sought consult in Rizal Medical Center, and then patient referred to

our institution private physician. Patient advised to continue the

medication that he takes.

Three days prior to admission, patient noticed that his right big toe

become black, the wound become bigger, patient sought consult at our

institution at out patient department. Patient was advised for surgical

procedure hence admission.

b. Past Medical History

No previous hospitalization. No known food and drug allergies.

Patient diagnosed last April 28, 2008, Diabetes Mellitus type II,

maintenance medication metformin 500 mg TID and Diclofenac 500 mg.

c. Family Health History

The patient’s father has a cyst on his breast. And his mother is

hypertensive. Most of his siblings are hypertensive which is a risk factor

of diabetes mellitus. But our patient is not hypertensive.

d. Personal and Social History

Patient is a highschool undergraduate. He is a tricycle driver since

2000. He started smoking and drinking alcoholic beverages when he was

15 years old and stopped 20 years ago.

 IV. LEVEL OF HEALTH FUNCTIONING

LEVEL OF BEFORE DURING ANALYSIS/

FUNCTIONING HOSPITALIZATION HOSPITALIZATION INFERENCE

a. health perception “The client defined health He considers himself as a Based from the gathered

and management as an important thing that healthy person despite of

you should take care of. what happened to him

Even though he has

diabetes mellitus he still

considered himself as a

healthy person because he

can still do his daily

activity.”

The patient urinates 4-5 According to the data

c. elimination pattern times a day. The client urinate 2x a day. collected, the patient

The color of the urine is The color of the urine is having difficulty in

light yellow. yellowish. elimination due to the

The patient defecates The patient can’t manage to operation conducted.

regularly. go to Comfort Room by

himself alone that’s why

his wife assists him to

 defecate.

“araw araw akong “.nahihirapan akong The client wasn’t able

d. activity exercise namamasada simula 6am- gumalaw-galaw dahil sa to do things

pattern 12nn ang tulog ko ay 4 pagkakaputol ng paa ko. independently.

hours lang.pagkagising Ngayon tinutulungan ako

ko ng 4am nag-eexercise ng asawa ko para

ako hanggang 5 ng makakilos papunta sa C.R

umaga,tapos 6 ng umaga at bumangon. Hindi ko na

balik pasada na ulit.” rin mkuha pang mag-

exercise ngayon.” as

He usually wakes up vervalized by our client.

around 4:00 in the

morning to prepare for his“paputol-putol ang tulog Before hospitalixation

e. sleep rest pattern work. The client also ko,3 hours lang the patient can only

stated that he doesn’t pinakamatagal kong tulog acquire a little time for

have enough sleep ditto” rest and sleep because

everyday because of his of his work.

work. During hospitalization

the patient can’t sleep

well because of the pain

brought by his

amputated leg.
 “Malabo na ang mata ko Having a poor sense of

at gumagamit na rin ako sight could cause delay

ng salamin sa mata kapag -Impaired vision of what he does. It is

f. Cognitive ako ay may babasahin” as really important for us

perceptual pattern verbalized by the client -comprehension is still at to have a good sense of

best sight especially when

-Impaired vision driving and reading.

-comprehension is still at -nothing wrong with his

best sense of hearing

-nothing wrong with his

sense of hearing

High self esteem believes Adjusted because of the

in facts and believes in discomfort caused by

what she believe is right the pain of the

He believes in facts and amputation

g. self perception Has irritations and set of believes in what he believe

pattern and self boundaries for himself is right Changed due to the

concept pattern operation happened

Intakes medications and

vitamins Has irritations and

 boundaries hor himself Gained additional for

Pushes himself to the fast recovery

limits by working

overtime and doing extra Intakes medications and Adjusted because of the

activities vitamins immobility

Pushes himself to the limits

Sees himself as a strong by working overtime

individual, competitive and doing extra

type of person and is activities Increased due to the

confident regarding him operation

self Sees himself as a strong

individual, competitive type

of person and is confident

regarding himself

They are all living

together in the same

house. And they have a

good relationship with Their major problem is that

each other. if how can they pay his

hospital bills. And he feels

h. role relationship that he is not capable of

pattern doing because

V. PHYSICAL ASSESSMENT
Biographic data:

Name: R. R Weight:

Address: Sampaloc Manila Height:

