INTRODUCTION

A. OVERVIEW of the STUDY

Diabetes Mellitus is a chronic disorder affecting carbohydrate, fat and protein

metabolism. It is characterized by elevated levels of glucose in the blood (hyperglycemia)
resulting from defects in insulin secretion, insulin action, or both. Normally, a certain
amount of glucose circulates in the blood. The major sources of this glucose are
absorption of ingested food in the gastrointestinal tract and formation of glucose by the
liver from food substances. Insulin is a hormone produced by pancreas to control the
level of glucose in the blood by regulating the production and storage of glucose. In the
diabetic state, the cells may stop responding to insulin or pancreas may stop producing
insulin entirely. This leads to hyperglycemia, which may result to several macrovascular
complications such as coronary artery disease, cerebrovascular disease, peripheral
vascular disease, kidney and eye disease and neuropathic complications. The major
classification of diabetes are: The Type I diabetes which is characterized by an acute
onset, usually before age so wherein the insulin-producing pancreatic beta cells are
destroyed by an autoimmune process and the Type II diabetes that usually occur in ages
older than 30 years and obese resulting from the decrease sensitivity to insulin (insulin
resistance) and impaired beta cell functioning resulting in decrease insulin production.
These types differ in their etiology, clinical course and management. Factors that increase
the incidence and severity of Diabetes Mellitus are heredity, age, sex, autoimmunity,
socioeconomic instability, unhealthy lifestyle, stress and obesity. Dietary modification
and exercise is necessary to avoid, or delay the onset of the disease. Untreated and long
term effects of such disease will lead to complications and death.
B. OBJECTIVE of the STUDY

At end of the study, I will be able to

1. Enhance my knowledge on the disease process
2. Establish a comprehensive and holistic nursing care plan on patients with DM
3. Impart patient’s teachings effectively that would encouraged active patient’s
participation and compliance.

C. SCOPE and LIMITATION

The study is limited only on the 3 days comprehensive actual patients care. It
focuses on the history of present and previous health status, construction and application
of actual nursing care plan to the chosen patient Mr. A using the knowledge of the
dynamics of disease process. It also covers some hospital visit in the span of patient’s
hospitalization.

DEVELOPMENTAL TASK

Human growth and development proceed in an orderly and predictable sequence.

We all can correlate ourselves with this concept since we all have gone through this,
perhaps we differ only at rates in achieving developmental milestones. Growing up
involves interrelated facets, the quantitative changes (growth) and the qualitative change
(development). Both parts rely on how the environmental influence and genetic
inheritance mold us, whether to take a step to the next level of growth and development,
or bound us to be stuck into a particular stage that apparently affects our health in all
aspects. Our physical size (height, skeletal and sexual age weight) must correspond to our
level of maturation. We do not merely grow taller and heavier as we grow older, but our
ability to perform skills, to think, to relate to people and to trust or have confidence in
ourselves must also increase in growth. By age, we have to accomplish the so called
developmental task successfully with all our satisfaction, because failure to undergo by
experience a stage that is a means to the next phase which is much complicated and
advance will bring about immaturity. In some cases when wherein the cause of falling
behind in the growth and development is illness, it is still capable to “catch up” growth
by all means of practicing the skills or setting a particular attitude in the cognitive
thinking.

It is important to obtain the knowledge of growth and development since the idea
can be utilize in patient care. By way of assessing and formulating an effective nursing
care plan which may lead to acquiring the ultimate goal of health promotion, restoration
and maintenance, and illness prevention.

FREUD’S PSYCHOSEXUAL DEVELOPMENT

STAGE AGE CHARACTERISTIC

GENITAL 13 years and after Energy is directed towards attaining a

mature sexual relationship. This stage involves
reactivation of the pregenital impulses. These
impulses are usually displaced, and the
individual passes to the genital stage maturity.
An inability to resolve conflicts can result in
sexual problems, such as frigidity, impotence,
and the inability to have a satisfactory sexual
relationship.

Implication:

My client Mr. A belongs to this stage, since he is now developing a sexual

maturity and learned to manage a satisfactory relationship with his lifetime partner. He
had been through relating with opposite sex and allowed himself to verbalize feelings
about new relationships.

ERIKSON’S PSYCHOSOCIAL DEVELOPMENT

STAGE AGE CENTRAL INDICATION INDICATIONS OF

TASK OF POSITIVE NEGATIVE
RESOLUTION RESOLUTION
Adulthood 25 to 65 Generativity Creativity, Self-indulgence, self-
years vs. Stagnation productivity, concern, lack of
concern for others interest and
 commitments.

Implication:

My client’s developmental task as a middle age is to extend his concern not just
from himself, but also to his family, community and the world. He is now confident of
his status in life and is able to juggle various role as a father, a grandfather, and as a
citizen of this country.

KOHLBERG’S STAGES OF MORAL DEVELOPMENT

AGE STAGE CHARACTERISTIC

Older than 12 (Level 3) Standard of behavior is based on adhering to

years Postconventional laws that protect the welfare and rights of
(5) others. Personal values and opinions are
Social contract, recognized, and violating the rights of others is
legalistic avoided
orientation

Implication:

My client is in this stage of moral development because he is now able to

establish a standard self-care which he believes a basis for adulthood that should be view
by the following up-coming generations. He sticks to his belief law-abiding and
recognizing the rights of others is a means of welfare.

HAVIGHURT’S DEVELOPMENTAL TASK

Robert Havighurst states, “The developmental task concept occupies a middle

ground between two opposed theory of education; the Theory of freedom-that the child
must learn to become a worthy, responsible adult through restraints imposed by society.
A developmental task is midway between an individual’s need and societal demand. It
assumes an active learner interacting with an active social environment.” A
developmental task is a task which arises at, or about a certain period in life of an
individual, successful achievement of which leads to his happiness and to success which
later tasks, while failure leads to unhappiness in the individual, disapproval by the
society, and difficulty with the later tasks. A developmental task provides a framework
that the nurse can use to evaluate the person’s general accomplishments. He describes
growth and development as occurring during (6) stages, each associated with six (6) to
ten (10) task to be learned, namely: infancy and early childhood, middle childhood,
adolescence, early adulthood, middle age and late maturity.
IMPLICATION:
My client is categorized under middle age in the Havighurst’s Developmental
Task Theory. In this stage, he is achieving adult civic and societal responsibility, assist
those teenage children to become responsible and happy adults, relating himself to his
spouse as a person and accepting the physiologic changes of middle age.

