TARLAC STATE UNIVERSITY

COLEGE OF NURSING
S.Y. 2008-2009

SUBMITTED BY:
RACHAEL ANN B. ESPINOSA
BSN III-A
GROUP A2

SUBMITTED TO:
MS. MARIA TERESA MENDOZA
CLINICAL INSTRUCTOR
 PATIENT’S PROFILE

NAME: Mr. M
AGE: 54 YEARS OLD
SEX: Male
CIVIL STATUS: Married
OCCUPATION: Jeepney Driver
RELIGION: Roman Catholic
POSITION IN THE FAMILY: Father
ADDRESS: Gerona, Tarlac
DATE OF BIRTH: July 16, 1953
NATIONALITY: Filipino
HEIGHT: 5’4
WEIGHT: 76 kg
DATE OF ADMISSION: July 10, 2008
CHIEF COMPLAIN: Non-healing wound on the ® foot
DIAGNOSIS: Type II Diabetes Mellitus uncontrolled
Diabetic foot ®

INTRODUCTION
 The cause of the common form of type II diabetes mellitus is
unknown. The genetic of type II are complex and not clearly defined.
Autoimmune mechanisms are not involved. Individuals with maturity
onset diabetes of youth (MODY), a subset o type II, are normal weight
to underweight. MODY is thought to be auto somal dominant because it
affects 50 % of first-degree relatives.

Cellular resistance is a factor for 60% to 80% of individuals with

type II DM. Insulin resistance is increase in obesity. Decrease beta cells
responsiveness to the plasma glucose level is noted, along with
abnormal glucagons secretion. Levels of insulin may increase to
compensate or insulin resistance in peripheral tissues, but there is still
a relative deficiency of insulin.

Pancreatic changes in individuals with type II DM are non-specific

and have been observed to a lesser degree in persons without DM.
Liver changes are related to elevated serum lipid levels.

Risk for developing diabetes after age 40 years old in general,

incidence increases with the age into the 70’s. Diseases results from
genetic susceptibility combined with environmental determinants and
other risk factors. It is associated with long duration obesity. Islet cell
antibodies are not present. Increased insulin resistance caused by
altered cellular metabolism and an intracellular post receptor defect.
Typically increased at time of diagnosis; may be normal or decreased.

The goal of treatment is restoration of euglycemia and correction

of related metabolic disorders. Dietary measures, including the
restriction of the total caloric intake, are of primary importance in the
overweight individual.

13 AREAS OF ASSESSMENT
1. SOCIAL STATUS
 Mr. M is a 54 year old male born on July 16, 1953. He is presently
residing at Gerona, Tarlac. He is third eldest son to a family of 11
members. He worked as a company driver of a Chinese businessman in
Angeles City, Pampanga for more than 10 years. But he is now
currently driving his own passenger jeepney. He is a high school under
graduate. He lives with his wife and 3 children including his 2 sons-in-
law and 2 grandsons. He declares that his salary is just enough to
sustain their daily needs. He interacts respectfully to others and is
friendly. His family is a devout Catholic and they go to church together
every Sunday.

NORMS: Social functioning of an individual is to form relationships

with others. Social support is a perception that one has an emotional
and tangible resource to call on when needed; perceived social support
is being followed by the family to express the love of the family,
financial aspects is one of the normal constraints in the family.
(Nursing Fundamentals by Daniels; An Introduction to Health and
Physical Assessment in Nursing by D’Amico and Barbarito)

ANALYSIS: The patient’s social status can be described as normal; he

has support system (the family) which he can turn to when face with
difficult periods particularly upon encountering emotional or coping
crisis and has a strong foundation of emotional stability. He has also
close family ties. He interacts well with others. He also communicates
with his fellowman thus, he gain many friends.

2. MENTAL STATUS

GENERAL APPEARANCE AND BEHAVIOUR:

Mr. M was not well groomed during our first encounter. He looks
restless, weak and lethargic. However, he appears to be responsive
whenever someone is asking him.