B.P.:

Age: 54 Temperatures: 36.8

Sex: Male Pulse Rate:72

Race/Ethnic Origin: None Respiratory Rate: 21

Marital Status: married Reason from admission: Wound of his right big toe

Occupation: Tricycle Driver

Religious orientation: Roman Catholic IBM:

Educational Attainment: High School Undergraduate

Health care financing and usual source of medical care: SSS

Areas to be Asses Actual Findings Normal findings Interpretation/ Analysis

Body built, height & >proprtionate, varie with Proportionate & varies with

weight lifestyle life style

Posture & Gait > not relaxed and erect Relax, erect posture &

posture and no coordinated coordinated movements

movements
Hygiene Not neat and clean Clean & Neat
Body/breath Odor No body odor and no No body odor or minor

breath odor body odor relative to work

of exercise; no breath odor

VI. ANATOMY AND PHYSIOLOGY

VII. PATHOPHYSIOLOGY
 VIII. LABORATORY RESULTS

LABORATORY/ ACTUAL NORMAL ANALYSIS/INFERENCE REFERENCE

DIAGNOSTIC RESULT VALUE
TEST
July 18 65 – 110 Diabetic
Clinicl chemistry.. 187mg/dl 7-20 syndromenephrotic
32mg/dl .52- 1.25 nephritis
Glucose 1.46mg/dl
Urea nitrogen
creatinine

July 18 10.8% AIC

Immunochem 4.2-6.5 Diabetic
Examination:
Glycosylated
hemoglobin(HBAIC
)

Color: brown
July 19 Consistency:
Clinical microscopy H2O
Examination:
Routine fecalisis

July 20
Clinical chem.
Creatinin.
19,600/cu.m
July 20 12.5gms/dl 5,000-
Hematology 37vol% 10,000
CBG 85% M: 13.5-18;
WBC Count 9% F:12.0-15.0
Hemoglobin 5% M: 40.0-
Hematocrit 1% 48.0;
Segmenters F:37.0-45.0
Lymphocytes 55-65
Monocytes 26-35
eosinophils 2-6
Moderate 1-5
july 21 growth of
Microbiology klebsiella
Examination: pneumonia
wound exudates isolated
culture and
sensitivity 19,700/cu.m
12.1gms/dl
36vol%
July 27 77% 5,000-
Hematology 19% 10,000
CBG 2% M: 13.5-18;
WBC Count 2% F:12.0-15.0
Hemoglobin M: 40.0-
Hematocrit 48.0;
Segmenters F:37.0-45.0
Lymphocytes 55-65
Monocytes 130 mnol/L 26-35
Eosinophils 5.0 mno/L 2-6
.92 mg/dL 1-5
July 27
Clinical chem.
Sodium 137-150
Potassium 14.4 secs. 3.6-5.0
Creatinine 12.9secs .52-1.25
67.4%
July 27 1.26
Hematology
Exam: protrombin
time and act 10.0-14.0
Protime
Control
% act. 13.5 secs.
INR 12.5secs
74.9%
July 28 1.18
Hematology
Exam: protrombin 10.0-14.0
time and act
Protime
Control
% act.
INR 15,600/cu.m
10.4gms/dl
Aug.1 31vol%
Hematology 88%
CBG 11% 5,000-
WBC Count 1% 10,000
Hemoglobin M: 13.5-18;
Hematocrit F:12.0-15.0
Segmenters M: 40.0-
Lymphocytes 48.0;
Monocytes F:37.0-45.0
55-65
26-35
2-6
 IX. COURSE IN THE WARD
 Upon admission patient was scheduled for disarticulation of right big toe
with debridement. The surgical procedure was done on the same day. Capillary blood glucose
monitoring.
 On the second day post operatively patient was on diabetic diet medication
was given. Capillary Blood Glucose monitoring was done. Capillary blood glucose monitoring.
 On the third day diet medication was given and also Capillary Blood Glucose
monitoring was done.
 Fourth hospital day patient was scheduled for repeat debridement of right foot,
where wound exudates was sent for Culture and Sensitivity test was given. Capillary blood
glucose monitoring.
 On the fifth day debridement of foot was done. Capillary blood glucose
monitoring.
 On the 6th hospital day patient complaint pain on the wound site but tolerable
and patient was advised for below knee amputation where Cardio Pulmonary clearance was
requested and done. Capillary blood glucose monitoring.
 On the 7th day Vital signs monitoring was done. Capillary blood glucose
monitoring.
 On the 8th day Capillary Blood Glucose monitoring and vital signs was done.
 On the 9th day wound cleaning was done. Capillary blood glucose
monitoring.
 On the 10th day intravenous fluid of PNSS 1L was started. Capillary blood
glucose monitoring.
 Intravenous fluid of PNSS was continued and was operated on the 11th
hospital day for below knee amputation patient tolerated the procedure well with no subjective
complaint, medication was continued. Capillary blood glucose monitoring.
 Surgical procedure and date performed, July 29- below the right knee
amputation. Capillary blood glucose monitoring.

