CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

Assessment is the step in the nursing process which involves the collection of data systematically

from the patient concerning the health status of the patient and family in recorded form that

accessible. The data collected could be subjective and objective. The method used in the collection

of the data includes: observation made on the patient and interview of patient and relatives. Also

review of patient’s records served as a data base upon which other steps of the nursing process are

built. It helps in the identification of patient’s problems and strengths which enables the in the nurse

to plan a comprehensive nursing care for the patient and the family.

PATIENT PARTICULARS

Mr.R.B.K is a 31year old man born to Mr. Kweku Mensah Brew and Mrs.Awotwe Araba at

Effiakuma in the Western Region of Ghana. Mr.R.B.K comes from Anombo in the Central Region

of Ghana and resides at Effiakuma New Site with some family members. Mr.R.B.K speaks Fante,

English and Twi. He is dark in complexion, weighs 65 kilograms and is 4.5 feet tall. He is not

married and has no child. Mr.R.B.K is a Christian and worships with the Roman Catholic Church.

He is self-employed. He sells provisions. According to him his next of kin is his brother Mr. Kweku

Brew

PATIENT’S FAMILY MEDICAL AND SOCIAL-ECONOMIC HISTORY

Patient’s relative(Akua) stated that, the family has no known hereditary and chronic disease but Mr.

R.B.K’s mother suffered and died of hypertension. He also said that, they always seek medical help

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from a pharmacy when they suffer minor headaches, abdominal discomforts and common cold. Even

though the money he gets from his work is not enough he manages to take care of some of his

siblings. His elder brother also sends money to the family monthly,

PATIENT’S DEVELOPMENTAL HISTORY

Mr. R.B.K was born at Effiakuma in the Western Region of Ghana. He was delivered with the

assistance of a traditional birth attendance (TBA) According to his sister, he was later sent to the

hospital for immunization. MR. R.B.K said he had his basic education, primary and Junior

Secondary Education at Anomabo. He then continued at Fijai Secondary school and completed in

2001. He studied Business. After school, due to financial problems he ended up in petty trading. He

started to develop secondary characteristics like hair growing in the axilla and pubic area at age of

16.He also developed a broad chest and a deep voice. His sister said he started to walk when he 1

year and begun to talk at the age of 2.

PATIENT’S LIFESTYLE AND HOBBIES

MR. R.B.K said he wakes up around 5:00am, says his prayer before stepping out of bed. He then

brushes his teeth, take his bath and take breakfast around 8:00 with his family. Then he leaves home

to his shop. He takes lunch around 1:00pm. During the day he reads graphic. He takes his bath in the

evening and enjoys his super around 7:00pm. He plays some indoor games like draft with friends in

the afternoons. He goes to church on Sundays. His favorite food is rice and stew or kenkey with

pepper and tilapia. He dose exercises in the evening. He neither smokes nor takes in alcohol. He also

joins the liberty keep fit club.

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PAST PATIENT’ MEDICAL HISTORY

According to Mr. R.B.K, has a problem with his right ear which started about fifteen (15) year ago.

He said that cannot hear with the right ear, so in conversation with others, they have to increase the

tone of their voice before he could hear but sometimes he uses hearing aid. He also said that, this is

not the first time of being on admission. According to his sister, this is the 6th time her brother has

been on admission at Effia-Nkwanta Regional hospital since he was diagnosed with diabetes

mellitus 2 year ago. He said he follows the dietary management and takes his insulin to help him

control the increasing glucose level.

PRESENT MEDICAL HISTORY

Patient was well until the 5th of September, 2011 at 9:30pm when he fell down in front of his door

whiles going to take his bath. Hi sister called for help and was rushed to the casualty unit for the

Effia-Nkwanta Regional Hospital around 11:00pm. He twitched at the casualty unit. Random blood

sugar was checked and it was 36.0mmol. He was seen by Doctor Barnes who diagnosed him with

Diabetes Mellitus (Hyperglyceamia) and was admitted to the male medical ward because his

condition was worsening.

ADMISSION OF PATIENT

Patient was admitted through the casualty of ENRH by Dr. Barnes to the male ward (C) on the 5th

September, 2011 at 6:00am with the diagnosis of Diabetes mellitus (hyperglycaemia). A call was

received from the casualty unit that they were bringing a patient with the diagnosis of Diabetes

Mellitus (hyperglyceamia) for admission. An admission bed was prepared to receive of the patient.

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He arrived at the ward at 7:00am on a stretcher in a conscious state in the company of a nurse and

his relative. They were warmly welcomed at the nurse’s station. The patient was made comfortable

in bed. The folder of the patient was collected and patient was identified by mentioning the name

and the sister responding. The relatives complained of sudden collapse.

His vital sign were checked and recorded as

Temperature 36.2 degree Celsius (0c)

Pulse 64 per minute (cmp)

Blood pressure 150/120 millimeter of mercury (mmHg)

Respiration 30 cycles per minute

Random blood sugar 36.0mmol/L.

Other complains which were present are blurred vision, headache, excessive urination, constipation.

Laboratory investigations requested included.

Haemoglobin estimation.

White Blood Cell count

Blood film for malarial parasites

Serum creatinine, urea and electrolyte for sodium, potassium, chlorine.

Urine for routine examination.

Blood for fasting blood sugar.

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Sickling

Platelete count

The specimens were taken sent to the laboratory immediately. Admission papers were prepared and

they included the temperature chart, treatment sheet, nurses’ note, costing sheet and blood pressure

(BP) chart. Urgent medication including 10units of soluble insulin and 500mls of Normal saline was

set up to run fast. Relatives were oriented to the ward and its annexes. They were also shown the

patient’s bed and informed to bring necessary toiletries to ensure proper care of patient. They were

asked about the national health insurance and fortunately the patient was covered. They were told

that they might buy some drug since the insurance does not cover all the drugs. Ward protocols

including visiting time, dietary procedures and payment of bills were explained. His name was

entered into the admission and discharge book and admission Columm of the daily ward state.

The following medications were prescribed and collected from pharmacy as patient was insured by

the National health Insurance Scheme (NHIS)

 iv sodium chloride 1000mls daily for two days

 insulin

 tablets Daonil 5mg daily for ten days

 tablets met for min 500mg twice daily for 10 day

PATIENT’S CONCEPTS OF ILLNESS

Patient admitted that he has been with the condition for the past ten (10) years and that he knew the

consequences of not following his treatment regimen. Patient strongly believes that, there is a

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spiritual influence on his condition but he believes that with prayers and co-operation on his part, he

will be free from the condition.

LITERATURE REVIEW ON THE DISEASE DEFINITION

Diabetes is a disease which develops when glucose (sugar) builds up in the blood. High blood

glucose (hyperglycaemia) can damage the body and may cause one to feel sick.

When food is eaten, it is changed into simple sugar. The main simple sugar is glucose. Glucose is the

body’s main fuel for energy. Energy is needed to keep the body working properly and to perform

function such as walking, talking, thinking etc.

Normally after eating, glucose is used right away for energy. Glucose that is used right away is

moved into body tissues (liver, muscles) to be stored for later use.