HEALTH HISTORY

Mr. A is dedicated to Islamic religion and is currently residing in Malabong,

Lanao del Sur. He eats every food he wants, except pork, and smokes 3-4 packs a month.
According to his daughter who assisted him during his admission, he is not an alcoholic
drinker and he has no known allergy. He has been diagnosed as having Type II Diabetes
Mellitus ten years ago taking variant medication of Mixtard 25 “u” SQ before breakfast
and is “u” before dinner. Long before, he usually experience headache, chest pain and
muscle weakness especially on his lower extremities.

HISTORY OF PRESENT ILLNESS

He begun to be uncomfortable and fainting in May 4, 2007, and experienced 2

episodes of malena at about ½ cup, followed by generalized muscle weakness. His
daughter started to infuse PNSS 4 L at 20 qtts/min at home and let him took Vitamin K
TID. He was took to Northern Mindanao Medical Center in a wheelchair having a
complaint of generalized weakness with the assistance of his daughter and was advised to
be admitted on May 6, 2007. His admitting vital signs are: Bp – 130/70mmHg; T – 36.6c;
PR – 79bpm; RR – 25 cpm. His admitting diagnoses are Type II Diabetes Mellitus, R/I
Liver Cirrhosis.
 DIAGNOSTIC EXAMINATION

HGT ULTRASOUND REPORT

May 6, 2007 05/06/07
5:30 am Impression:
Result: 139 g/dL – Hyperglycemia Consider liver cirrhosis thickened
gallbladder wall likely due to moderate
By Dr. Edgardo Abadiano, MD ascites minimal spleenomegally
atheromatous abdomena aorta normal
kidney and pancreas

HEMATOLOGY (05/06/07)
Conventional Unit Result
Hematocrit 35.0 – 50.0 % 19.1 - Anemia
Hemoglobin 11.0 – 16.5 7.0 - Anemia: Fluid Retention
WBC Count 5.0 – 10.0 1/mm 5.0
Platelet Count 140,000 – 440,000 164,000

Differential Count
Conventional Unit SI unit Result
Segmenters 55 – 65 % .55 - .65 59
Lymphocytes 25 – 35 % .25 - .35 41 - Chronic/Viral Infection
BLOOD TYPE: B RH TYPE: POSITIVE

HBSAG (06/07/07)
Result: HBSAG – Non reactive (–) Hepatitis

Hematology
06/07/07 10:35 am
Result Unit Reference
White Blood Cell count 4.8 1013/VL 5.0 – 10.5 - Hepatic Dysfunction
Red Blood Cells 3.49 1016/VL 3.80 – 5:80 - Anemia: Fluid overload
Hematocrit 10.6 g/dL 35.0 – 50.0 - Anemia
MCV 91.1 Fl 82.0 – 92.0
MCH 30.4 pg 26.5 – 33.5
Platelet count 120 1013/VL 140 – 440
Differential Count
Segmenters 77.0 % 55 – 65
Lymphocytes 22.0 % 25 – 35 - Chronic/ Viral Infection

LIPID PROFILE (May 7, 2007)

Flagging Result Normal Range
Glucose HI 123 mg/dL 74 – 106 - Hyperglycemia
Cholesterol 113 mg/dL 0 – 200
Truglycerides 63 mg/dL 0 - 150
Direct HDLC LO 21 mg/dL
LDL 79 mg/dL
DL 13 mg/dL
UNCONJ. BILI .8 mg/dL
TOTAL BILI .7 mg/dL
DIRECT BILI 0 mg/dL

(May 7, 2007)
Sodium LO 133 mmol/L 137 – 145 - Acute Renal Failure
Potassium 3.7 mmol/L 3.5 – 5.1
Albumin LO 2.0 g/dL 3.5 – 5.0 - Hypertension and
Hepatic Dysfunction

MEDICAL ORDERS

Date: 05/06/07
Day 1
DOCTOR’S ORDER RATIONALE
1. Start Venoclysis of PNSS 1 L 15
qtts/min
2. Monitor vital signs every 2 hrs. and
record on the patient’s chart.
3. O2 inhalation 1L.min via nasal cannula
4. Note the stool characteristic
5. NPO temporarily
6. Strict I and O
7. Secure pt. blood type and inform
undersign once available
8. Therapeutics:
a. Pantoprazol 40mg IVTT q12
b. Hemostan 1 ampule IVTT q8
c. Vit. K 1 amp IV OD
d. Mixtard 25 “u” SQ before breakfast
and 15 “u” SQ before dinner
9. DIAGNOSTICS:
Routine CBC, HGT, Ultrasound the
upper abdomen, HBSAG, and Blood
Chemistry
Date: 05/07/07
Day 2
DOCTOR’S ORDER
1. Hold Mixtard while on NPO
2. NPO except meds
3. V/S q2 and note the character if <90
BP
4. Transfuse 1 unit of PRBC blood type
after cross matching to run for 6 hrs.
5. Schedule for gastroscopy and obtain
consent
6. Therapeutics:
1. To maintain electrolyte balance.
2. To monitor v/s of pt. and determine
condition and progress every 2 hours.
3. To provide O2 supply and prevent
hypoxia.
4. To determine the presence of occult
blood and microorganisms (bacteria,
viruses)
5. To obtain accurate result in blood
chemistry (BUN, Lipid profile)
6. To obtain accurate intake and output
of the patient.
7. To obtain the correct blood
component once needed for blood
transfusion.
8.
a. To suppress gastric acid secretion
b. To promote blood coagulation
c. To promote hepatic formation of
active coagulation.
d. Increase insulin; insulin supplement
9. To determine the cause of illness, and
formulate and verify diagnosis.
RATIONALE
1. To facilitate stored glucose
utilization.
2. To obtain pt. stable condition and
control the disease symptoms.
3. To determine the condition and
progress of the pt. and note for signs
of hypovolemia manifested by
hypotension.
4. To restore blood volume and the
capacity of blood to carry O2.
5. For diagnostic purpose and avoid
legal problems.
6.
 a. Pregabalin (Lyrica) 75 mg BID
05/08/07
Day 3
1. Induce second unit of PRBC
2. May have soft diabetic diet
3. Therapeutics:
a. Pantrorprazole 30g itab OD
b. Humulin 70/30 set before breakfast
c. Diamiaon 1 tab P. O BID
4. Diagnostic: HGT BID, CBC
5. Provide photocopies of lab result
6. May go home against medical advise
7. Terminate IV when consume
PATIENT PROFILE
Name: Mr. A
Civil Status: Married
a. Prevents neuropathic pain and
seizures
1. To restore blood volume and the
capacity of blood to carry O2.
2. To prevent diabetes complications.
3.
d. To suppress gastric acid secretion.
e. Facilitate glucose restoration and
reduce level of glucose excess.
f. Promotes blood coagulation for
effective hemostasis.
4. To determine pt. condition and
progress
5. To obtain legal basis of confinement
6. To obtain legal order for discharge
7. For discharge
Sex: Male

