PRESENTED TO:

MRS. DOLORES S. MALOLES RN,MSN

PRESENTED BY:

Ayala, Mhel Marjorie

Ayala, Rose Ann
Banta, Kathleen
Molina, Mariel
Santos, Kim Genesis
OBJECTIVES OF THE CASE
PRESENTATION
General Objective:

At the end of the presentation, it is

critically important that the students are
expected to gain the necessary
information regarding Diabetes Mellitus
for them to determine the appropriate
nursing care management they should
provide to those patients having this kind
of illness. In addition, students will help
the patient to work toward adapting to life
with a chronic condition.
SPECIFIC OBJECTIVES:
The students will be able to:

 Understand the nature of DIABETES

MELLITUS.
 Differentiate between type 1 and type 2
diabetes.
 Distinguishes its clinical manifestations and
predisposing factors.
 Outline the Anatomy and Physiology, as well
as its Pathophysiology of the disease or
condition.
 Determine the health status of the
patient through:

 Knowing the past history and present

illnesses of the patient of the patient as well
as their family health history.
 Conducting physical examinations.

 Analyzing the laboratory examination done

and correlate it to the present condition of
the patient.
 Determine the appropriate nursing care that
should be provided to the client.
 Understand the different drugs that the client
is taking and determine how it will benefit
the client as well as the possible adverse
effect it may give.
 Create a good and a therapeutic nurse-
patient interaction.
 Teach the client’s relatives on how to
minimize the risk developing DIABETES
MELLITUS.
OVERVIEW:

DIABETES MILLETUS is a group of metabolic

diseases characterized by elevated levels of glucose
in the blood (hyperglycemia) resulting from abnormal
endocrine secretion by the pancreas (either an
absolute or relative insulin sufficiency), an insufficient
number of insulin receptor sites on cell, a postreceptor
defects, or a combination of abnormalities, alters the
metabolism of food. Eventually, structural
abnormalities develop in a number of different body
tissues. The four general components of diabetes are
hyperglycemia, large blood vessel (macrovascular)
dse., small blood vessel (microvascular) dse., and
neuropathy. A useful definition of diabetes is
symptomatic (polyuria, polydipsia, and polyphagia) or
asymptomatic state of altered CHON, CHO, and fat
metabolism.
 Normally a certain amount of glucose
circulates in blood. The major sources of glucose are
absorption of ingested food in the gastrointestinal
(GI) tract and formation of glucose by liver from
substances and stored as glycogen.

The blood glucose level is consistently

monitored by cells of the islet of the langerhans of
the pancreas. If the concentration of glucose in the
bloodstream begins to increase, more insulin is
secreted by the beta cells of the islet of the
langerhans and blood glucose level decrease as the
excess glucose is converted to glycogen. Conversely,
if glucose level decrease, the alpha cells in the islet
secrets glucagon, which increase the blood glucose
level by stimulating the liver by releasing the
glycogen. The release of glycogen is converted to
glucose to maintain blood glucose levels within the
 Insulin a hormone produced by the
pancreas, controls the level of glucose in the
blood by regulating the production and storage of
glucose. In the diabetic state, the cell may stop
responding to insulin or the pancreas may stop
producing insulin entirely.
SIGNS AND SYMPTOMS
 lethargy
 polyuria, polydipsia and polyphagia
 sudden weight loss
 slow wound healing
 urinary tract infections
 gum disease
 blurred vision
 Irreducible mental fatigue
 Numbness of the hand and feet
 Feeling of tiredness much of the times
CLASSIFICATIONS:

☺ Type 1 Diabetes (insulin dependent diabetes

mellitus)

☺ Type 2 Diabetes (non insulin dependent

diabetes mellitus)