DEFINITION OF DIABETES MELLITUS

This is a heterogeneous group of disorders of carbohydrates, fat and proteins metabolism

characterized by chronic hyperglycaemia, degenerative vascular changes and neuropathy.

TYPES OF DIABETES MELLITUS

There are several types of diabetes, Type 1, Typed 2, Gestational and diabetes mellitus associated

with other conditions.

THE TYPE 1 OR INSULIN DEPENDENT DIABETES MELLITUS

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In the type 1 diabetes, the insulin-producing pancreatic beta cells are destroyed by an autoimmune

process. As a result, patients little or no insulin and require insulin injections to control their blood

glucose levels. Type 1 diabetes affect approximately 5% to 10% of people with the disease. This is

characterized by an acute onset, usually before 30 years of age.

CAUSE OF TYPE 1 DIABETES MELLITUS

Type 1 diabetes mellitus can be causes by;

1. Autoimmune (Immunological)

2. Antibodies which destroy the beta cell

3. Some viruses can precipitate autoimmune action (environmental).

4. Genetic predisposition to the condition

5. People with human leuckocyte antigen are predisposed to get type 1 diabetes mellitus.

PATHOPHYSIOLOGY OF TYPE 1 DIABETES MELLITUS

This begins either destruction of the pancreas as the main causes. Regardless of the specific cause,

the destruction of the beta cells results in decreased insulin production, unchecked glucose

production by the lover and fasting hyperglycaemia.

In addition, glucose derived from food cannot be stored in the lover but instead remains in the blood

stream and contributes to postprandial (after meal) hyperglycemia. If the concentration of glucose in

the blood exceeds the renal threshold for glucose then appears in the urine (glucosuria).

When excess glucose is excreted in the urine, it I accompanied by excessive loss of fluids and

electrolytes. This is called osmotic dieresis.

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Because insulin normally inhibits glucogenolysis (breakdown of stored glucose) and

gluconeogenesis (production of new glucose from amino acids and other substrates), these processes

occur in an unrestrained fashion in people with insulin deficiency and contribute further to

hyperglycaemia. In addition, fat breakdown occurs, resulting in an increased production of ketone

bodies, which are the byproducts of fat breakdown.

THE TYPE 2 DIABETES MELLITUS

In type 2 diabetes, people have decreased sensitivity to insulin (called insulin resistance) and

unpaired beta cell functioning resulting in decreased insulin production. Type 2 diabetes affects

approximately 90% to 95% of people with the disease. It occurs more commonly among people who

are older than 30 years of age and obese, although its incidence is rapidly increasing in young people

because of the growing epidemic of obesity in children, adolescents, and young adults. Initially, type

2 diabetes is treated with diet and exercise. If elevated glucose levels persist, diet and exercise are

supplemented with oral and diabetic agents.

CAUSES OF TYPE 2 DIABETES MELLITUS

1. Obesity

2. Lack of exercise/sedentary work

3. Lack of insulin receptors which inhibits their binding action

4. Genetic factor

5. Age

6. Family history

7. Diet

8. Ethnic group

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PATHOPHYSIOLOGY OF TYPE 2 DIABETES MELLITUS

The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired

insulin secretion. Insulin resistance refers to decreased tissue sensitivity to insulin. Normally, insulin

binds to special receptors on cell surfaces and initiates a series of reaction involved in glucose

metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less

effective at stimulating glucose uptake by the tissues (muscle) and at regulating glucose release by

the liver.

The hyperglycaemia is as a result of impaired production of insulin. There is increased

glycogenolysis as well as absorption of glucose form the intestine and decrease glucose uptake

which leads to hyperglycaemia.

GESTATIONAL DIABETES MELLITUS

Gestational diabetes mellitus is any degree of glucose intolerance with its onset during pregnancy.

Hyperglycemia develops during pregnancy because of the secretion of placental hormones, which

causes insulin resistance. It normally occurs in the 2nd and 3rd trimesters of pregnancy. After delivery,

blood glucose levels in women with gestational diabetes mellitus usually return to normal. However,

any woman who has had gestational diabetes mellitus develops type 2 diabetes later in life.

Diabetes mellitus can be associated with other conditions, these include;

1. Disease of the pancreas

2. Some drugs like corticosteroids or oestrogen containing preparation

3. Those on hormonal therapy example family planning.

EPIDEMIOLOGY

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Diabetes is the leading cause of new blindness among 50-70 year old. There are approximately

2.5million people in the United Kingdom (UK) with diagnosed diabetes and approximately 600,000

people who remain undiagnosed (British Heart Foundation 2006).

AETOILOGY CAUSES OF DIABETES MELLITUS

The exact causes of diabetes mellitus are unknown but there are risk factors

Risk Factors for Diabetes Mellitus

1. Hereditary

2. Dysfunction of the pancreas

3. Sedentary lifestyle

4. Obesity

5. Tobacco use

6. Insulin deficiency

7. History of gestational diabetes or delivery of babies over 91b

8. Race/ethnicity e.g. African Americans

9. Hypertension (≥ 14000000/900mm/Hg)

10. Age ≥ 45 years

GENERAL PATHOPHYSIOLOGY

Insulin is secreted by beta cells, which are one of four types of cells in the islets of langerhans in the

pancreas. Insulin is an anabolic (the building up or synthesis of cell structures form digested food

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materials), or storage, hormone. When a person eats a meal, insulin secretion increases and moves

glucose from the blood into muscle, liver, and fat cells. In those cells, insulin;

1. Transports and metabolize glucose for energy

2. Stimulates storage of glucose in the liver and muscle (in the glycogen)

3. Signals the lover to stop the releases of glucose

4. Enhance storage of dietary fat in adipose tissue

5. Accelerates transport of amino acids (derived from dietary protein) into cells.

Insulin also inhibits the breakdown of stored glucose, protein, and fat.

During fasting periods (between meals and overnight) the pancreas continuously release a small

amount of insulin (basal insulin); another pancreatic hormone called glucagon (secreted by the alpha

cells of the islets of langerhans) is released when blood glucose levels decrease and stimulates the

liver to release stored glucose. The insulin and the glucagon together maintain a constant level of

glucose in the blood by stimulating the release of glucose from the liver. Initially, the liver produces

glucose through the breakdown of glycogen (glycogenolysis). After 8 to 12 hours without food, the

lover forms glucose from the breakdown of non carbohydrate substance, including amino acid

(glyconeogenesis).

CLINICAL MANIFESTATIONS

Clinical manifestations depend on the patient’s level of hypergluycaemia. Classic clinical

manifestations of all types of diabetes include the “three Ps”:

1. Polyuria (increased urination)

2. Polydipsia (increased thirst)

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3. Polyphagia (increased appetite)

4. Glucosuria

Other symptoms include;

1. Fatigue and weakness

2. Dizziness

3. Muscle wasting

4. Sudden vision changes

5. Tingling or numbness in hands or feet

6. Dry skin

7. Skin lesions or wounds that are slow to heal,

8. Recurrent infections

The onset of type 1 diabetes may also b e associated with sudden weight loss or nausea, vomiting or

abdominal pains if diabetic ketoacidosis has developed.