Age: 64

Religion: Islam

Nationality: Filipino

Address: Malabong, Lanao del Sur

Admission Date: May 06, 2007

Date Discharge: May 15, 2007

Informant: Daughter

Final Diagnosis: Diabetes Mellitus Type II, R/I Liver Cirrhosis

Place of Confinement: A3 F2 Medical Ward NMMC

Admitting Vital Signs:

Bp – 130/70 mmHg; PR – 79 bpm; RR – 25 cpm; T- 36.6 C

 DRUG STUDY

Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Effects/ Nursing
Name of Name Ordered Frequency/ of Action Indication indication Toxic Precaution.
Ordered Route Effects
Drug
Phoenix Pantoprazole 05-06-07 Antiulcer 40 mg IVTT Suppress Elosive Contraindi- Headache, Step IV
sodium Drugs q12 gastric acid esphagitis cated to pt. insomnia, treatment
secretion caused by hyper- diarrhea, when P.O
diabetes sensitive to dizziness, form is war-
mellitus drugs. chestpain, ranted. Can
nausea & be given
vomiting without
regard to
meals
Mephyton Vit. K 05-06-07 Vitamins and 1 amp. IVTT Promotes Hypothrombo- Contraindi- Dizziness, Monitor PT
analogue minerals OD active nemia caused cated to py. hypotension, or INR to
phytond- coagulation by Vit. K mal- Hyper- weak pulse determine
dione absorption & sensitive to dosage effec-
drug theraphy drug. tiveness. S.C.
route is pre-
ferred to
avoid
hematoma.
 DRUG STUDY

Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Effects/ Nursing
Name of Name Ordered Frequency/ of Action Indication indication Toxic Precaution.
Ordered Route Effects
Drug
Human Humulin 05-06-07 Insulins 12 “u” SQ Helps Moderate to Contraindi- Hypogly- Used in pt.
Insulin 70/30 before decrease severe cated to pt. cemia, with
breakfast glucose hyperglycemia hypersensi- hypokalemia. circulatory
level. tive to drugs Pruritus. collapsed,
& episodes diabetic
of hypogly- ketoacidosis
cemia or hyperka-
lemia
30% soluble Mixtard 30 05-06-07 Insulins 25 “u” SQ Increase Insulin Hypogly- Allergy & Watch for
human HM before insulin for requiring cemia & lipoatrophy any signs of
mono- breakfast, 15 insulin diabetes insulinomia allergy and
component “u” SQ supplement mellitus hyper-
insulin & before dinner glycemia.
70% OD.
isophane
human
mono-
component
 DRUG STUDY

Generic Brand Date Classification Dose/ Mechanism of Specific Contra- Side Effects/ Nursing
Name of Name Ordered Frequency/ Action Indication indication Toxic Effects Precaution.
Ordered Route
Drug
Pregabalin Lyrica 05-06-07 Anticonvulsant 75mg P.O Prevents Neuropathic Contraindi-cated Dizziness, Instruct pt.
BID neuropathic pain pain, and in pt. that is euphoric that drug may
and partial epilepsy. hyper-sensitive to mood, affect this
seizures drugs. confusion ability to
decrease in drive and
libido operate
machinery.
Tranexamic Hemostan 05-07-07 Haemostatics 1 amp. Antihemorrhagic Traumatic Contraindicated in Nausea, Not advisable
acid IVTT 98 & antufibrolytic injuries; pt. that is vomiting, to use in
for effective hemorrhage hypersensitive to anorexia, prolonged
hemostasis drug hypotension period in pt.
predispose to
thrombosis.
Slictazide Diambron 05-08-07 Oral Antidia- 1 tab P.O Stimulate insulin Type II Contraindicated Nausea, Adjustment
betic agents RID before secretion from diabetes when use dose in headache, of dosage
breakfast & pancreatic B Type I diabetes rashes, GI may required
dinner (2 cells. with trauma or disturbance in cases of
wks) infection trauma and
shock
ANATOMY AND PHYSIOLOGY

Glucose is the leading source of energy for the human body. Glucose is stored in the
body for rapid release in times of stress and so that the serum concentration of glucose can be
maintained at a level that provides a constant supply of glucose to the neurons. The minute-to-
minute control of glucose level is the function of endocrine pancreas gland. The endocrine part
of the pancreas produces hormones in collection of tissue caked the islets of Largerhans. These
islets contain endocrine cells that produce specific hormones. The alpha cells release glucagons
in response to low glucose levels. The beta cells release insulin in response to high glucose level.
Delta cells produce somatostatin, which blocks the secretion of insulin and glucagons. These
hormones work together to maintain the serum glucose level within normal limits.
Insulin is the hormone produced by the beta cells of the islets of Langerhans. The
hormone is released into the circulation when levels of glucose around these cells rise. Insulin
circulates through the body and reacts with specific insulin receptor sites to stimulate transport of
glucose into the cells to be used for energy, a process called facilitated diffusion. Insulin also
stimulates the synthesis of glycogen, the conversion of lipids into stored far in the form of
adipose tissue, and the synthesis of needed protein from amino acids.