☺ Gestational diabetes mellitus

☺ Diabetes mellitus associated with other

conditions or syndrome.
INDIVIDUALS WHO ARE AT HIGH RISK OF
DEVELOPING TYPE II DIABETES MELLITUS
INCLUDE PEOPLE WHO:
 obesity
 have a relative with diabetes mellitus
 belong to a high-risk ethnic
 Pregnancy
 have been diagnosed with gestational diabetes or
have delivered a baby weighing more than 9 lbs (4 kg)
 have high blood
 have a high density lipoprotein cholesterol level
and/or triglyceride
 have had impaired glucose tolerance or impaired
fasting glucose on previous testing
 Physiologic or emotional stress
 Some medication
DIAGNOSTIC TESTS
♠ Random blood glucose test — for a random
blood glucose test, blood can be drawn at any time
throughout the day, regardless of when the person
last ate. A random blood glucose level of 200 mg/dL
(11.1 mmol/L) or higher in persons who have
symptoms of high blood glucose suggests a diagnosis
of diabetes.

♠ Fasting blood glucose test — fasting blood

glucose testing involves measuring blood glucose
after not eating or drinking for 8 to 12 hours (usually
overnight). A normal fasting blood glucose level is less
than 100 mg/dL. A fasting blood glucose of 126 mg/dL
(7.0 mmol/L) or higher indicates diabetes. The test is
done by taking a small sample of blood from a vein or
fingertip. It must be repeated on another day to
♠ Hemoglobin A1C test (A1C) — The
A1C blood test measures the average
blood glucose level during the past two
to three months. It is used to monitor
blood glucose control in people with
known diabetes, but is not normally
used to diagnose diabetes. Normal
values for A1C are 4 to 6 percent. The
test is done by taking a small sample of
blood from a vein or fingertip.

♠ Oral glucose tolerance test — Oral

glucose tolerance testing (OGTT) is the
most sensitive test for diagnosing
diabetes and pre-diabetes. However,
the OGTT is not routinely recommended
because it is inconvenient compared to
a fasting blood glucose test.
PREVENTION:

 Restricteating sweet foods

 Limit CHO intake

 Eat a nutritious balanced diet

 Have a good healthy lifestyle

 Exercise daily

 Avoid drinking and smoking

 Have a regular blood glucose monitoring

TREATMENT AND MANAGEMENT:

 Have a combination of nutritious diet,

exercise and weight loss
 Provide supplement e.g. insulin

 Oral herb medications such as aloe vera and

bitter melon
 Enhance lifestyle modifications

 Control glucose intake

 Peer support

 Have a special care for any complications

e.g. wound
PERSONAL DATA

Name: Mrs. ER
Age: 83 y/o
Gender: Female
Address: Lucena City
Nationality: Filipino
Religion: Roman Catholic
Birthday: March 19, 1926
Room# 5302
Attending Physician: Dra. Canela
Chief Complaints: Fever and chills
Admitting Diagnosis: T/C Viremia
Final Diagnosis: UTI, CHF 2º to CAD & HASCVD,
Anemia
PAST & PRESENT HEALTH
HISTORY
Present health history:
Prior to admission with 6 days of moderately high grade fever
then late accompanied by fever, and chills.
Past health history:
General health
♥ The patient was conscious and coherent. Pale in appearance,

with body weakness and in respiratory distress.

Childhood Illness:
♥ The only illness she experienced was common colds, cough,

and fever.
Immunization
♥ Incomplete immunization

Hospitalization
♥ Patient hospitalized during her teenage years due to
appendectomy in Quezon Medical Center, H-mole surgery on
1992 at MCDGH, DM was diagnosed on 1995, and stroke on
1999.
Current Medications
Her current medications are: Tempra Forte,
Sodium Chloride, Lactulose, Humulin, Furosimide,
Serc, Iberet, Catarstat, Captopril, Clopidogrel,
Bactobran, Digoxin, Bumetanide, Ciprofloxasin,
Kalium Durule, Zynapse.