9. Blurred vision (if glucose levels are very high)

10. Vaginal infections

DIAGNOSTIC EVALUATIONS

This can be obtained from the following;

1. Blood tests – Blood sugar determination is made from a specimen of venous blood

following a period of four (4) to eight (8) hours of fasting. The tests included;

a.Fasting Blood Sugar (FBS). This usually done around 6am before the patient eats hence

“FASTING”. It levels range from 3.5mmol/L to 6.4mmol/L.

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b. Random Blood Sugar (RBS)y

It is taken any time when patient has already eaten and the normal level ranges from 5.6mmol/L to

10.1mmol/L.

This is done to know the ability of the patient to control excess sugar intake.

These are other routine investigations which include:

 Screening the urine for protein

 Urea and electrolyte

 Liver biochemistry and random lipids which are useful to exclude an associated

hyperlipidaemia

 Urinalysis for presences of glucose

OVERALL MANAGEMENT OF DIABETES MELLITUS

The main goal of diabetes treatment is to normalize insulin activity and blood glucose level to reduce

the deve4lopment of vascular and neuropathic complications. Therefore, the therapeutic goal for

diabetes management is to achieve normal blood glucose level (euglycaemia) without hypoglycemia

while maintaining high quality of life.

Diabetes management has five (5) components.

1. Nutritional therapy

2. Exercise

3. Monitoring

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4. Pharmacologic therapy

5. Education

NUTRITIONAL THERAPY

Nutrition, meal planning and weight control are the foundation of diabetes management. The most

important objective in the dietary and nutritional management of diabetes are controlled by total

caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and

normalization of lipids and blood pressure to prevent heart disease.

Nutritional management of diabetes includes the following goals;

1. Providing all the essential food constituents (e.g. vitamins, minerals) necessary for optional

nutrition.

2. Meeting energy needs

3. Achieving and maintaining a reasonable weight

4. Preventing wide daily fluctuations in blood glucose levels, with blood glucose levels as

close to normal as is safe practical to prevent or reduce the risk for complications.

5. Decreasing serum lipid levels, if elevated, to reduce the risk for macro vascular disease.

Diet is a major factor in the control of diabetes mellitus and is the first line of management in type 2

diabetes. The prescribed “diabetes diet” has been replaced by an individualized diet regimen with the

patient assuring responsibility for planning, implementation and adjusting the diet to the needs and

lifestyle.

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1. Complex rather than simple carbohydrates should be used to help stabilize blood sugar.

Meals should include more complex carbohydrate rich foods such as starches and fibers, and fewer

simple or refined sugars.

2. Less added fat, fewer fatty foods, and low-cholesterol items are recommended.

Polyunsaturated (vegetable) fat soluble be sued in place of saturated (manly animal) fats.

3. Limitations are placed on salt and general sodium use

4. The menu should be varied according to the patient’s ethnic and cultural background, life-

style, foods preferences, exercise, routine, and eating habits. The emphasis should be on what is

allowed rather than on what is forbidden. The meal plan should be adapted to the diabetic, not the

diabetic to the meal plan.

5. When insulin is taken, special consideration must be given to ensure adequate carbohydrate

intake to correspond to the time when insulin is most effective and less carbohydrate when insulin is

least effective.

6. Obese diabetics should be on a strict weight-control programme. Many will have normal

plasma glucose after the loss weight.

7. Routine blood glucose testing before each meal and at bed-time is necessary during initial

control, in unstable patients, and during illness. Well – controlled, stabilized patients may be

followed with fewer tests daily.

8. Intensive nutritional counseling by a professional diet counselor should be done initiating

and repeated several times with every patient.

EXERCISE

Exercise promotes the utilization of carbohydrates and enhances the action of insulin.

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1. Insulin – treated patients may develop hypoglycemia after exercise unless they take extra

carbohydrates beforehand.

2. Patients should be encouraged to exercise on a regular basis each day

3. Exercise in the diabetic with microangiopathy should be discussed with the physician

because of potential harmful effects

4. Diabetics with blood glucose levels over 25m/dl or who have ketones in their urine should

not begin exercising because elevated blood glucose levels will cause increased secretions of

glucagon, growth hormone and catecholamine, resulting in high blood glucose levels.

BENEFITS OF EXERCISE FOR PEOPLE WITH TYPE 1 DIABETES MELLITUS

1. It improves the action of insulin in the body

2. It reduces fats in the body

3. It lower high blood pressure

BENEFITS OF EXERCISE FOR PEOPLE WITH TYPE 2 DIABETES MELLITUS

1. It helps to reduce weight

2. It improves the action of insulin in the body

3. It improve blood glucose control

4. It reduces fats in the blood

5. It lowers high blood pressure

6. It decreases fat in the body

7. It builds muscle tissues

PRECAUTIONS FOR EXERCISE IN PEOPLE WITH DIABETES

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1. Use proper footwear and, it appropriate, other protective equipment

2. Avoid exercise in extreme heat or cold

3. Inspect feet daily after exercise

4. Avoid exercise during periods of poor metabolic control.

PHARMACOLOGIC THERAPY

As previously stated, insulin is secreted by the beta cells of the islets of Langerhans of glucose by

muscle at, and liver cells. In the absence of adequate insulin, pharmacologic therapy is essential.

There are two (2) man type of diabetes medicine. These are insulin injection and diabetes pills.

INSULIN THERAPY

GENERAL POINT

1. When the patient cannot produce an adequate amount of insulin, it is necessary to give it by

injection.

2. Insulin lowers the blood glucose level by decreasing the release of glucose from the liver

and increasing the utilization of glucose by muscle and fat cells.

3. One or more insulin injections each day is required for patients with insulin-dependent

diabetes.

4. Patients with non-insulin-dependent diabetes may require insulin during an cute illness,

infection, stress, surgery or pregnancy.

5. Obese patients can usually achieve normal blood glucose by calorie restriction and weight

loss.

All insulin types are injected. It is never to be swallowed

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18
TYPES OF INSULIN

Time Agent Onset Peak Duratio Indications

Course n

Rapid- Lispro 10 – 1 hour 2–4 Used for rapid reduction of

acting (Humalog) 15mi 40-50min hours glucose level, to treat
Aspart n 2–4 postprandial hyperglucaemia,
(Novolog) 5– hours and or to prevent nocturnal
15mm hypoglycemia.
Short-acting Regular ½-1 2 - 3 hour 4–6 Usually administered 20-30
(Humalog R, hour hours minutes before a meal; may be
Novolin R, taken alone or in combination
IIetin II with longer acting insulin.
Regular
Intermediate NPH (neural 2–4 4 – 12 Usually taken after food.
acting protamine hour hours
Hagedorn)
(Humulin N,
IIetin II 3–4 4 – 12
Lentin, IIetin hours hours
II NPH,
Novolin
(Lentel).
Novolin N
(NHJ)
Long-acting Ulteralente 6-8 12-16 hour 20-30 Used primarily to control
(“NHJ”) hours hours fasting glucose level
Mixtard
Nordisk
Very long- Glargine 1 Continuous 24 hours Used for basal dose.
acting (Lantus) hours (no peak)

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The four (4) main areas of injection are the abdomen, upper arms (position surface), thighs (anterior

surface), and hips. Insulin is absorbed faster in some areas of the body than other. The speed of

absorption is greatest in the abdomen and decrease progressively in the arm, thigh, and hip,

respectively.

