CASE STUDY ON-

Diabetes Mellitus

Submitted To - Submitted By -
Ms Anju Kamini
Nursing Lecturer Msc 1st yr
PIPRAMS PIPRAMS

Submitted on-
4 /March/2021

HISTORY COLLECTION:

I. Bio data:
 Name: Ravindra kumar
 Age: 45 year
 Gender: male
  Marital Status: Married
 Religion: Hindu
 Occupation: business
 Income: 35000 per month
 Address: Dalanwala
 Bed number: 103
 Ward number: 5
 Date of Admission: 3 march 2021
 Diagnosis/ Provisional Diagnosis: Diabetes Mellitus
 Name of the consultant: Dr. Bhupendra Bhati

II. Chief Complaints/ Presenting Complaints:

 Mr. Ravindra kumar was admit on 3rd march 2021 at 9 pm with the chief complaints of
fatigue, headache, poor appetite and giddiness after all the examination dr. diagnosed that
the patient had diabetes mellitus.

III. History of Illness:

 History of present illness: onset
 History of past illness: there is no history of any disease condition like tuberculosis,
asthma etc.

IV. Family History:

Relation
Sl Name of the family Health
Age Sex Education with
no members status
patient
1 Mr. Ravindra kumar 45 M Graduate patient unhealthy
2 Ms. Reena kapoor 42 F 12th wife healthy
3 Akash 14 M 10 son healthy
4 Arnav 11 M 6 son healthy
5 Pooja 6 F 2 daughter healthy

 Family tree.

IV. Socio-economic Status:

 Monthly income is 35000 rupees.
 Assets
 Own house [√] [√/x]
 Four wheelers [×] [√/x]
 Two wheelers [√] [√/x]
 TV [√] [√/x]
  Refrigerator [√] [√/x]

V. Environmental Status:
 Type of house: Pakka
 Lighting and ventilation of house: Good
 Water source and it's sanitation: Good
 Drainage system: Open
 Presence of vectors such as flies, mosquitoes etc. Yes
 Waste disposal system including toilet facility: Good

VI. Personal History:

 Personal appearance and physique: Good
 Nutritional status: Good
 Hygiene: Good
 Mental status: Good
 Habits and hobbies: Mr. Ravindra kumar’s love to play cricket.

PHYSICAL ASSESSMENT:

I. General Conditions:
 Appearance : Good
 Sensorium : Good
 Cooperativeness : Good
 Gait and posture : Good
 Height and weight : 164 cm

II. Vital Signs:

SL
VITALS PATIENT VALUE NORMAL VALUE REMARK
NO
1 Temperature 99 F 98.6 F abnormal
2 Pulse 82 beats/ min 60 to 80 abnormal
3 Respiration 22/ min 16 to 20 abnormal
4 Blood Pressure 140/90mmofHg 120/80 mmHg abnormal

III. HEAD TO TOE ASSESSMENT:

 Head:
 Color the hair:- black
 Scalp:- clear
 Skull:- normal
  Face:
 Skin for any scars:- no
 Injuries:- no

 Eyes:
 Check visual acuity and screen the visual fields:- good
 Note position and alignment of the eyes;- good
 Observe the eyelids:- present
 Check any abnormal secretions, infections etc.:- NIL

 Ears:
 There is no discharge and infection in ear
 Auditory acuity:- good

 Nose and Sinuses:

 There is no discharges, abnormal growth, and infection etc.

 Mouth and Pharynx:

 Lips:- dry
 Teeth:- white
 Tongue:-clean
 Palate :- no
 Tonsils:- no
 Sense of Gustation (taste):- present

 Neck:
 There are no masses or unusual pulsations in the neck.
 Range of motion of the neck is good

 TRUNK: CHEST, ABDOMEN AND BACK

 Back:
 Back is normal and there is no problem in spine.
 Axillae:
 Axillary nodes absent

Chest
 Shape of the chest: Normal

Abdomen.
 Inspection
 Shape:- normal
 Scars:- no
 Masses :- no
  Palpation
 Abdomen softness:- good
 organ enlargement:- no
 Abnormal masses:- no
 Bulges or swelling:- no