Allergies
♂ No known allergies 

Habits
♂ Eating sweet foods
 Family History
Mother Father

Patient Husband

Daughter Daughter Son Daughter Daughter

LEGEND:

DIABETES HYPERTENSION HYPERTENTION

MELLITUS AND DIABETIS
Nutritional-Metabolic Pattern
 Appetite: poor
 Usual daily menu: rice, pork/fish and
vegetables
 Metabolic: weight loss

Elimination Pattern
 The client defecates once a day
 The client voids four times a day

Activity/Exercise
 Impaired range of motion

Oxygenation/Perfusion
 with ineffective breathing pattern.
 With oxygen @ 2:31pm.
PHYSICAL
ASSESSMENT
General Appearance
 Body built is appropriate to age
 No body odor
 In respiratory distress

Skin
 Pallor skin
 With dry skin
 With fair skin turgor
 With bed sore approximately 3cm wide in left
posterior gluteal muscle
Hair
 Black and short hair

 Equally distributed on scalp

 Without tenderness or lesion on scalp

Nails
 With long finger and toe nails

 With 3secs capillary refill

Skull and Face
 Skull is proportionate to body size
 Normochepalic
 Smooth skull contour
 Without masses or nodules
 Symmetrical facial grimace

Eyes
 Eyebrows and eyelashes evenly distributed
 With pale conjunctiva
 No swelling or tenderness in lacrimal glands
 Symmetric eyeballs, with equal size of pupils
and white sclera
 Pupils equally dilated reacted to light
 Blurred vision at times
Ears
 Color same as facial skin

 With symmetrical auricle position and size

 With elastic auricle

 Without discharge

Nose
 Symmetrical

 Without nasal secretions

 Without tenderness

 With pinkish mucosa

Mouth
 With slightly dry lips

 With permanent teeth

Neck
 Neck muscle proportionate to body size

 With normal range

 With palpable lymph nodes

Chest
 With symmetrical chest wall expansion

 In respiratory distress

 With normal and clear breath sounds

 With normal heart sounds

Abdomen
 With soft abdomen upon palpation

Lower Extremities
 not edematous legs and feet
ANATOMY AND
PHYSIOLOGY
Pancreas
The pancreas is a gland organ in
the digestive and endocrine system of
vertebrates. 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.
These enzymes help in the further
breakdown of the carbohydrates, protein,
and fat in the chyme.
 Under a microscope, stained sections of
the pancreas reveal two different types of
parenchymal tissue. Lightly staining clusters of cells
are called islets of Langerhans, which produce
hormones that underlie the endocrine functions of
the pancreas. Darker staining cells form acini
connected to ducts. Acinar cells belong to the
exocrine pancreas and secrete digestive enzymes
into the gut via a system of ducts.

Structure Appearance Function

Lightly staining, Hormone production
Islets of Langerhans large, spherical and secretion (
clusters endocrine pancreas)
Digestive enzyme
Darker staining,
production and
Pancreatic acini small, berry-like
secretion (
clusters
exocrine pancreas)
Functions

The pancreas is a dual-function gland, having features

of both endocrine and exocrine glands.

Endocrine
The part of the pancreas with endocrine
function is made up of approximately a million cell clusters called
islets of Langerhans. There are four main cell types in the islets. They
are relatively difficult to distinguish using standard staining
techniques, but they can be classified by their secretion: glucagon,
insulin, somatostatin, and PP cells secrete pancreatic polypeptide.

The islets are a compact collection of endocrine

cells arranged in clusters and cords and are crisscrossed by a dense
network of capillaries. The capillaries of the islets are lined by layers
of endocrine cells in direct contact with vessels, and most endocrine
cells are in direct contact with blood vessels, by either cytoplasmic
processes or by direct apposition. The islets are busily manufacturing
their hormone and generally disregarding the pancreatic cells all
around them, as though they were located in some completely
different part of the body.
Exocrine
 In contrast to the endocrine pancreas, which secretes hormones into
the blood, the exocrine pancreas produces digestive enzymes and
an alkaline fluid, and secretes them into the small intestine through
a system of exocrine ducts in response to the small intestine
hormones secretin and cholecystokinin. Digestive enzymes include
trypsin, chymotrypsin, pancreatic lipase, and pancreatic amylase,
and are produced and secreted by acinar cells of the exocrine
pancreas. Specific cells that line the pancreatic ducts, called
centroacinar cells, secrete a bicarbonate- and salt-rich solution into
the small intestine]
Regulation
 The pancreas receives regulatory innervation via hormones in the
blood and through the autonomic nervous system. These two inputs
regulate the secretory activity of the pancreas.