Systematic rotation of injection site within an anatomic area recommended preventing localized

changes in fatty tissue.

DIABETES PILLS (HYPOGLYCAEMIC AGENTS)

These are pills taken by mouth to control blood glucose. They are effective only in people with types

2 debate. The three (3) types of pills commonly used are;

1. Daonil

2. Tolbutamide

3. Metformin

Daonil and Tolbutamide are best to be taken 30 minute before meals. They may increase appetite

and weight gain in certain people.

Metformin should be taken with meals. It reduces appetite and therefore helps to reduce weight. It

side effects in some people include nausea, diarrhea, and abdominal discomfort. They are less

serious if the pill is taken with food.

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COMPLICATIONS

Complication which may occur in diabetes mellitus can be divided in acute and chronic or long term.

ACUTE COMPLICATIONS

HYPOGLYCAEMIA

Hypooglycaemia (abnormally low blood glucose level) occurs when the blood glucose level falls to

less than 50 to 60mg/dl (1.7 to 3.3mmol/L)

CAUSES

Hypoglycaemia can be caused by

1. Too much insulin or oral hypoglycemia agent

2. Too little food

3. Excessive physical activity after administration of the drug

4. It often occurs before meals, especially if meals are delayed or snacks are omitted

5. Drinking alcohol without eating

CLINICAL MANIFESTATIONS

The clinical manifestations of hypoglycemia may be grouped into two categories adrenergic

symptoms and central nervous system (CNS) symptoms.

Adrenergic symptoms

1. Sweating 4. Palpitaiton

2. Tremor 5. Nerousnes

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3. Tachycardia 6. Hunger

Central Nervous System (CNS)

1. Inability to concentrate 8. Memory lapses

2. Headache 9. Numbness of lips and tongue

3. Lightheadedness 10. Slurred speech

4. Confusion 11. Emotional change

5. Impaired coordination 12. Double vision

6. Irrational or combative behavior

7. Drowsiness

In severe hypoglycemia, central nervous system function is impaired that the patient needs to the

assistance of another person for treatment hypoglycemia, symptoms many include;

1. Disoriented behavior

2. Difficulty arousing from sleep

3. Loss of consciousness

MANAGEMENT

Immediate treatment must be given when hypoglycemia occurs. The usual recommendation is for

15g of a fasting-acting concentrated source of carbohydrate such as the following, given orally

1. Three or four commercially prepared glucose tablets

2. 4 to 6oz of fruit juice or regular soda

3. 6 to 10 hard candies

4. 2 to 3 teaspoons of sugar or honey

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DIABETIC KETOACIDOSIS (DKA)

DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in available

insulin results in disorders in the metabolism of carbohydrate, protein and fat

CAUSE

1. Absence/inadequate amount of insulin

2. Error in drawing up insulin

3. Intentionally skipping treatment

4. Untreated diabetes/undiagnosed diabetes

5. Insufficient insulin prescription.

CLINICAL FEATURE

1. Hyperglycaemia

2. Dehydration and electrolyte loss

3. Acidosis

PATHOPHYSIOLOGY

Without insulin, the amount of glucose entering the cells is reduced, and production and release of

glucose by the lover is increased. Both factors lead to hyperglycaemia. In an attempt to rid the body

of the excess glucose, the kidneys excrete the glucose along with water and electrolytes (e.g. sodium,

potassium). This osmotic diverse, which is characterize by excessive urination (polyuria), leads to

dehydration and marked electrolyte loss. The dehydration and lead to increased thirst (polydipsia).

Dehydration can cause weakness and headache in the patient.

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Another effect of insulin deficiency or deficits is the breakdown of fat (lipolysis) into fatty acids and

glycerol. The free fatty acids are converted into ketone bodies by the lover. In DKA, there is

excessive production of ketone bodies because of the lack of insulin, this would normally prevent

this from occurring ketone bodies are acids, their accumulation in the circulation leads to metabolic

acidosis.

Metabolic acidosis leads to increasingly rapid respirations. Increased keton bodies result in acetone

breath, poor appetite and nausea. Metabolic acidosis results in nausea, vomiting and abdominal pain.

CLINICAL MANIFESTATIONS

The hyperglycemia of DKA leads to polyuria and polydipsia (increased thirst). In addition, the

patient may experience

1. Weakness

2. Headache

3. Blurred vision

The ketosis and acidosis of DKA lead to gastrointestinal symptoms such as anorexia, nausea,

vomiting, abdominal pain, muscle cramps and constipation

Late Manifestation

1. Kussmaul breathing-very deep respiratory movement

2. Sweetish odour of the breath due to ketonaemia

3. Hypotension and weak, thread pulse

4. Stupor and coma

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DIAGNOSTIC EVALUATIONS

A. BLOOD ANALYSIS SHOWS:

Glucose elevated, bicarbonate decreased, arterial pH decreased strongly positive plasma ketone

B. URINE ANAYSIS SHOWS:

Strongly positive for sugar and ketone, and moderately positive for protein.

MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA)

1. The patient may need as much as 6 to 10L of IV fluids to replace fluid losses caused by

polyyria, hyperventilation, diarrhea and vomiting

2. Initially, 0.9% sodium Chloride (N/S) solution is administered at a rapid rate usually 0.5 to

1L/hour for 2-3 hours

3. When blood glucose level reaches 300mg/dL (16.6mmol/L) or less, than IV solution may

be changed to dextrose 5% in H2O to prevent a precipitous decline in the blood glucose level.

4. The major electrolyte of concern during medication of DKA is potassium

5. Insulin administered enhances the movement of potassium from the extracellular fluid into

the cells.

HYPERGLUCAEMIA COMA

Hyperglycemia coma develops when the blood glucose is very, very high. The blood glucose may be

over 30mml/L (600mg/dL). It develops when there is not enough insulin in the body to keep the

blood glucose form building up to very high levels.

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SIGNS AND SYMPTOMS

1. Drowsiness

2. Dry mouth and body tissues

3. Inability to speak

4. Lethargy

5. Nausea and vomiting

6. Abdominal pains

7. Disorientation

8. Excessive thirst

9. Air hunger

10. coma

This condition is very serious and requires treatment right away.

MANAGEMENT OF HYPERGLYCAEMIA

1. administer the prescribed insulin solution

2. replace lose electrolytes by given Normal Saline

LONG-TERM COMPLICATIONS FO DIABETES UNDERLING CONSIDERATION

1. diabetes is the most common cause of new blindness and new cases of end-stage renal

disease

Accelerated atherosclerosis causes an increased incidence of myocardial infarction, stroke and

gangrene.

2. Because diabetics are living longer, thee complications are becoming more common.

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VASCULAR COMPLICATIONS

1. The specific pathologic lesion (microangiopathy) of long-standing diabetes is thickening of

the capillary basement membrane in every organ.

2. The prevalence of microangiopathy parallels the duration and severity of hyperglycaemia.

3. Inter capillary glomerulosclerosis (Kimmelstiel – Wilson syndrome), the specific renal

disease of diabetes, results from the thickening of the capillary basement membrane in the glomeruli.