(A) In a healthy person, when food is digested

Glucose levels in the blood stream rise

Pancrease releases insulin

Helps the body take up glucose, insulin also helps convert glucose into
glycogen, which is stored in the liver and muscle until needed for fuel.

Hormones regulate the release of insulin by causing blood

sugar levels to drop

Pancreas secrete less insulin

 In cases of those persons with diabetes mellitus, the pancreas produces little or no insulin
which helps the body’s tissue absorb glucose for energy. The condition may develop if muscle,
fat, and liver cells respond poorly to insulin (peripheral resistance). In people with diabetes,
glucose levels build up in the blood an urine, causing excessive urination, thirst, hunger, and
problems with fat and protein metabolism. Diabetes is classified here in its common types. In
type I, formerly called insulin-dependent diabetes mellitus (IDDM) and juvenile-onset diabetes,
the body does not produce insulin or produces only in inadequate quantities. Symptoms usually
appear suddenly, typically in individuals under 20 years of age. Most cases occur around
puberty- around age 10 to 12 in girls and 12 to 14 in boys. It has been studies that immune
system attacks and destroys insulin-producing cells, known as beta cells, in the pancrease due to
genetic and environmental factors (viruses, stress, malnutrition, unhealthy lifestyle). In type II
diabetes, formerly known as non-insulin dependent diabetes mellitus (NIDDM) and adult-onset
diabetes, the body’s delicate balance between insulin production and the ability of cells to use
insulin goes awry. Symptoms characteristic of Type II diabetes include those found in Type I
diabetes, as well as repeated infections, or skin sores that heal slowly, or not at all, generalized
tiredness and tingling, or numbness in hands or feet.

(B) In person with diabetes mellitus, the pancreas produces

insufficient levels of insulin or the body is unable to use insulin.

Food digested

Pancreas cannot produce enough insulin

The body is forced to breakdown fats instead of glucose for

energy. Poisonous chemicals called ketones are excreted in the
urine

Ketoacidosis/hyperglycemia

Coma/death
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Imbalance At the end of 2-3 Independent: At the end of 2-3
“Dili man nako nutrition related days, the client 1. Foster patient’s participation in 1. Provide understanding days the patient was
gakasabtan ako to insufficient will gain planning a diet menu with regarding pt.’s nutritional able to gain
gabation, di nako insulin optimal control glucose control considering pt.’s needs and promote sense of information regarding
ganahan mokaon, production. of blood glucose cultural background and setting involvement. control to his blood
daghan pa gyud and maintain dietary prescription as basis. glucose level by
ginabawal sa ako,” desired weight. Discuss it with the client. following the dietary
as verbalized by the 2. Weigh daily pre-breakfast. 2. Assess adequacy of nutritional prescription and the
patient. intake. health teachings.
3. Provide small sips of liquid on the 3. To avoid/lessen the sense of
OBJECTIVE: lips while on NPO. thirst and maintain GI function. The client also
- Poor skin turgur 4. Observe for signs of 4. One blood glucose level manifested improve
- Cracked skin hypoglycemia like changes in reduced and insulin is given sense of well being
- Weight loss level of consciousness, headache hypoglycemia can occur. and no further weight
(1) day 46 kg and hunger. loss noted.
(2) day 45.0 kg Dependent:
- muscle weakness 1. Monitor laboratory studies such as 1. To obtain information about the
CBC, HGT & lipid profile. glucose level of the pt. and
2. Administer meals as ordered by administer adequate amt. of
the physician. insulin to correct imbalance.
a. start IVF of PNSS1L at a. To promote hydration and fluid
15gtts/min and electrolytes imbalance.
b. Humulin 70/30 25 “u” b. Helps decrease glucose level
before breakfast & 15 “u” in case of hyperglycemia.
before dinner.
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Risk for With in the Independent: After 9 days of
OBJECTIVE: infection related hospital stay, 1. Promote good handwashing by 1. Reduce risk of cross- patient’s
- dizzy to high glucose client will the student nurse, staff and the contamination. confinement, no signs
- fatigue level and maintain patient. of infection noted.
- generalized muscle alteration in optimum health 2. Assess signs of infection and 2. To assess if pt. is admitted with
weakness circulation and will be free inflammation (fever, wound, infection which may develop a The patients wound
- loss of appetite from any signs of drainage, purulent sputum). nesocomial infection. was dry and starts to
- with non-healing 3 infection. 3. Maintain aseptic technique in IV 3. High glucose in the blood heal.
cm. wound on the monitoring, administration of creates an excellent medium for
left foot. medication, and rotate IV site as bacterial growth.
indicated.
4. Place in semi-fowler’s position. 4. Facilitates lung expansion;
reduce risk of aspiration.
5. do daily wound dressing 5. to prevent wound infection.
aseptically
Dependent:
1. Let the patient take:
a. Diamicron 1 tab P. O BID a. To stimulate insulin
before breakfast and dinner secretion from pancreatic
B cells.
b. Humulin 70/30 12 “4” SQ b. Helps decrease glucose
before breakfast level

NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 DIAGNOSIS
SUBJECTIVE: Fatigue related At the end of 8 Independent: At the end of 8 hrs.
“Usahay mora ko ug decrease hrs., the client 1. Obtain baseline data regarding pt. 1. To assess pt.’s ability to the client was able to
gakalipong ug metabolic energy will increase in V/S. perform desired activity and regain satisfying
gapaminhod production energy level and avoid complications. energy to be able to
kanunay akong mga improve his 2. Discuss with pt. the need for 2. Provide motivation to perform daily routine
tiil,” as verbalized ability to activity and identify activities that increase activity even though activities by his own.
by the patient. participate on leads to fatigue. pt. may feel too weak
routine activities initially. The client verbalized
OBJECTIVE: 3. Teach the pt. how to do leg rising, 3. To promote blood circulation improve sense of well
- dizzy/fainting turn from side to side during and acid base balance. being after having an
- Tingling and prolong lying position and hour of mid-
numbness of his demonstrate breathing technique afternoon nap.
lower extremities to enhance long expansion
- generalized muscle 4. Monitor V/S before and after 4. Indicates physiological level
weakness activity. of tolerance.
- fatigue 5. Alternate activity with periods of 5. Prevents excessive fatigue.
sleep/rest.
6. Discuss ways of conserving 6. So that the pt. will be able to
energy while bathing, transferring, accomplish more with a
etc. decreased expenditure of
energy.
 EVALUATION