 Auscultation
 Bowel sounds:- good

EXTREMITIES: UPPER AND LOWER EXTREMITIES

 Skin and nails :- healthy
 Pulses: present
 Joint mobility: good
 Movement of lower extremities:- good

V. Investigations
SL PATIENT NORMAL
DATE INVESTIGATION REMARK
NO VALUE VALUE

1 3/3/2021 Hb A1C 6.7% UPTO 5.7%

2 3/3/2021 Blood sugar(fasting) 150 100 to 125 increase

OGTT (oral glucose

3 3/3/2021 159 mg/dl 140 mg/dl increase
tolerance test)

120 to 145
4 3/3/2021 Blood sugar random 200 mg/dl Increase
mg/dl
VI. Treatment:

SL NAME OF THE FREQUEN SIDE

DOSE ROUTE ACTION
NO DRUG Y EFFECT
Improve
blood sugar
Diarrhea,
control by
nausea,
improving
1 Metformin 500 mg oral vomiting,
sensitivity
lactic
OD of your
acidosis
body tissue
to insulin
2 Amryl 1 mg Oral Help your Difficulty in
body to swallowing,
secrete more dizziness,
 OD itching, skin
rash,
puffiness or
insulin
swelling
around the
eyes
Anxiety,
Help to chills,
reduce dizziness,
3 Sitagliptin 25 mg Oral
OD blood sugar depression,
level headache,diar
rhoea
Its lowering Hypoglycemi
level of a, headache,
4 Insulin R 10 unit Sc
Tds glucose in hunger,
the blood dizziness

VII. Description of disease and Comparison with Client picture.

 Definition:- Diabetes mellitus refers as “Diabetes” A chronic disease associated with
sugar glucose level in blood. It is two types 1. Insulin dependent diabetes mellitus 2. Non
insulin diabetes mellitus.

Related Anatomy and Physiology: - every cell in the human body needs energy in order
to function. The body’s primary source of energy is glucose, a simple sugar resulting
from the digestion of foods containing carbohydrates. Glucose from the digested food
circulates in the blood as a ready energy source for any cell that needs it. Insulin bond to
a receptor site on the outside of the cell through which glucose can enter. Some of the
glucose can be converted into concentrated energy sources like glycogen or fatty acids
and saved for later use. When there is no enough insulin produced or when the doorway
no longer recognizes the insulin, the insulin stays in the blood rather entering the cell.
Epidemiology related to Client E
Risk factors and Etiology

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

Obesity present Obesity present

Bad diet intake Living a sedentary life style
Poor life style Increasing age
Cushing syndrome

Clinical features

IN CLIENT BOOK REVIEW INTERPRETATIONS

Nausea Blurred vision

 Nausea, vomiting
Abdominal pain
Vomiting
Lethargy
Lethargy
Polyphegia
Weight loss
Polyuria
Polyphegia
Weight loss
Polyuria
Hyperventilation
Abdominal pain
Glycouria
Breath- smell of acitone

Diagnostic Evaluations with interpretation

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

Random blood sugar Random blood sugar done

Blood sugar fasting Blood sugar fasting done
HbA1C HbA1C done
OGTT OGTT done

Complications:

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

Glaucoma
Neuropathy ulcer
Ulcers
Skin infection
Hypertension
Ischemic heart disease
Depression
Hypertension
Skin infection
Hearing loss
Gum disease
Kidney failure

Management:

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

Tab. Metformin Tab. Metformin

Tab. Amryl Tab. Amryl
Tab. Novalog
 Tab. sitagliptin
Inj. Insulin R
Inj. Apidra

Nursing
management

 Assess the
general
condition of Disease process and treatment
patient options
 Assess the
vital signs of Nutritional management
the patient
 Maintain skin Incorporating physical activity
integrity of into lifestyle
patient to
prevent ulcer. Using medication safely
 Provide
comfortable Monitoring blood glucose
position and
and calm Comfortable position
environment
 Maintain Maintain skin integrity
personal
hygiene Administer medicine as per
 Nutritional doctors order
management
should be
maintain
especially give
low sugar diet
 Monitor blood
glucose level
periodically
 Administer
medicine as
prescribed by
doctor