4. Microangiopathy of the vessels supplying the skin, peripheral nerves, and walls of large

artery may be a factor in skin diseases, neuropathy, and atherosclerosis.

5. Major vessel occlusion (micronagiopathy) resulting from atherosclerosis causes stroke,

myocardial infarction, intermittent claudicating, and gangrene. The progress of atherosclerosis is

accelerated in diabetics.

DIABETES RETINOPATHY

It is a progressive impairment of retinal circulation that cause vitreous haemorrhage and loss of

vision.

1. Incidence and severity of retinopathy are related to the duration and degree of control of

diabetes; half of the patients who have had diabetes for more than 10 years have some evidence of

retinopathy.

2. Impaired vision and blindness are caused by haemorrhage and revascularization into the

vitreous with the formation of scar tissue and eventual detachment of the retina.

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DIABETIC NEUROPATHY

It affects the peripheral and autonomic nervous system and produces a wide variety of syndromes

CATARACT

This develops more frequently in people with diabetes because high blood glucose level can lead to

the formation of cataract. Cataract is an accumulation of substances like sugar in the lens of the eye

which causes clouding and welling.

GLAUCOMA

Is an increase in intraocular pressure which results in atrophy of the optic nerve which can lead to

blindness

NEPHROPATHY

The renal function may be slowly impaired by change in the glomerular capillaries and by sclerotic

changes in the large renal vessels. The patient may manifest albuminurea and some degree of

hypertension.

ARTHERIOSCLEROSIS

This is a gradual loss of elasticity in the wall of arteries due to thickening and calcification. It is

accompanied by high blood pressure, an precedes the degeneration of internal organs associated with

old age or chronic disease.

NURSING CARE OF A DIABETIC PATIENT

The following nursing care must be undertaken for patient with diabetes mellitus

28
1. Appear firm and consistent in giving care

2. The patient must be reassured, although her disease cannot be cured, it can be controlled

for her to live a normal life.

3. Ensure that patient is put in well ventilated room

4. Make patient comfortable in bed with little or less disturbances

5. Skin, mouth, hair, care of hands and feet and general body comfort should be taken care off

6. Encourage adequate an accurate nourishing and healthy eating habits

7. Educate on signs and symptoms of hyperglyucaemia patient

8. Ensure patient maintains the normal weight and strength by exercising regularly

9. Ensure constant assessment of vital signs (at least thrice a day) to detect any deterioration.

10. Educate patient and relative on diabetic diet and make sure patient takes in the adequate an

appropriate calories

11. Encourage patient to chat with other patients to relive allay anxiety

12. Educate patient on the importance of exercises

PREVENTION OR CONTROLLING OF THE DISEASE COMPLICATIONS

The major goal of controlling diabetes is to keep the blood sugar level normal. Healthy foods,

exercise and checking blood glucose can be used to manage the blood glucose level and also

administration of pills and insulin can help to control it. Taking special care of the skin and feet is

very important. There may be more problems with infections, especially if the blood glucose is not

controlled. It is also important to keep the whole body clean. Pay special attention to the armpits,

under the breast, private parts, and between the toes. These are the areas where infections are more

likely to develop. Some people with diabetes may have nerve damage and poor blood flow which

29
can lead to many skin and foot problems. These include loss of feeling, dryness, ulcers and poor

wound healing. Good skin and foot care can help to prevent long term problems such as amputation.

EDUCATION

SKIN CARE

1. Patient should bathe twice a day as follows:

a. The use of mild soap and warm water should be encourage

b. Tell patient to dry the self with a dry clean towel

c. The patient should gently rub the skin with skin lotion, Shea butter or cocoa butter

CARE OF THE HANDS

1. Educate patient to protect he hands when handling hot thing

a. Tell patient to sue a pad or cloth when removing cooked foods or objects form fire

2. To avoid patient being cut, patient should prepare food with extra care as follows:

a. When patient is preparing fins, she should remove the fins with scissors

b. She should remove the scales very carefully with a knife and also handle all meat with

bones very carefully.

CARE OF FOOT AND NAIL

The feet should be carefully examined everyday especially the heels and between the toe, look

for sores, cracks, cuts, blisters, colour changes and over grown nails.

In care for the feet and nails,

1. Patient should wash feet at least twice a day

30
2. Avoid the use of very hot or cold water when washing the feet

3. Patient should avoid soaking the feet in hot or cold water because it may damage the skin

4. Encourage patient to use comfortable footwear that fits well and should avoid wearing high

heeled, tight and pointed shoes.

5. Tell the patient to wear shoes made of soft material

6. Educate patient to wear socks made of cotton wool and avoid socks with hole

7. Cutting of toe nails should be carefully done. The toenails will be easier to cut after

bathing.

8. The patient should ask for help from family, health care personnel or chiropodist if

necessary

9. The toenails should be cut across using nail clippers

10. Avoid the use of blades or knives in cutting the nails

11. Advice patient not to remove corns or calluses with chemicals, blades or knives.

12. The patient should not walk barefooted even inside the room, to help prevent stepping on

sharp objects like pins, blades or knives.

13. Educate the patient to avoid crossing the legs when sitting because it may slow blood flow

the feet.

14. Advice the patient to report to the health care personnel if any of the following problems

are noticed: sores, cracks, blisters, boils, feeling, pain, itching, loss of feeling, and swelling. 10

CARE OF THE WOUNDED SKIN

1. Small cuts or sores should be given special care as follow;

31
a. Wash fresh burns with cold water

b. Wash other cuts or sores with warm salty water

c. Cover with clean material (a piece of clean cloth, bandage or gauze).

d. Application of iodine if available

e. Report to health care personnel if there I a cut or burn as soon as possible

2. Serious skin should be cared for by health care personnel

3. Avoid applying herbs and strong balms like “alcobalm, “koto rub”

4. The patient should avoid beaching the skin

5. Educate patient to avoid making cuts on the kin to apply herbal medicine

6. Tell patient to avoid making tattoos (drawings and marks) on the body

PROGNOSIS

This depends on the clinical presentation and severity of the complication. It can be said to be

better if a patient come early and bide by the diet, exercise and drug treatment

VALIDATION OF DATA

All information or data collected from the patient and his family and information collected form

laboratory investigations, diagnosis, signs and symptoms and treatment performed on the patient

was cross checked with the literature review and was confirmed to be valid.

32
 CHAPTER TWO

ANALYSIS OF DATA

Analysis is the second step in the nursing process. Here information are separated into

component parts and forming a comprehensive judgment from which a final conclusion is made

about the patient’s condition.