At the end of 3 days on taking care of my patient Mr. A was able to elaborate to him the
nature of his disease condition in as much as he wanted to know more about it. He was indeed
suffering for generalized muscle weakness and numbness of his lower extremities as he always
complain it to me and to his daughter. I always have my initial assessment every shift. Observing
him whether he is still experiencing dizziness accompanied by a mild high blood pressure of
13/80 mmHg or still unable to perform self-care. After the administration of medications, he had
maintained a varying blood pressure of 100/70 mmHg with a pulse rate of 66 bpm, respiratory
rate of 23 cpm and a body temperature of 36.6 that I monitored every 2 hours. I had performed
blood transfusion with him once and that was successfully infused. His vital signs was closely
monitored before and after the blood transfusion to determine signs of hyperglycemia or
hypoglycemia and conduct a nursing action against it. He was able to gain understanding
regarding his dietary nutritional needs, the importance of his medication, and exercise before he
was discharged at 4:10 pm against medical advice. He was approachable and cooperative person
I’ve met who is eager enough to be cured and I was able to establish a rapport to him without a
problem. Having him as my patient during clinical exposure means learning Diabetes Melletus
disease process. I am so thankful presenting this case because I have learned a lot starting from
laboratory results, the physiology and pathophysiology of disease, drug study and the nursing
management for this kind of case. To generalize the experience, my interventions, the standard
nursing care and the patient health teaching was effective as manifested by his satisfying
performance on leg rising, and modifying his diet and lifestyle aiming to prevent complications
of his disease.
 IMPLICATION

The patient will be able to gain control to his condition by instructing him to take his
medication ordered by the physician regularly with food or after meals to avoid epigastric pain.
Exercise such as elevation of legs alternately, and breathing exercise must be properly
demonstrated so that he can utilize it in home setting. He should be aware about his chronic
illness and the prevention of the possible complications. Review the importance of proper diet
and note the schedules of insulin therapy, and glucose testing. Most of all, health modification
regarding patient’s unhealthy habit of smoking must be emphasized to prevent an outburst of
another illness that may threaten his life.

REFERRALS

Regular check-up is very important in patient with chronic illness. Safe environment and
good sanitation must also be provided to prevent infection which will lead to complication of the
infected site. Family support also play importance in enhancing patient’s motivation by all means
of giving him regular medications at the appropriate time, monitoring his diet 1400 kcal/day with
200g/day of CHO, 100g/day of CHON and 30g/day of fat. Encouraging low sodium diet and of
course, avoid sugar. If necessary, assist him in taking meals regularly, maintain adequate fluid
intake and again, avoid over-eating. Health care providers, must give emphasis on family
education regarding the nature of the disease and its prevention. Conveying to them that proper
diet and exercise will avoid or delay the onset of the disease. Before discharge from the hospital
institution, healthy teaching must be properly communicated, referring them to the nearest
hospital or health center that could assist them and note the date one week after discharge a
follow-up check-up with the patient and his regular glucose monitoring.
BIBLIOGRAPHY:

Smeltzer, Suzzane C. and Bare, Brenda G. Textbook of Medical-Surgical Nursing. 9th ed.
Philadelphia: Lippincott Williams and Wilkins. 2000.

Karch, Amy M. Focus on Nursing Pharmacology. Philadelphia: J. B. Lippincott Co. 2000.

Doenges, M. E., Moorehouse, M. F. and Geissler, A. C. Nursing Care Plans: Guidelines for
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Kozier, B., Erb, G., et. al. Fundamentals of Nursing: Concepts, Process, and Practice. 7th ed. New
Jersey: Pearson Education Inc. 2004.

Udan, J. Q. Medical-Surgical Nursing: Concepts and Clinical Application. 1st ed. Philippines:
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FishBack, F.T. Nurse’s Quick References to Common Laboratory and Diagnostic Tests. 2nd ed.
Philadelphia: J. B. Lippincott Co. 1998.

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Saunders Company. 1989.
IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Fluid Volume deficient related to Osmotic diuresis (from

hyperglycemia) as evidence by weakness; thirst; sudden weight loss.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses,
good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte
levels within normal range.
ACTIONS/INTERVENTIONS RATIONALE

Independent

Obtain history from patient/SO related to Assists in estimation of total volume depletion.
duration/intensity of symptoms such as vomiting, Symptoms may have been present for varying amounts
excessive urination. time (hours to days). Presence of infectious process
results in fever and hypermetabolic state, increasing
Monitor vital signs: insensible fluid losses.

Hypovolemia may be manifested by hypotension and

Note orthostatic BP changes; tachycardia. Estimates of severity of hypovolemia may be
made when patient’s systolic BP drops more than 10 mm
Hg from a recumbent to a sitting/standing position. Note:
Cardiac neuropathy may block reflexes that normally
increase heart rate.

Lungs remove carbonic acid through respirations,

Respiratory pattern, e.g., Kussmaul’s respirations, producing a compensatory respiratory alkalosis for
acetone breath; ketoacidosis. Acetone breath is due to breakdown
acetoacetic acid and should diminish as ketosis is
corrected.

Correction of hyperglycemia and acidosis will cause the

Respiratory rate and quality; use of accessory
muscles, periods of apnea, and appearance of
cyanosis;
respiratory rate and pattern to approach normal. In
contrast, increased work of breathing; shallow, rapid
respirations; and presence of cyanosis may indicate
respiratory fatigue and/or that patient is losing ability to
compensate for acidosis.

