UNIVERSITY OF THE EAST

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

#64 Barangay Doña Imelda Aurora Boulevard Quezon City 1113
Telephone No. 713-33-09 ; 715-08-61 local 289

COLLEGE OF NURSING

MEDICAL SURGICAL NURSING CASE #1

NCM 112

Submitted by:

RLE Group 7

BONIFACIO, Angel Kaye S.

EMBILE, Aleeyah Jasmine U.
GUIYAB, Lyka Alexandra Marie B.
LAUTCHANG, Anne Beatrice P.
MAGSINO, Samantha Nicole Y.
OYOS, Nicole Rose G.
PEÑAROYO, Mary Aldraine D.
RICAFORTE, Angelica T.

August 31, 2021

SCENARIO:

A female patient (aged 27 years) was admitted to the hospital, presenting with poor wound
healing on the left toe with a measurement of 5x10cm. Upon assessment, the nurse noticed
edema of both legs with a grade of 3 and loss of sensation of the left foot. Physician ordered for a
Random Blood Sugar test (RBS)

By the middle of the month the patient was readmitted with a worsening state. The clinical
admission diagnosis was Diabetes Mellitus.

On day 2 after the second admission, the physician suggested articulation of the left toe.

Insulin injection (Humulin-R) was ordered.

After a further few days of surgical operation, the patient presented a phantom limb pain.

After 2 weeks , the patient was capable of gross movements of both legs and left arm the patient
was discharged.

Introduction:
● Types
The types of diabetes mellitus may differ in cause, clinical course, and treatment.
○ Type 1 diabetes
■ It is previously referred to as insulin-dependent diabetes mellitus
■ It is characterized by the destruction of pancreatic beta cells, which are the
cells that make insulin for the body.
■ The glucose of the body does not move into the cells due to the lack of
insulin; instead, the glucose builds up in the blood.

○ Type 2 diabetes
■ It is previously referred to as non-insulin dependent diabetes mellitus
■ The body’s cells are not able to efficiently respond to insulin. In later
stages, the body may have problems in producing enough insulin.
■ It can result in glucose buildup in the blood due to insulin resistance

○ Gestational diabetes mellitus (ADA, Expert Committee on the Diagnosis and

Classification of Diabetes Mellitus, 2003)
■ It is any degree of glucose intolerance with its onset during pregnancy.
■ This is a result of the secretion of placental hormones that causes insulin
resistance.
 ■ After delivery, the blood glucose of the patient returns to normal.
However, there is an increased risk of developing type 2 diabetes mellitus
later in life.

● Etiology
○ A major factor in the development of type 2 DM is cellular resistance to the effect
of insulin. This resistance is increased by obesity, inactivity, illnesses, medications
and increasing age. In obesity, insulin has a decreased ability to influence glucose
metabolism and uptake by the liver, skeletal muscles and adipose tissue

● Risk factor
○ Obesity- Fatty cells contribute to Diabetes Mellitus because fatty tissue
contributes to the resistance of cells to insulin.
○ Family History- Although there is no identified HLA linkage, the children of a
person with type 2 DM have a two to fourfold increased risk of developing type 2
DM and a 30% risk of developing a glucose intolerance (the inability to
metabolize carbohydrate normally)
○ Inactivity
○ Age- Type 2 DM can occur at any age but it is usually seen in middle age and
older people.
○ Race or ethnicity
○ In women, a history of gestational DM, polycystic ovary syndrome, or delivering
a baby weighing more than 9 lb.
○ Metabolic syndrome, a cluster of manifestations associated with type 2 DM.
Hypertension, visceral obesity, low levels of high-density lipoproteins, high levels
of triglycerides, elevated C-reactive protein, and a fasting blood glucose greater
than 110 mg/dL increases the risk of DM, coronary heart disease, and stroke
(Porth & Matfin, 2009).

● Sign and symptoms

○ Polydipsia
○ Polyuria
○ Fatigue/ Body malaise
○ Blurred vision
○ Glycosuria
○ Pruritus
○ Mood changes
○ Acanthosis nigricans
○ Hyperglycemia
○ Polyphagia
 ○ Weight loss despite increased food intake
○ Paraesthesia

● Diagnosis
○ HbA1C of 6.5% or higher
○ Fasting plasma glucose: ≥125 mg/dL (≥7.0 mmol/L)
○ Two-hour plasma glucose level ≥200 mg/dL (≥11.1 mmol/L) during an OGTT,
using a glucose load of 75 g
○ Random plasma glucose greater than or equal to 200 mg/dL (≥11.1 mmol/L)
○ Urine testing - for presence of ketones and glucose