Sympathetic (adrenergic) Parasympathetic (muscarinic)

decreases secretion from increases stimulation from

beta cells, increases secretion alpha cells and beta cell
from alpha cells
PATHOPHYSIOLOG
Y
COURSE IN THE
WARD
 The patient was admitted last July 1, 2009 at the
Emergency Room of Mt. Carmel Diocesan General Hospital
under Dra. Canela, attending to the chief complaint of 6
days fever and chills. The following orders were given:
ordered DM diet, CBC, urinalysis, NA, K exam, plain NSS
1Lx12hrs, ECG, to start TEMPRA FORTE 1tab every 4 hrs.

 1:30 am through verbal order of Dr. Custodio to NOD, give

humolin R “u” SQ now, for repeat RBS after 1 hr.,
urinalysis, urine c & s now acquire sample by straight
catch, spot oxygen check, RBS, BUN, creatinine, AST, ALT
serum NA, same IVF to follow, medications starts given
were: NACL tab 1tab TID, Ciprofloxacin (ciprobax XR)
500mg tab 1 tab OD, start lactalose 30ml OD HS, fecalysis
to include exam for occult blood, humulin R 4 “u” SQ now,
monitor RBS TID ac, refer to Dr. Edwin Dayahan for DM.

 6:45 pm may give serc 8mg 1tab, 1tab now + dizziness

o On July 2 ordered to continue RBS, insulin same done
frequency, at 10am verbal order of Dra. Guinto to NOD, same IVF
to follow PNSS 1Lx 2hrs, erythropoietin 4,000 “V” (RENOGEN) SQ
stat dose only, start Furosemide (LASIX) 40mg tab ½ tab OD, refer
to Dra. Grace Sy for optha evalis, same IVF to follow, continue O2
inhalation at 2LPM via nasal cannula, if ok with Dra. Canela and
patient please refer to Dra. Alba,

 6pm phone order of Dra. Canela to NOD, please refer to Dra. Alba,
at the same time Dra. Alba had a phone order to NOD, OR will see
patient, patient seen and examined, may give jerc 8mg tab every
8hrs for dizziness, please send to KM 18 (MAB) tom at 10am for
cooperation of Optha Exam, refer PRN

 7:59pm txt order by Dra. Canela to NOD, carry out suggestion of

Dra. Alba.
o On July 3 at 1:50am txt order by Dra. Canela to NOD, may
give Dulcolax adult suppository per anum, continue
manitor RBS same frequency, CXR-PA, spot O2 check,
serum NA+ today, present IVF to consume, start from
supplement 1 Beret Active 1tab OD, Furoremide 20mg
now, at 4pm the patient unable to go to for completion of
optha exam, refer PRN, resume Catarstat 1 drop 3x a day,
present IVF to consume, spot O2 check.

o On July 4 2D echo with Doppler study, spot O2 check,

atrovent UDV nebulizer now, MGH anytime, Home Meds
were CIPROBAX XR 500mg 1tab OD #5, NACL tab 1tab BID
#60, FLURERAMIDE (LASIX) 40mg tab ½ tab OD q AM #30,
DIGOXIN (LANOXIN) 0.25mg tab ½ tab OD q AM #30,
IEBRET Active 1cup OD #30, ATROVENT UDV nebulizer BID
#30,ERYTHROPOIETIN (RENOGEN) 4,000 “V” SQ injection
stat dose only, refer discharge, continue meds, start
CAPTOPRIL 25mg tab ¼ tab OD,

 9:45pm textorder by Dra. Canela to NOD (insert d5w 1L x

KVO)
o ON July 5 continue meds, decrease Flureramide
40mg tab ½ tab BID, start CLOPIDOGREL 75mg
tab (plavix) 1tab OD.