Nursing diagnosis:
1. Risk for unstable blood glucose level related to hyperglycemia as evidenced by
patient’s observation and examination.
2. Risk for fluid volume deficit related to hyper metabolic stage like fever and
dehydration as evidenced by patient’s examination
 3. Acute abdominal pain related to disease condition as evidenced by physical
examination and patient’s facial expression.
4. Disturbed sleeping pattern related to anxiety as evidenced by observation and
patient’s verbalization.
5. Knowledge deficit related to disease condition and treatment options.

Nursing Care Plan:

NURSING
SL IMPLIMETATI
ASSESSMENT DIAGNOSI GOALS PLANNING EVALUATION
NO ON
S
 Assess the
general
condition of
the patient

Administer
iv fluids and
medicine to
the patient
Assessed the
Maintain general condition
input output of the patient
chart
Subjective data:
Administered iv
patient says that Provide calm fluids and
he is felling very Risk for environment medicine to the
Reduce
week and having unstable
the patient
drowsiness blood Monitor the Patient’s
patient
glucose condition
1 symptom vital signs of Maintained input
Objective data: level related improved to
s within the patient output chart
patient is having to some extend
minimum
drowsiness and hyperglyce
hour Provided calm
vitals are not mia
environment
appropriate
Monitored the
vital signs of the
patient
 Assess the
general
condition of
the patient

Provide
comfortable
position

Provide low
cholesterol
diet

Administer
antispasmodi
c drugs

Assessed the
general condition
Subjective data:
of the patient
patient says that
he is having
Provided
abdominal pain Acute
Reduce comfortable Patient
since 4-5 days abdominal
the position abdominal pain
2 pain related
severity reduced to some
Objective data: to disease
of pain Provided low extend
patient having condition
cholesterol diet
pain as and
evidenced by
Administered
facial expression
antispasmodic
drugs
 Assess the
general
condition of
patient

Provide
comfort and
noise free
environment

Advice
patient to do
physical
exercise

Administer
medicine as
Assessed the
per doctor
general condition
order
Subjective data: of patient
patient says that
he cannot sleep Provided comfort
at night and day Disturbed and noise free
as well sleeping Improve environment Patient sleeping
3 pattern patient pattern improved
Objective data: related to sleep Advised patient to to some extend
patient is having anxiety do physical
sunken eyes with exercise
darkness under
the eyes Administered
medicine as per
doctor order
 Assess the
general
condition of
patient

Provide
psychologica
l support to
the patent

Provide
health
education to
the patient
Assessed the
Teach patient
general condition
about the
of patient
disease
Subjective data: condition
Provided
patient says he is Fear and
psychological
having doubt confusion
support to the
regarding related to Clear the
patent Patient looks in
4 disease condition hospitalizati doubt of
confident
on and patient
Provided health
Objective data: disease
education to the
patient looks condition
patient
confused
Taught patient
about the disease
condition
 Health Education:
1. Advice patient to take proper rest
2. Ask patient to take sugar free diet
3. Ask patient to do checkup their sugar as regular bases
4. Advice patient to maintain personal hygiene
5. Advice patient to do physical exercise
6. Advice patient to take medicine on time
7. Provide psychological support to the patient and their family members

CONCLUSION
Diabetic patient Ravindra have concern about all of their problems and managing well. He is
very conscious about the disease condition and taking all required precaution. He is very perfect
on his diet and medicine. He got the discharged from the hospital with knowledge and
confidence which will helpful in his health progress.

BIBLIOGRAPHY
BRUNNER’S & SUDDHARTH; Text book of medical surgical nursing; Edition 12 th, Published
by lippencott Williams & wilkins
Page no- 823-829, 961-962
Websites: www.wikipedia.com
www. Web Md.com