X. NURSING CARE PLAN

CUES INFERENCE/AN NURSIN GOAL/PL INTERVENTI RATIONA EVALUATI

ALYSIS G AN ON/ LE ONt
MINI- DIAGNO IMPLEMENT
Subjec PATHOPHYSIO SIS ATION
tive: LOGY
“hindi Patient After 8
gumag Increased in blood Poor Independent: may behours of
aling sugar level. wound Observe foradmitted nursing
ang healing sign ofwith intervention
sugat related to infections andinfection, s, the patient
ko” inflammations. which was able to
(my could identify
wound Promote goodhave. intervention
s are Poor circulation hand washingprecipitate s to prevent
not by nurse andd or reduce
healing patient ketoacidoti risk of
) as c state, orinfection.
verbali Poor wound Maintain may
zed by healing aseptic develop a
the technique fornosocomial
patient IV insertioninfection.
procedure,
Object administration Reduces
ive: of medication,the risk of
Woun and providingcross
d at maintenance contamina
the and side care. tion
right Rotate IV sites
big toe as indicated. high
glucose in
provide the blood
conscientious creates an
skin care,excellent
gently massagemedium
bony areas.forfection.
Keep the skin
dry, linens dryMinimizes
and wrinklethe risk in
free. bacterial
growth.
Place in semi
fowler’s Peripheral
positions. circulation
may be
Encourage impared,
adequate placing
dietary andpatient at
fluid intake ofincreased
3000 ml perrisk for
day. skin
irritation
Collaborative: or
Obtain breakdow
specimen forn and
culture andinfection.
sensitivities as
indicated Facilitates
lung
expansion
 and
reduces
risk of
aspiration

Decrease
susceptibili
ty to
infection.
Identifies
organisms
so the most
appropriat
e drug
therapy
can be
instituted.

XI. DISCHARGE PLANNING

MEDICATION
Amlodipine 10mg 1tab (morning)

Glimeperide 2mg 1tab OD

Metformin 500mg 1tab TID

Tramadol + Paracetamol 1tab TID

EXERCISE
Practice bending the amputated leg

TREATMENT
CBG monitoring TID a.c

HEALTH TEACHING

OUT-PATIENT FOLLOW UP
Follow- up at IM OPD 1 week after discharge
DIET
Breakfast: (360 calories, 52.5 grams carbohydrate)
1 slice toasted whole wheat bread with 1 teaspoon margarine
1/4 cup egg substitute or cottage cheese
1/2 cup oatmeal
1/2 cup skim milk
1/2 small banana
Snack: (Each has 60 calories or 15 grams carbohydrate. Pick two per day.)
16 fat-free tortilla chips with salsa
1/2 cup artificially sweetened chocolate pudding
1 ounce string cheese plus one small piece of fruit
3 cups "lite" popcorn

Lunch: (535 calories, 75 grams carbohydrate)

1 cup vegetable soup with 4-6 crackers
1 turkey sandwich (2 slices whole wheat bread, 1 ounce turkey and 1 ounce low-fat
cheese, 1 teaspoon mayonnaise)
1 small apple

Dinner: (635 calories, 65 grams carbohydrate)

4 ounces broiled chicken breast with basil and oregano sprinkled on top
2/3 cup cooked brown rice
1/2 cup cooked carrots
1 small whole grain dinner roll with 1 teaspoon margarine
Tossed salad with 2 tablespoons low-fat salad dressing
4 unsweetened canned apricot halves or 1 small slice of angel food cake

XII. DRUG STUDY