The analysis includes;

1. Comparison of data with standard

2. Patients family strengths

3. Health problems identified

4. Nursing diagnoses

COMPARISON OF DATA WITH STANDARD

The comparison of data with standard covers;

a. Tests

b. Cause

c. Clinical features

d. Treatments

e. Complications

DIAGNOSTIC TESTS AND INVESTIGATION

1. Random blood sugar

2. Hemoglobin estimation

33
3. White blood cell count

4. Serum for potassium, sodium, chlorine, creatinine, urea

5. Blood for fasting blood sugar

6. Sickling

7. Urine for routine examinations

8. Plateletes count

9. Blood film for malaria parasite

10. Serum lipid profile

34
 DIAGNOSTIC TESTS AND INVESTIGATIONS

DATE SPECIMEN INVESTIGATION RESULT NORMAL VALUE INTERPRETATION REMARKS

6/9/11 Blood White blood cell 13.5k/uL 4.1-10.9k/u%L The cells were slightly Antibiotics
count above the normal were
range, indicating the prescribed and
presence of infection. administered
6/9/11 Blood Red blood cell count 3.95x106/uL 12.0-18.0g/dL The red blood cell was Ferrous sulfate
below normal range was prescribed
indicating the presence and
of anaemia administered
6/9/11 Blood Haemogobin level 10.8g/dL Male 13.0-18.0g/dL The hemoglobin level Haematinics
estimation was slightly below were
Female normal rnage indicating prescribed and
11.0-16.0g/dL mild aneamia. administered
and patient was
fed with a well
balanced diet
to improve his
blood volume
6/9/11 Blood Platelet count 253x103uL 140.-440k/uL The platelet level as No treatment
within normal range was given

6/9/11 Blood Urea Cretinine 5.15mmol/L 2.10-7.10mmol/L Urea was within No specific
normal treatment was
given Patient
105.1umol/L 53.0-106.1 Creatinine was normal was fed with a
indicating normal high protein
kidney diet and
encouraged to
take more
fluids
6/9/11 Blood Fasting blood sugar 19.9mmol/L 4.2-6.4mmol/L Fasting blood sugar Injectable
level was above normal soluble insulin
(hyperglyceamia) 60night was
given

35
7/9/11 Blood Sickling Negative, Negative Suggested that, patient No treatment
normal shape is not a sickle cell
is biconcave patient was given.
and non-
nucleated

7/9/11 Blood Malaria parasite No malaria Malaria parasite Patient does not have No treatment

parasite was should not be malaria. was given.

seen in the seen.

blood

36
CAUSES OF PATIENT’ CONDITION AS COMPARED WITH THE LITERATURE

REVIEW

This is comparing what the literature review ay with what is presented by the patient. Literature

review has predisposing factors which lead to diabetes mellitus and these are;

1. Hereditary

2. Dysfunction of the pancreas

3. Sedentary lifestyle

4. Obesity

5. Tobacco use

6. Insulin deficiency

7. Race and ethnicity

With reference to the information gathered from the literature review about the causes of the

condition. Mr. RBK’s condition may be caused by

1. Poor Diet

2. Stress

3. Age

4. Insulin deficiency

37
 TABLE 2

CLINICAL FEATURES EXHIBITED BY PATIENT AS COMPARED WITH THE

LITERATURE REVIEW

LITERATURE FEATURES BY PATIENT

REVIEW FEATURES
1. Polyuria 1. Patient presented with excessive
micturition (polyuria)

2. Polydipsia 2. Patient experience polydipsia

(excessive thirst)

3. Polyphagia 3. Patient complained of hunger within

(excessive hunger) 30 minutes of eating

4. Weight loss 4. Patient lost some weight during

hospitalization

5. Weakness and
fatigue 5. Patient complained of body
weakness and felt tired when he walked

6. Dehydration and 6. Patient was dehydrated due to

hypovolaemia excessive micturition

7. Blurred vision 7. Patient experienced blurred vision

due to the early onset of seizures

38
 COMPARISM OF GENERAL TREATMENT FROM BOOKS AND THAT OF THE

PATIENT

LITERATURE REVIEW PATIENT’S SPECIFIC TREATMENT GIVEN

TREATMENT FOR DIABETES
MELLITUS
DIET Patient was served as well balanced diet after stressing
on the diabetic diet. He was served three (3) times daily
at the same time and same quantity. Apples and oranges
were also given as snacks. This diet management is
forever.
EXERCISE Patient was educated and encouraged on the need for
regular exercise as it is essential for good health.
DRUGS Tablets Daonil was prescribed
Tablets Daonil
Tablets Metformin was prescribed 500mg tid x 15 days
Tablets Metformin
Tolbutamide was not prescribed
Tolbutamide
Soluble insulin was prescribed during hospitalization
4..Short-Acting insulin
Medium-acting insulin was not prescribed
e.g. Soluble Insulin
5.Medium-Acting Insulin
Mixtard was prescribed 20mane 10 evening x 30 days
e.g. Lente Insulin
6.Long-Acting Insulin
e.g. Mixtard

1. IV sodium chloride 1000m’ daily for 2 days

2. Injection insulin was given depending on blood glucose level

3. Tablet Daonil 5mg daily for ten days

4. Tablets metformin 500mg twice daily for 10 days

5. Tablet Diclofenac

39
 TABLE 3: PHARMACOLOGY OF DRUGS

DATE DRUG DOSAGE/ROUTE CLASSIFICATION DESRIED ACTUAL SIDE

OF EFFECTS ACTION EFFECTS/

ADMINISTRATI OBSERVED REMARKS

ON

6/9/11 Daonil 5mg daily*10 days Anti -diabetic An inhibitor of It regulated blood Nausea, vomiting and
intestinal
orally glucose level. Blood diarrhea. Patient did
alphaglucosidaces
glucose level was not exhibit any of
delays the digestion
and absorption of decreased these side effects.
starch and sucrose
6/9/11 Metformin 500mgbd*10 days Anti -diabetic Decreasing It regulated blood Anorexia nausea,
gluconeogenesis
tablet orally and by increasing glucose level by vomiting diarrhoea,
peripheral
reducing it. abdominal pain
utilization since it
acts only in the metallic taste and
presence of
endogenous insulin, lactic acidosis. .
it is effective only
in diabetics with Patient did not
some residual
exhibit any of these
functioning
pancreatic islet side effects.
cells
6/9/11 Tablet 100mg x 6 days Non-steroidal anti- Relives Patient was relieved of Dizziness,depression

40
 diclofenac orally inflammatory inflammation, pain bodily pains. nausea,vomiting,head

analgesics and fever. ache,eye pain, taste

disorders. . Patient

did not exhibit any of

these side effects.

8/9/11 Sodium 1 liter daily for two Isotonic fluid and For replacement of Fluid and electrolyte Aggravation of heart

chloride days intravenously electrolyte sodium sodium chloride balance failure, oedema,

and water. For the maintained .Patient was pulmonary embolism

treatment of well hydrated loss of potassium,

intracellular volume abscess tissue

deficit. necrosis, Patient did

not exhibit any of

these side effects.

9/9/11 Injection Dosage depends on 1.Anti-diadetic and Reduces blood Blood glucose level Urticaria,

insulin the level of sugar in glucagon. glucose level by was brought under hypoglycemia,

mixtard. the blood. increasing blood control with reduced swelling Patient did

glucose transport result of 6mmol/L not exhibit any of

across muscles and these side effects..

fat cells membrane.

41
 Promotes

conversion of

glucose to its

storage from

glucogen for it to

be stored.

42
 COMPLICATION OF LITERATURE REVIEW AS COMPARED WITH THAT OF THE

PATIENT.