o On July 6 Verbal Order of Dra Canella to NOD

same IV fluids to Follow D5W 1L x KVO, expose
pressure sort air dry apply BACTROBAN ointment
BID, start DIGOXIN (lanoxin) 0.25mg ½ tab OD
 On July 7 the Doctor ordered to continue the meds at the
same dose, ordered some procedure like CBC, CREATININE,
NA+, RBS, K+, TP, A/G now, strict aspiration, precaution
please, strict turning sched, include 3 eggwhites in patient diet,
and to D/C FLURORIMIDE, BUMETAMIDE (blurirex) 1mg tab 1tab
BID, chest pain: PO of Dra. G Reyes to NOD that the patient
amy give ISODRIL 5mg / 1tab now, repeat ECG, once with chest
pain, give high Biologic Value, protein in diet

 On July 9 Dra. Guinto ordered the same IVF to follow D5W

KVO, to continue meds with the same dose, advice NGT
insertion for Tube feedings,
 On July 10 at 1am VO by Dra. Guinto to NOD same IVF to
follow D5W KVO, refer to Dr. Gerard Salazar for Neuroconsult
and NGT, insert NGT, tube start of 1000 KCAL/day with egg
whites / high biologic value protein devided into 6 equal
feedings, on the same date the Dr. ordered to continue meds/
NGT incorporate ZUCOVIAMINE S2 to present IVF, CONSUME
CIPROBAX XR, pullout NGT and refuse insertion, continue diet
and meds per orem

 On July 11 Strict turning scheds, exposed pressure sore all

the time, and to continue meds,

 On July 12 Dra. Canella Important cinsider new cerebral

infarction on the L MCA disturbation have been precepatated
by her current infection, suggest do Cranial CT SCAN, plainm
tom am, zynapse 1g / IV q 8, observe strict aspiration prec.
When feeding, hold IBERET ACTIVE AND SERC, start
Erythropoietin (RENOGEN) 4,000 “U” SQ, 2x/week, IVF to
follow PNSS,1L + MOVIAMIN S2 KVO, carry out, suggestion of
Dr. Salazar.
 On July 13 the Doctor ordered to continue monitoring RBS ,
same dose & frequency, relay CT SCAN result to DR. Salazar,
spot O2 check, CBC serum Creatinine, NA+, K+ in am cranial CT
SCAN noted, old THALAMI INFARCT R, NEW CORONA RADEATH
INFARCT L (PEREVENTICULAR)., The Doctor also ordered to
elevate head to 30 degrees and to continue zynapse;
clopodogrel

 On July 14 , the Doctor suggest kalium DUROL TID,

 11:30 V.O by Dra. Reyes to NOD same IV fluids to follow plain

NSS 1L=MS2 x KVO.

 On July 15 the doctor ordered to continue meds and IVF, spot

O2 check

 On July 16 the doctor ordered to continue meds and IVF and

possible Discharge once ok with Dr. Salazar.
NURSING
CARE PLAN
DRUG STUDY
 LABORATORY
INTERPRETATION
LABORATORY TEST RESULT NORMAL RANGE INTERPRETATION

Crea 0.5-1.5 mg/dL HIGHER: impaired renal

function, dehydration,
July 2 – 1.1
cancer, heart failure, shock

July 5 – .8 LOWER : decreased mucous

muscle mss (e.g., myasthenia
gravis, muscular dystrophy),
debilation
K+ 3.5-5.0 mEq/L HIGHER: acidosis, daibetic
July 1 - 4.8 ketoacidosis,
hypoaldestrionsm, assive
July 4 - 3.7 crshing tissue disfunction,
rnal failure use of
July 5 - 2.9 pottasiumsparring diuretics.