Although fever, chills, and diaphoresis are common with

Temperature, skin color/moisture.
infectious process, fever with flushed, dry skin may
reflect dehydration.

Assess peripheral pulses, capillary refill, skin turgor, and Indicators of level of hydration, adequacy of circulating
mucous membranes. volume.

Monitor I&O; note urine specific gravity. Provides ongoing estimate of volume replacement needs,
kidney function, and effectiveness of therapy.

Provides the best assessment of current fluid status and

Weigh daily.
adequacy of fluid replacement.
Dependent
Administer fluids as indicated: Type and amount of fluid depend on degree of deficit and
Isotonic (0.9%) or lactated Ringer’s solution without individual patient response. Note: Patients with DKA
additives; often severely dehydrated and commonly need 5–10 L of
isotonic saline (2–3 L within first 2 hr of treatment).

Monitor laboratory studies, e.g.:

Hct; Assesses level of hydration and is often elevated because
of hemoconcentration associated with osmotic diuresis.

BUN/creatinine (Cr); Elevated values may reflect cellular breakdown from

dehydration or signal the onset of renal failure.

Serum osmolality;
Elevated because of hyperglycemia and dehydration.
Sodium;
May be decreased, reflecting shift of fluids from the
intracellular compartment (osmotic diuresis). High
sodium values reflect severe fluid loss/dehydration or
sodium reabsorption in response to aldosterone secretion.

Potassium.
Initially, hyperkalemia occurs in response to metabolic
acidosis, but as this potassium is lost in the urine, the
absolute potassium level in the body is depleted. As
insulin is replaced and acidosis is corrected, serum
potassium deficit becomes apparent.

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements related to insulin
deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased
protein/fat metabolism) as evidenced by recent weight loss; weakness, fatigue, poor muscle tone.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Ingest appropriate amounts of calories/nutrients.
Display usual energy level.
Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Assesses adequacy of nutritional intake (absorption and
Weigh daily or as indicated.
utilization).

Identifies deficits and deviations from therapeutic needs.

Ascertain patient’s dietary program and usual pattern;
compare with recent intake.
Hyperglycemia and fluid and electrolyte disturbances can
Auscultate bowel sounds. Note reports of abdominal
decrease gastric motility/function (distension or ileus),
pain/bloating, nausea, vomiting of undigested food.
affecting choice of interventions. Note: Long-term
Maintain nothing by mouth (NPO) status as indicated.
difficulties with decreased gastric emptying and poor
intestinal motility suggest autonomic neuropathies
affecting the GI tract and requiring symptomatic
treatment.

If patient’s food preferences can be incorporated into the

Identify food preferences, including ethnic/cultural needs.
meal plan, cooperation with dietary requirements may be

If patient’s food preferences can be incorporated into the
meal plan, cooperation with dietary requirements may be
facilitated after discharge.
Dependent
Perform fingerstick glucose testing.
Monitor laboratory studies, e.g., serum glucose, acetone,
pH, HCO3.
Provide diet of approximately 60% carbohydrates, 20%
proteins, 20% fats in designated number of meals/snacks.
Administer other medications as indicated, e.g.,
metoclopramide (Reglan); tetracycline.
NURSING DIAGNOSIS: Infection, risk for [sepsis] related to high glucose levels, decreased
leukocyte function, alterations in circulation preexisting respiratory infection, or UTI.
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques, lifestyle changes to prevent development of infection.
ACTIONS/INTERVENTIONS
Independent
facilitated after discharge.
Once carbohydrate metabolism resumes (blood glucose
level reduced) and as insulin is being given,
hypoglycemia can occur. If patient is comatose,
hypoglycemia may occur without notable change in level
of consciousness (LOC). This potentially life-threatening
emergency should be assessed and treated quickly per
protocol. Note: Type 1 diabetics of long standing may not
display usual signs of hypoglycemia because normal
response to low blood sugar may be diminished.
Bedside analysis of serum glucose is more accurate
(displays current levels) than monitoring urine sugar,
which is not sensitive enough to detect fluctuations in
serum levels and can be affected by patient’s individual
renal threshold or the presence of urinary retention/renal
failure. Note: Some studies have found that a urine
glucose of 20% may be correlated to a blood glucose of
140–360 mg/dL.
Blood glucose will decrease slowly with controlled fluid
replacement and insulin therapy. With the administration
of optimal insulin dosages, glucose can then enter the
cells and be used for energy. When this happens, acetone
levels decrease and acidosis is corrected.
Complex carbohydrates (e.g., corn, peas, carrots,
broccoli, dried beans, oats, apples) decrease glucose
levels/insulin needs, reduce serum cholesterol levels, and
promote satiation. Food intake is scheduled according to
specific insulin characteristics (e.g., peak effect) and
individual patient response. Note: A snack at bedtime (hs)
of complex carbohydrates is especially important (if
insulin is given in divided doses) to prevent
hypoglycemia during sleep and potential Somogyi
response.
May be useful in treating symptoms related to autonomic
neuropathies affecting GI tract, thus enhancing oral intake
and absorption of nutrients.
RATIONALE
Observe for signs of infection and inflammation, e.g., Patient may be admitted with infection, which could have
fever, flushed appearance, wound drainage, purulent precipitated the ketoacidotic state, or may develop a
sputum, cloudy urine. nosocomial infection.

Promote good handwashing by staff and patient. Reduces risk of cross-contamination.

Maintain aseptic technique for IV insertion procedure, High glucose in the blood creates an excellent medium
administration of medications, and providing for bacterial growth.
maintenance/site care. Rotate IV sites as indicated.

Peripheral circulation may be impaired, placing patient at

Provide conscientious skin care; gently massage bony
areas. Keep the skin dry, linens dry and wrinkle-free.
Place in semi-Fowler’s position.
Reposition and encourage coughing/deep breathing if
patient is alert and cooperative. Otherwise, suction
airway, using sterile technique, as needed.
Provide tissues and trash bag in a convenient location
sputum and other secretions. Instruct patient in proper
handling of secretions.
Encourage adequate dietary and fluid intake
(approximately3000 mL/day if not contraindicated by
cardiac or renal dysfunction), including 8 oz of cranberry
juice per day as appropriate.
increased risk for skin irritation/breakdown and infection.
Facilitates lung expansion; reduces risk of aspiration.
Aids in ventilating all lung areas and mobilizing
secretions. Prevents stasis of secretions with increased
risk of infection.
Minimizes spread of infection.
Decreases susceptibility to infection. Increased urinary
flow prevents stasis and aids in maintaining urine
pH/acidity, reducing bacteria growth and flushing
organisms out of system. Note: Use of cranberry juice can
help prevent bacteria from adhering to the bladder wall,
reducing the risk of recurrent UTI.