LITERATURE REVIEW FOR THE PATIENT

LONG TERM COMPLICATION

1. Retinopathy The patient did not experience retinopathy

2. Neuropathy The patient did not experience neuropathy

3. Nephropathy The patient did not experience nephropathy

4. Glaucoma The patient did not experience glaucoma

5. Cataract The patient did not experience cataract

6. Arteriosclerosis The patient did not experience arteriosclerosis

7. Gangrene The patient did not experience gangrene

METABOLIC EMBERGENCIES

LITERATURE REVIEW PATIENT

Hyperglucaemia Patient had hypergluycaemia

Hypoglucaemia Patient did not experience hypoglucaemia

Diabetic ketoacidosis Patient did not experience diabetic ketoacidosis

43
PATIENT / FAMILY STRENGH

Strength identified that helped in the successful treatment and care of M.R.B K and family

included the following.

1. Patient was able to sleep between short intervals.

2. Patient was able to perform self care activities when assisted.

3. Patient and family participated in the care activity and adhered to the medical and nursing

advice given to them.

4. Patients church mother visited regularly and prayed for him to help to meet his spiritual

need

5. Patient was ready to learn about the condition.

HEALTH PROBLEMS

The following are ht health problems identified with the patient.

5/9/11

1. Patient complained of inability to sleep at night.

2. Patient inability to perform self-care activities.

3. Patient complained of inability to pass stool

6/9/11

1. Patient urinated a lot during the day

2. Patient vomited for about five (5) time

44
 7/9/11

1. Patient complained of in ability toperform self- care activities

2. Patient complained of inability to pass stool

8/9/11

1. Patient was at risk of infection

9/9/11

1. Patient had no knowledge about the disease, it complication and management.

10/9/11

Patient complained of hunger during the night

45
NURSING DIAGNOSES

This is the actual or potential problems that are amendable to resolution by means of nursing

actions. The following nursing diagnoses were drawn from patient’s health problems.

5/9/11

1. Sleep pattern disturbance related to nocturia

2. Fluid volume deficit, related o excess urine output (polyuria)

3. Potential for fluid and electrolyte imbalance related to vomiting.

6/9/11

1. Alteration in physical body comfort, related to general body pain

2. Alteration in bowel movement (constipation) related, to low roughage intake.

7/9/11

1. Risk for altered nutrition more than body requirement related to polyphagia

8/9/11

1. High risk for infection related to prolonged catheter in situ

9/9/11

Knowledge deficit related to condition (diabetes mellitus) and its management.

46
 CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

Planning is the third stage in the nursing process. It involves a carefully chosen nursing

diagnoses formulated based on assessment findings on patient and family strengths. From the

nursing diagnoses, appropriate expected outcomes are identified with measurable and focus

goals to guide the care. It demands setting priorities and limits to meet one’s objectives.

The nursing care plan is very important to the nurse and the patient. This is because it

encourages the nurse to use her initiative and judgments rightfully to nurse the patient. It helps in

researches and also serves as a legal document for both the nurse and the patient. It also serves as

a communication link between health care providers (nurse) and aids in the continuity of care.

OBJECTIVE OUTCOME CRITERIA

5/9/11

1. The patient will assume normal sleep pattern within 72 hours

2. The patient will have normal fluid volume within 2 day

3. The patient will attain normal fluid and electrolyte balance within 2 days

6/9/11

1. The patient will attain physical body comfort within 3 day

2. The patient will attain free bowel movement within 72 hours

7/9/11

1. The patient will be free from infection

47
8/9/11

1. Patient will attain a fair knowledge of condition, (diabetes mellitus) its complication and

management 3 day

9/9/11

The patient will maintain normal nutritional pattern within 3 days.

48
 TABLE 4

CHAPTER THREE NURSING CARE PLAN

DATE/ NURSING OBJECTIVES/OUTCOME NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSES CRITERIA ORDER INTERVENTION TIME
5/9/11 Sleep pattern The patient will assume 1. Reas 1.The patient was told 9/9/11 The goal fully met I.B
At disturbance sure that with effective At as patient
8:30am related to normal sleep pattern within patient. nursing care he will 8:30am verbalized felling
nocturia maintain his sleep rested and sleeping
72 hours as evidenced by pattern. uninterrupted

1. Patient verbalizing felling 2.The Patient was

2. Decr advised to void when
rested ease fluid going to bed.
intake at
night.
3. Patient was assisted
3. Enc to use adult diaper
ourage the when retiring to bed.
use of
adult
diapers at
night. 4. Block nursing was
practiced in other to
4. Plan allow period of
nursing uninterrupted sleep.
activities.
5. Nursing activities
were documented.
5. Doc
ument
nursing

49
activities.

50
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSES OUTCOME ORDER INTERVENTION TIME
CRITERIA
5/9/11 Fluid volume Patient will 1. Reassure the 1. The patient was reassured 8/9/11 The goal fully IB
At deficit related have normal patient. that is because of her At met as patient
12:00am to excess urine fluid volume condition that was why she 12:00am had a normal
output with 2 days as was passing a lot of urine but urine output.
(polyuria) evidenced by: is under controlled.
2.Asess for signs 2.The patient was observed
and symptoms of for dry skin, sunken eyes and
dehydration dry mucous membrane.
3.Monitor input 3.The patient’s intake and
and output and output was monitored and
record documented.
4. Set intravenous 4.An intravenous line was set
line. by the doctor.
5. Monitor site of 5.The site was monitored for
iv cannula swelling and there was none.
insertion for
swelling.

6. Rehydrate the 6.The patient was given

patient. prescribed intravenous
infusion (N/S) for 2 days to
restore the fluid loss.

51
DATE/ NURSING OBJECTIVE NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSES /OUTCOME ORDER INTERVENTION TIME
CRITERIA
5/9/11 Potential for Patient will attain normal 1.Remove any 1.All nauseous 8/9/11 The goal fully met I.B
At fluid and fluid and electrolyte nauseating objects. substances were At as patient had good
4:00pm electrolyte balance within 2 days as removed around the 4:00pm skin turgor.
imbalance evidenced by patient.
related, to
vomiting. a. The patient verbalizing 2. Provide emesis 2. The patient was
the ceasation of vomiting. bowl. provided with an
b.The nurse observing no emesis bowl when
signs of dehydration. necessary.
3.Observe the 3. The patient’s
vomitus and record vomitus was observed
for its consistency,
colour, amount and it
was recorded.
4.Observe for signs
of dehydration 4. The patient was
observed for the signs
of dehydration
(sunken eye,d ry
mouth, etc) and none
was experienced.
5.Rehydrate the
patient. 5.The patient was
given prescribed
Ringers Lactate 2
liters for 2 days to
restore the fluid and
electrolyte balance
(potassium).

52
DATE/ NURSING OBJECTIVE NURSING NURSING DATE/ EVALUATIO SIGN
TIME DIAGNOSES /OUTCOME ORDER INTERVENTION TIME N
CRITERIA
6/9/11 Alteration in Patient will 1. Assess the level 1. The patient’s pain level was 10/9/11 The goal fully I.B
At physical body attain of pain and assessed by the use of pain At met as patient
9:00am comfort (head) physical body reassure patient. chart and was reassured that it 9:00am performed self-
related to pain. comfort will be relieved. care activities
within 3 days without an
as evidenced 2. Assist patient to 2. The patient was assisted assistance.
by; maintain personal with bathing, mouth, hands
hygiene. and feet care.
a. The patient
verbalizing 3.Ensure patient’ 3. The patient’s bed was neatly
the absence of comfort laid and was made comfortable
pain. in it.