LOWER: alkalosis,
cushing’s syndrome,
diarrhea (severe) diuretic
therapy, GI fistula, pyloric
obstruction, starvation,
vomiting, alcoholism, burns.
LABORATORY INTERPRETATION
LABORATORY RESULT NORMAL RANGE INTERPRETATION
TEST
Na+ July 1 – 124 136-145 mEq/L HIGHER: Cushing’s syndrome,
dehydration, diabetis, incipidus,
July 2 – 129 excessice IV sodium, insufficient
water intake, impaired renal
July 3 – 132 fucntion
LOWER: severe burns, addison’s
July 4 – 133 disease, diabetic ketoacidosis,
diuretic therapy, excessive
July 5 – 139 gastrointestinal tract loss, water
intoxication.
Hematocrit July 1 - .29 M: 42 – 52 vol. % Higher: dehydration, eclampsia,
high altitudes, polycythemia,
July 4 - 0.30 F: 37 – 47 vol. % congenital heart disease, burns.
July 5 - .31 LOWER:anemia, bone mwrrow
dysfunction, cirrhosis,
hemorrhage hemolytic reactions,
leukemia.
 LABORATORY INTERPRETATION
LABORATORY RESULT NORMAL RANGE INTERPRETATION
TEST

HgB July 1 - 9.7 M- 14-18.0 g/dL HIGHER:Chronic obstructive

F- 12.0-16.0 pulmonary disease (COPD),
July 4 - 10.4 g/dL heart failure, hemoconcentration,
high altitudes, polycythemia.
July 5 - 10.30
LOWER:hemolytic reactions,
hemorrhage, iron deficiency
anemia, renal disease, sickle cell
disease, synthemic dupuss
erythematozus.

WBC July 1 - 8.95 5-10,000/ uL Higher:inflammatory and

infectious process, leukemia,
July 4 - 10.5 tissue necrosis.
July 5 - 7.01
LOWER: bone marrow failure,
chemotherapy, drug toxicity,
overwhelming infection,
autoimmune disease
 LABORATORY INTERPRETATION

LABORATORY RESULT NORMAL RANGE INTERPRETATION

TEST

Segments July 1 - 0.60 50-65% HIGHER: Cushing’s syndrome,

eclampsia, gout, inflammatory
July 4 - .72 disease, ketoacidoses, myelocytic,
leukemia, stress acute infection.
July 5 - 0.84
LOWER: addison’s disease,
aplastic anemia, overwhelming
infection, radiation therapy.
Lymphocyte July 1 - 0.40 20%-40% HIGHER: chronic infections,
hepatitis, lymphocytic
July 4 - 0.28 leukemia, mononucleosis,
multiple myeloma, viral
July 5 - 0.16 infections.
 LABORATORY INTERPRETATION
CT Scan Impression:
 Old Thalamic Infarct Right

 Generalized Athropy

Cardiac Evaluation Interpretation:

 Eccentric left ventricle with hypokinesia of all
left ventricular segments except for the
posterobasal and basal lateral left ventricular
free wall.
 There is Doppler evidence of reduced systolic
and diastolic compliance.
 Normal right ventricular dimension with
adequate wall motion and contractility.
 Dilated left atrial dimension.
 Thickened mitral valve leaflets and chordae with low flow
configuration; mitral annular calcification.
 Calcified aortic cusps with slight restriction of motion; aortic
annular calcification.
 Structurally normal tricuspid valve and pulmonic valve with
good opening and closing motion.
 Normal main pulmonary artery and aortic root dimension.
 Calcified antero-postero aortic wall.

Chest X-ray Roentgenological Report

Impression:
 Atheromatous aortic knob.
DISCHARGE PLAN

 Make sure the pt. and

family have information on
referrals for follow-up
counseling.
 Determine evaluation needs
to be made before the pt. is
discharged or leaves the
agency .
 Determine the appropriate
quantities of the prescribed
medications to lend home
with the pt.
HEALTH TEACHINGS
Inform the patient the importance of follow-up
appointments
 Promotion of health from illness.
 Healing process from treatment.

Encourage communication of patient

 Assess the motional state of the patient, self-esteem,
confirming or justifying any fears patient may have
concerning recurrences of cancer.
 Have patient talk about activities they enjoyed before
treatment.
 Explain they are getting their life back while adapting
to reality of having cancer and possibilities of
recurrences.
 Encourage patient to perform range of motion exercise
in the affected parts as frequently as the patient’s
condition warrants limit.
OUT PATIENT DISCHARGE
 Follow-up check-up in the out-
patient department.

Diet
 High fiber, low-fat, low salt, and low
sugar diet.
Thank
You!!!!