Dependent
Identifies organism(s) so that most appropriate drug
Obtain specimens for culture and sensitivities as
therapy can be instituted.
indicated.

Administer antibiotics as appropriate. Early treatment may help prevent sepsis.

NURSING DIAGNOSIS: Risk for disturbed sensory perception related to endogenous chemical
alteration: glucose/insulin and/or electrolyte imbalance.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Maintain usual level of mentation.
Recognize and compensate for existing sensory impairments.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Monitor vital signs and mental status. Provides a baseline from which to compare abnormal
findings, e.g., fever may affect mentation.

Address patient by name; reorient as needed to place,
person, and time. Give short explanations, speaking
slowly and enunciating clearly.
Schedule nursing time to provide for uninterrupted rest
periods.
Decreases confusion and helps maintain contact with
reality.
Promotes restful sleep, reduces fatigue, and may improve
cognition.
Protect patient from injury (avoid/limit use of restraints as
able) when level of consciousness is impaired. Place bed
in low position. Pad bed rails and provide soft airway if
patient is prone to seizures.
Evaluate visual acuity as indicated.
Provide bed cradle. Keep hands/feet warm, avoiding
exposure to cool drafts/hot water or use of heating pad.
Assist with ambulation/position changes.
Dependent
Monitor laboratory values, e.g., blood glucose, serum
osmolality, Hb/Hct, BUN/Cr.
Carry out prescribed regimen for correcting DKA as
indicated.
NURSING DIAGNOSIS: Fatigue related to altered body chemistry: insufficient insulin as
evidenced by overwhelming lack of energy, inability to maintain usual routines, decreased
performance, accident-prone impaired ability to concentrate, listlessness, and disinterest in
surroundings.
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL
Verbalize increase in energy level.
Display improved ability to participate in desired activities.
ACTIONS/INTERVENTIONS
Independent
Discuss with patient the need for activity. Plan schedule
with patient and identify activities that lead to fatigue.
Alternate activity with periods of rest/uninterrupted sleep.
Monitor pulse, respiratory rate, and BP before/after
activity.
Discuss ways of conserving energy while bathing,
Disoriented patient is prone to injury, especially at night,
and precautions need to be taken as indicated. Seizure
precautions need to be taken as appropriate to prevent
physical injury, aspiration.
Retinal edema/detachment, hemorrhage, presence of
cataracts or temporary paralysis of extraocular muscles
may impair vision, requiring corrective therapy and/or
supportive care.
Reduces discomfort and potential for dermal injury. Note:
Sudden development of cold hands/feet may reflect
hypoglycemia, suggesting need to evaluate serum glucose
level.
Promotes patient safety, especially when sense of balance
is affected.
Imbalances can impair mentation. Note: If fluid is
replaced too quickly, excess water may enter brain cells
and cause alteration in the level of consciousness (water
intoxication).
Alteration in thought processes/potential for seizure
activity is usually alleviated once hyperosmolar state is
corrected.
RATIONALE
Education may provide motivation to increase activity
level even though patient may feel too weak initially.
Prevents excessive fatigue.
Indicates physiological levels of tolerance.
Patient will be able to accomplish more with a decreased
transferring, and so on. expenditure of energy.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding disease, prognosis,

treatment, self-care, and discharge needs related to lack of exposure/recall, information
misinterpretation or unfamiliarity with information resources.

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Verbalize understanding of disease process, potential complications.
Identify relationship of signs/symptoms to the disease process and correlate symptoms with
causative factors.
Correctly perform necessary procedures and explain reasons for the actions.
Initiate necessary lifestyle changes and participate in treatment regimen.

ACTIONS/INTERVENTIONS RATIONALE

Independent

Create an environment of trust by listening to concerns, Rapport and respect need to be established before patient
being available. will be willing to take part in the learning process.

Work with patient in setting mutual goals for learning. Participation in the planning promotes enthusiasm and
cooperation with the principles learned.

Select a variety of teaching strategies, e.g., demonstrate Use of different means of accessing information promotes
needed skills and have patient do return demonstration, learner retention.
incorporate new skills into the hospital routine.

Discuss essential elements, e.g:

What the normal blood glucose range is and how it Provides knowledge base from which patient can make
compares with patient’s level, the type of DM informed lifestyle choices.
patient has, the relationship between insulin
deficiency and a high glucose level;

Reasons for the ketoacidotic episode; Knowledge of the precipitating factors may help avoid
recurrences.

Acute and chronic complications of the disease, Awareness helps patient be more consistent with care and
including visual disturbances, neurosensory and may prevent/delay onset of complications.
cardiovascular changes, renal
impairment/hypertension.

Demonstrate fingerstick testing, or similar monitoring

system, and have patient/SO return demonstration until
proficient. Instruct patient to check urine ketones if
glucose is higher than 250 mg/dL.
Self-monitoring of blood glucose four or more times a
day allows flexibility in self-care, promotes tighter
control of serum levels (e.g., 60–150 mg/dL), and may
prevent/delay development of long-term complications.
Note: Various new devices have been released or are in
testing. Some use a laser perforator instead of a sharp
lancet, others are bloodless. In addition to glucose levels,
several devices can measure glocosylated albumin
(fructosamine) in the home, providing a measure of blood
glucose control over the past 7–10 days.

Discuss dietary plan, limiting intake of sugar, fat, salt, Medical nutrition therapy for diabetes encourages patient
and alcohol; eating complex carbohydrates, especially to make meal choices based on individual unique needs
those high in fiber (fruits, vegetables, whole grains); and and preferences. Awareness of importance of dietary
ways to deal with meals outside the home.