LEVEL OF CONSCIOUSNESS:
As I talked to him, he is increased in level of alertness, conscious
and coherent. He responded to some questions appropriately.

ORIENTATION:
Mr. M is aware of his present condition. He knows some of the
reasons why he was admitted in the hospital. The patient is well
oriented about the time, place, person, and date. And he is able to
answer all questions asked.

SPEECH:
 Mr. M’s spoken words can be clearly understood. He can
understand and able to speak Tagalog, Ilocano and a bit of Pampango.

NORMS: Patients should be able to reason, to find meaning, and make

judgment from information, to demonstrate rational thinking and
perceive realistically. Appearance and behavior; posture must be
relaxed. Patients should be dressed appropriately with the season, age,
and gender. Grooming and hygiene should be proper and neat. Should
typically able to state their name, location, the date, month, season,
and time of the day. Ability to form words (articulation) should be
understood and clear. (An Introduction to Health and Physical
Assessment in Nursing by D’Amico and Barbarito; Physical
Examination and Health Assessment by Carolyn Jarvis)

ANALYSIS: His appearance, level of consciousness, behavior, speech,

cognitive abilities, and memory does not show any significant
deviations from an average person and thus, considerately shows no
mental impairment.

3. EMOTIONAL STATUS

Mr. M was relaxed and calm even though he doesn’t have

enough sleep because of the interruptions o opening and closing the
door of their ward. He also wanted to go home despite of his condition
as much as possible because of thinking about the increasing bills and
that they have no money to pay.

NORMS: Normal copping pattern or emotions stability could include

acceptance of the problem, adjustment to it, expressing of self-
perception and self-control of emotions, probable temporary use o
defense mechanism and support system (Fundamentals of Nursing by
Kozier).
Carrying out emotional feelings through words and facial
expressions are normal signs of present physical condition (Nursing
Fundamentals by Daniels)

ANALYSIS: The patient manifests acceptance of health condition and

felt support from his family and is capable of controlling his emotions.
He also is experiencing anxiety because of the worrying on how to get
the money in paying or his hospital bills.
4. SENSORY PERCEPTION

SENSE OF LIGHT: Patient can open his eyes. Upon assessment,

papillary reflex is done. Complaint of blurred vision and cannot read
small letters at the distance of 3 feet. Blinking reflex was symmetrical
and involuntary.
SENSE OF TASTE: can able to recognize different taste of food such as
salty and sour foods.

TACTILE SENSITIVITY: Patient was generally warm to touch upon

assessment and he can perceive and able to distinguish hot and cold
temperature.

AUDITORY ACUITY TEST: Patient can hear the words I was talking to him
a to a distance of 2 meters and he was able to hear me.

SENSE OF SMELL: According to the patient, he can recognize good and

bad odors.

NORMS: Normal visual acuity of the person is 20/20. Visual acuity can
be impaired by pathology affecting the optic nerve or
neovascularization of the optic nerve with resultant bleeding and
related to diabetes mellitus. The patient should be able to perceive
light touch, superficial pain, and temperature accurately. Should be
able to distinguish and identify the odor with each nostril. Normal
sensation would be accurate perceptions of sweet, sour, salty, and
bitter tastes. (Health and Assessment and Physical Examination, 3rd
Edition by Estes)

ANALYSIS: Systemic disease like diabetes mellitus damages the

choroids and retina of the eye, causing visual acuity which is present in
the patient. But the remaining sensory organs functions in normal
state.

5. MOTOR STABILITY

Mr. M has limited range o motion especially in the affected area.

He cannot turn from side to side without assistance. But he can use his
upper extremities in feeding his self.

NORMS: Full range of motion on voluntary muscles should be

performed without strain and there are no feelings of pain or
tenderness. (Nurse’s Handbook of Health Assessment by Weber)

ANALYSIS: The patient cannot perform activities that require full

motion and he cannot ambulate normally because o his condition. He
has limited movement.