● Treatment and management

○ Self-monitoring of blood glucose (SBMG)
■ Allows the patient to make decisions regarding their food intake, activity
pattern, and medication dosages. It also alerts the patient on acute episodes
of hyperglycemia or hypoglycemia.
○ Nutritional therapy
■ Individualized meal planning is important to maintain blood glucose levels
to prevent or slower down the risk of the development of chronic
complications of diabetes.
■ Reduction of saturated and trans fats, and low carbohydrates.
■ Nutrition concentrating on no excess weight gain and balanced intake of
carbohydrates, protein, and fat.
○ Regular exercise
■ It increases the uptake of glucose by muscle cells, potentially reducing the
need for insulin

● Medications
○ Insulin
■ Works by controlling the patient’s blood sugar level and allowing storage
of excess glucose.
■ Insulin is not a cure for diabetes; rather, it is a means of controlling
hyperglycemia.
■ The five types of insulin are:
● Rapid-acting insulins
● Regular or short-acting insulins
● Intermediate-acting insulins
● Long-acting insulins
● Premixed insulins
 ○ Oral hypoglycemic agents
■ Biguanide (Metformin)
● first-line treatment for type 2 diabetes
● works by preventing the production of glucose in the liver,
improving the body’s sensitivity towards insulin and reducing the
amount of sugar absorbed by the intestines.

Guide questions:
1. Identify the subjective and objective cases

Subjective Objective

● Female ● Poor wound healing on the left toe

● 27 years old with a measurement of 5x10cm
● Phantom limb pain ● Grade 3 edema of both legs
● Loss of sensation of the left foot
● Patient articulation of left toe

2. Based on the scenario identify the priority nursing diagnosis and state its rationale

Nursing Diagnosis Level of Rationale

Prioritization

Ineffective peripheral High Ineffective peripheral tissue perfusion is the decrease in

tissue perfusion the blood circulation in the periphery.
related to excessive
fluid accumulation in Complications of Diabetes Mellitus involve a myriad of
the tissue as comorbidities including the serious complications of
evidenced by grade 3 poor wound healing, chronic ulceration, and resultant
pedal edema, loss of limb amputation.
sensation, and poor
wound healing ​In Diabetes Mellitus, the body doesn’t use insulin
properly, high levels of glucose can accumulate in the
bloodstream. The damaged blood vessels can result in
poor blood circulation. When the blood doesn’t circulate
properly, fluid gets trapped in certain parts of the body,
such as the legs, ankles, and feet. This accumulation of
fluid is called edema.

Diabetes patients often have circulation issues, which

can cause wounds to heal slowly or not at all. Due to the

Acute pain related to High
severed neural
connections as
evidenced by
presenting a phantom
limb pain.
Unstable blood High
glucose related to
cellular resistance to
the effect of insulin
as evidenced by
grade 3 pedal edema,
loss of sensation, and
poor wound healing
tendency to slow healing, swelling can also occur after a
foot or ankle injury.
Over time, high blood sugar can damage the nerves in
your lower extremities and other parts of your body
which causes numbness.
Acute pain is an unpleasant sensory and emotional
experience that occurs from an actual or potential tissue
damage. Since the patient had undergone an articulation
of his left toe, phantom limb pain can be felt in the area.
The nerve endings at the side of the articulation are still
active and continue to send pain signals to the brain even
if the body part is not present.
This may cause discomfort and discomposure to the
patient, and may affect her day to day activities. This is a
high level of prioritization; measures can be done for the
pain to be managed or tolerated according to the
patient’s preference.
Type 2 Diabetes Mellitus is a type of endocrine disorder
in which the body’s cells do not respond to the produced
insulin. Cellular resistance to the effect of insulin is a
major factor in the development of type 2 DM.
Resistance to insulin results in decreased glucose
utilisation which results in hyperglycemia. Without the
effect of insulin, the organs can't make good use of the
sugar in the blood, so the sugar builds up.
Hypoglycemia commonly occurs in people who use
insulin or take certain tablets to reduce high blood sugar.
It results primarily from a mismatch between insulin
intake (e.g. an error in insulin dose), physical activity
and carbohydrate availability (e.g. omitting a meal).
When there is an unstable blood glucose, if it has been
too high for a long time, alterations in the
microcirculation in the person with diabetes results in
the capillary membrane to thicken, eventually resulting
in decreased tissue perfusion. Poor circulation then
contributes to loss of sensation and slows down the
healing process of the wound.
 3. What plan or goal would be appropriate for the client?
4. Identify the 10 independent, 3 dependent, 5 collaborative nx intervention
5. Formulate your evaluation for the client’s care

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Unstable blood Short term: Independent Short-term:

● Female glucose related to After 1 hour of Monitor vital signs of the For baseline data and for early GOAL MET.
● 27 years old cellular nursing patient regularly and signs treatment if complications occur. After 1 hour of
● Phantom resistance to the intervention, the of hypoglycemia DM patients who uses insulin as nursing
limb pain effect of insulin patient will be able part of his/her treatment plan is at intervention, the
as evidenced by to acknowledge high risk for hypoglycemia patient was able to
Objective: grade 3 pedal factors that may demonstrate
● Poor wound edema, loss of lead to unstable Perform blood glucose Blood glucose level must be at glucose monitoring
healing on sensation, and glucose through testing before meals and at around 140-180 mg/dL properly and
the left toe poor wound verbalization of bedtime verbalize the
with a healing understanding of importance of
measurement body and energy Position the patient’s leg To help extra fluid to move back compliance to
of 5x10cm needs and slightly above the heart. towards the heart for circulation health/treatment
● Grade 3 importance of Place a trochanter or soft to the rest of the body. regimen.
edema of compliance to pillow underneath the
both legs health/treatment patient’s legs.
● Loss of regimen. Long-term:
sensation of Review the client’s common Multiple factors can play a role at GOAL MET.
the left foot Long term: situations that could any time, such as missing meals, After 2 days of
● Patient After 2 days of contribute to glucose or infection or other illness nursing intervention
articulation nursing instability on daily, the patient was able
of left toe intervention, the occasional, or crisis bases. to maintain lowered
patient will be able blood glucose level
to achieve and Educate the patient on how To continuously monitor blood and has
maintain glucose to perform self-monitoring glucose levels and ensure that it demonstrated
level within a of blood glucose
satisfactory range.
Educate the patient about
the importance of balanced
exercise and food intake,
antidiabetic agents, and
energy expenditure.
Identify food preferences,
including ethnic and cultural client’s food preferences into the
needs.
Assess the patient's weight
daily
Educate the patient about
the proper ways of taking
prescribed medications.
Identify the client’s support
person that may also need
information about the
planned diabetes regimen.
Dependent
Administer Insulin as
prescribed by the physician
is within normal range efficacy in
management of
To understand the relationship of diabetes mellitus
proper exercise that helps to through proper
balance the glucose levels by health practices.
facilitating uptake of glucose into
cells, and food intake.
Incorporating as many of the
meal plan as possible increases
cooperation with dietary
guidelines after discharge.
Assesses adequacy of nutritional
intake— both absorption and
utilization
DM patient needs to learn about
taking insulin or oral
hypoglycemic drugs to lower
blood glucose
Client’s support persons like
parents, spouse and caregivers
also need to be provided with
right information as they also
take part in the client’s treatment.
To maintain the blood glucose of
the patient within normal range
and slow down the progression
of microvascular disease
Administer glucose
solutions (5% dextrose and
half- normal saline) as
prescribed by the physician
Administer antidiabetic
medications as prescribed
by the physician
Collaborative
Refer to a registered
dietitian for an
individualized diet
restriction
Refer patient to exercise
physiologist or physical
therapist
Glucose solutions may be added
after insulin and fluids have
brought the blood glucose to
approximately 180 mg/dL. As
carbohydrate metabolism
approaches normal, care must be
taken to avoid hypoglycemia.
Antidiabetic medications are
medications that aims to achieve
normoglycemia and to stabilize
and control blood glucose levels
Antidiabetic medications relieve
symptoms of diabetes such as
thirst, excessive urination, and
ketoacidosis. It also prevents the
development of or slow the
progression of long-term
complications of the disease
Modifications in patient’s food
intake will contribute in
stabilizing blood glucose levels
Being active helps in the body’s
sensitivity to insulin. Physical
activity helps control blood sugar
levels. Specific exercises can be
 prescribed to the patient, based
on her limitations and lifestyle
practices.

Refer to counselling Lifestyle counselling provides

encouragement and
empowerment to patients with
diabetes mellitus. Further
self-management is achieved
through information on how to
manage their disease.

Monitor laboratory test To ensure that the values are in

results (Urinalysis, FBG, normal range and provide early
OGTT) treatment

Refer to support groups To reduce stress and anxiety, and

to be able to improve skills in
coping with the challenges
brought about by the disease
6. Based on nursing assessment, the patient experiences phantom limb pain after
surgical operation. What is phantom limb pain?
Phantom Limb Pain is a state wherein the patient experiences pain on the area that
had been amputated. Although the area or limb is amputated the nerve endings of the site
of amputation continuously send signals to the brain that make the brain think that the
limb is still there. Phantom Pain results from a mix up in nervous system signals
specifically between the brain and spinal cord. This kind of pain is typically mild but
sometimes patient may feel a stronger pain that came from the amputated limb. It
typically feels like burning, cramping or shooting.

7. List down measures in maintaining skin integrity of the patient with edema
● Elevate edematous extremities, and handle with care.
● Observe for reddened, blanched, and excoriated areas.
● Monitor for proper placement of tubes, catheters, and other devices. Assess skin
and tissue affected by the tape that secures these devices.
● Encourage and instruct in frequent position changes in bed and chair. Assist with
active or passive range of motion (ROM) exercises
● Provide and instruct in good skin care (example: shower instead of bath, washing
areas thoroughly using mild soap, drying gently and lubricating with lotion or
emollient).
● Check the fit of shoes or slippers and change as needed.
 BIBLIOGRAPHY

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