Review medication regimen, including onset, peak, and
duration of prescribed insulin, as applicable, with
patient/SO.
Review self-administration of insulin and care of
equipment. Have patient demonstrate procedure (e.g.,
drawing up and injecting insulin, insulin pen technique,
or use of continuous pump).
Discuss timing of insulin injection and mealtime.
Review individual’s target blood glucose levels.
Discuss factors that play a part in diabetic control, e.g.,
exercise (aerobic versus isometric), stress, surgery, and
illness. Review “sick day” rules.
Review effects of smoking on insulin use. Encourage
cessation of smoking.
control aids patient in planning meals/sticking to regimen.
Fiber can slow glucose absorption, decreasing
fluctuations in serum levels, but may cause GI
discomfort, increase flatus, and affect vitamin/mineral
absorption.
Understanding all aspects of drug usage promotes proper
use. Dose algorithms are created, taking into account drug
dosages established during inpatient evaluation, usual
amount and schedule of physical activity, and meal plan.
Including SO provides additional support/resource for
patient.
Verifies understanding and correctness of procedure.
Identifies potential problems (e.g., vision, memory, and
so on) so that alternative solutions can be found for
insulin administration. Note: If multiple daily injections
are required, combinations of regular, intermediate, and
long-acting insulin are used. If the pump method is used,
patient programs his or her own basal and bolus settings.
Only regular insulin is administered, with a basal dose
throughout the day and bolus doses before meals and as
needed. An insulin pump more closely mimics normal
pancreatic activity because the basal rate may be changed
relative to patient’s activity level, presence of
stressors/infection or menstrual cycle.
One of the many inconveniences people with diabetes
cope with is having to decide at least 30–60 min in
advance when they are going to have a meal for the
timely administration of regular Humulin injections. A
newer product, insulin lispro (Humalog), may be helpful
because it works best when taken within 15 min of eating.
With the onset twice as fast as regular human insulin and
a duration approximately half as long, Humalog closely
mimics pancreatic activity. However, hypoglycemia may
develop more rapidly and be more severe than with use of
regular insulin. A blood glucose level below 80 mg/dL
indicates that insulin should be injected after eating rather
than before the meal.
Although this range varies per person, the ideal range for
the adult diabetic is considered to be 80–120 mg/dL.
Note: Patients with an insulin pump may maintain blood
glucose levels between 120 mg/dL and 200 mg/dL with
no urinary ketones.
This information promotes diabetic control and can
greatly reduce the occurrence of ketoacidosis. Note:
Aerobic exercise (e.g., walking, swimming) promotes
effective use of insulin, lowering glucose levels, and
strengthens the cardiovascular system. A “sick day”
management plan helps maintain equilibrium during
illness, minor surgery, severe emotional stress, or any
condition that might send glucose spiraling upward.
Nicotine constricts the small blood vessels, and insulin
absorption is delayed for as long as these vessels remain

Establish regular exercise/activity schedule and identify
corresponding insulin concerns.
Instruct in importance of routine examination of the feet
and proper foot care. Demonstrate ways to examine feet;
inspect shoes for fit; and care for toenails, calluses, and
corns. Encourage use of natural fiber stockings.
Recommend avoidance of over-the-counter (OTC) drugs
without prior approval of healthcare provider.
Review signs/symptoms requiring medical evaluation,
e.g., fever; cold or flu symptoms; cloudy, odorous urine,
painful urination; delayed healing of cuts/sores; sensory
changes (pain or tingling) of lower extremities; changes
in blood sugar level, presense of ketones in urine.
Identify community resources, e.g., American Diabetic
Association, Internet resources/online diabetes bulletin
boards, visiting nurse, weight-loss/stop-smoking clinic,
contact person/diabetic instructor.
constricted. Note: Insulin absorption may be reduced by
as much as 30% below normal in the first 30 min after
smoking.
Exercise times should not coincide with the peak action
of insulin. A snack should be ingested before or during
exercise as needed, and rotation of injection sites should
avoid the muscle group that will be used in the activity
(e.g., abdominal site is preferred over thigh/arm before
jogging or swimming) to prevent accelerated uptake of
insulin.
Prevents/delays complications associated with peripheral
neuropathies and/or circulatory impairment, especially
cellulitis, gangrene, and amputation. Note: Studies show
that approximately 15% of all patients with diabetes will
develop a foot or leg ulcer during the course of the
disease. Also 50% of all nontraumatic lower extremity
amputations occur in people with diabetes. Prevention is
therefore critical.
These products may contain sugars/interact with
prescribed medications.
Prompt intervention may prevent development of more
serious/life-threatening complications.
Continued support is usually necessary to sustain lifestyle
changes and promote well-being.
 PATHOPHYSIOLOGY

Diabetes Mellitus - chronic disorder affecting carbohydrate, fat and protein metabolism.
Predisposing Factors: Age (64 yrs old), Diet, Lifestyle
Precipitating Factors: Family History, Stress, Obesity

Inadequate insulin

Carbohydrate Metabolism Fat Metabolism

Protein Metabolism

Increase lypolysis of adipose

Increase Glucose Breakdown of muscle tissue
Production protein into amino acids

Increase
Gluconeogenesis Plasma Free acids

S/Sx: Acetone Breath

Decrease utilization of Nausea and Vomiting
glucose by skeletal muscles, Kausmaul’s Resp.
organs and cells Ketosis

Hyperglycemia
S/Sx: Polyphagia,
Cell Dehydration Cell Starvation Muscle weakness
Muscle Wasting
Fatigue
Decrease Blood
Viscosity

Hypovolemia
Shock Muscle wasting
 S/Sx: Polyuria,
Polydipsia
Draw out fluids from the
renal tubules
Thrombosis

S/Sx: Delayed Wound Healing

Numbness of the Lower Extremities
Poor Turgor
Osmotic Diuresis

Decrease organ perfusion

Decrease Circulating
blood volume

Decrease Renal Function

Hypovolemia

Metabolic Acidosis

Shock

Decrease Cellular K

Cardiac Dysrhythmias