4. Administer 4. The patient was given

prescribed prescribed tablet Diclofenac
analgesics to relive 75mg bd for 6 days, orally and
pain. pain was relieved.

53
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSES OUTCOME ORDER INTERVENTION TIME
CRITERIA
7/9/11 High risk for Patient will be 1. Explain 1. The procedure of catheter 11/9/11 The goal fully I.B
At infection free from procedure to care was explained to the At met. There was
8:30am related to infection patient. patient. 8:30am no sediment in
prolonged within 3 day as urine tube or bag
catheter in situ evidenced by 2. Provide privacy. 2.The patient was provided indicating
a. The nurse privacy with a screen around absence of
observing no the bed. infection.
sediments in
the urine bag. 3. Perform catheter 3.Catheter care was
care. performed under an aseptic
b.The nurse technique
observing on
pus at urethra 4. Ensure comfort. 4. The patient was made
orifice comfortable in bed, (the bed
was free from cramps and
straightened).
5.Ensure
5. All the procedures were
documentation
documented in the nurse’s
note.

54
DATE/ NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE/ EVALUATION SIGN
TIME DIAGNOSES OUTCOME ORDERS TIME
CRITERIA
8/9/11 Knowledge Patient will 1. Assess the Patient was assessed on the 13/9/11 The goal fully I.B
At deficit related, attain a broad patient’s level of understanding of its cause of At met as patient
11:00a to condition knowledge of knowledge. diabetes mellitus, complication 11:00am was able to
m (diabetes condition and and its management of the answer all
mellitus) and its management disease. questions that
its within 4 days as were asked.
management. evidenced by: 2. Educate The patient was educated on
patient on the the condition that is the cause,
1. Patient’s condition. complication and management.
ability to
answer The patient was educated to
questions 3. Educate avoid self care medication
correctly. patient to avoid which will cause more
self-care complication to him health.
2. Patient medication.
participating in The patient was advised on
the management regular check-ups after
of the disease. 4. Advice discharged.
patient on regular
check-up. The patient was educated on the
signs an symptoms. (Polyuria,
polydipsia, polyphagia etc) of
5. Educate the condition.
patient in the
signs of the The patient asked
disease. tactfully questions and they
were answered.
6. Allow The patient was thought how to
patient to ask give the insulin injection.
questions on the
condition.

7. Teach
patient the
55
 administration of
insulin.

DATE/ NURSING OBJECTIVE/ NURSING ORDER NURSING DATE/ EVALUATIO SIGN

TIME DIAGNOSES OUTCOME INTERVENTION TIME N
CRITERIA
9/9/11 Risk for altered Patient will 1. Reassure pattern. The patient was reassured 13/9/11 The goal fully I.B
At nutrition more maintain normal of gaining normal eating At met as patient
12:00pm than body nutritional pattern with adequate 12:00pm return to normal
requirement pattern within 3 nursing care. eating pattern.
related to days as
polyphagia. evidenced by
a. Patient 2. Asses nutritional The patient nutritional status
verbalizing status. was assessed by
normal eating determining the type of food
pattern. taken, time and frequency.

b.Nurse
visualizing Planning of patient diet was
3. Plan diets with
normal eating done with patient and
patient and relatives.
pattern. relative, taking into
consideration patient’s food
preference and ethnicity.

4. Offer small Patient was offered small

frequent feed. feed at a time as tolerated
and at frequent intervals.

5. Serve patient The patient was served with

with snacks. biscuit and orange juice
after eating.

6. Monitor glucose The patient glucose level

level. was checked (10.0mmol/L)

56
 and recorded.

All procedures were

7. Document documented in the nurse’s
findings. note.

57
 CHAPTER FOUR

IMPLEMENTATION OF PATIENT/FAMILY CARE PLAN

Implementation is the fourth step of the nursing process. This is where actions are taken to solve

the patients/family problems.

It refers to carrying out the proposed plane of care by the nurse. It is the process of putting the

nursing intervention and others stated for a particular patient into action.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO MR. R.B.K

DAY OF ADMISSION ( 5/9/11)

Mr. R.B.K was admitted through the casualty unit of ENRH by Dr. Barnes to the male ward on

the 5th September, 2011 at 6:00am. He was in a conscious state and made comfortable in bed.

The relatives were wet come to the nurse station, introduced to the staff present and made

comfortable on chairs. Patient’s name and particulars were confirmed and the relatives reassured

that he was in good hands. Later, they were oriented to the ward environment.

The vital signs were checked and recorded as follows:

Temperature 36 – 2 degree Celsius (0C)

Pulse – 64 per minute (cmp)

Respiration 30 cycles per minute

Blood pressure 150/120 millimeter of mercury (mmHg)

58
Random blood sugar 36.mls of Normal saline was set up to run fast. He and the relatives were

assured of quality care from the medical team. A care plan was prepared and her name entered

into the admission and discharge book, ward state and nurses notes.

FIRST DAY OF ADMISSION (6/9/11)

He was given bed bath and month care. At 6:00am his blood sugar level was checked which read

28.0.0mml/L and 10units of soluble insulin was injected subcutaneously. He took porridge and a

slice of bread afterwards. The patient was taught the foods high in fiber like unpeeled fruits nut,

cereals and vegetables. He was also encouraged to increase activity (walking) which medical

condition allowed.

SECOND DAY ADMISSION97/9/11)

The random blood sugar was 20.4mml/L and 10unit of soluble insulin was administrator

subcutaneously. He was assisted to with bathing and oral toileting. Tablets diclofenac 100mg bd

x 6 days orally and intravenous sodium chloride 1000m/s daily for two days was administered as

prescribed in the morning at 6:00am.

He was served rice pudding as locally called “rice water and slice of bread for a breakfast. He

complained of difficulty in passing stool (constipation). He was reviewed by the doctor in-charge

who ordered the continuation of treatment. His bed was neatly to take in lots of water and

roughages to relive the constipation.

At 6:00pm the random blood sugar was 19.5mmol/L and 8 units of soluble insulin were

administered. He was fed with rice balls and palm nut soup with fish and was assisted to bath.

He was made comfortable to sleep.

59
THIRD TO FOURTH DAY ON ADMISSION (8/9/11-9/9/11)

On the 8th September the random blood sugar was 24.5mmo/L and 100unit of soluble insulin was

administered. He was educated on the condition that is the causes, complication and

management. Table didofenac 100mg bd x 6 day and Table Daonil 5mg daily for ten day was

administered. The vital signs were checked and recorded.

On the 9/9/11 at 6:30am the random blood sugar was 15.10 unit of soluble insulin was given. He

took his bath and later had breakfast. He was served with biscuit and orange juice after eating.

He was seen chatting with other patient and he look happy.

FIFTH TO SIXTH DAY ON ADMISSION (10/9/11-11/9/11)

On the 10/9/11, the random blood sugar level dropped to 10.9mmol/L. all the medication was

served and no complaint lodged. He was getting better and was encouraged to eat at regular

intervals and not to fast. He was also educated on the condition and told how diabetes mellitus

come about how it can be controlled and the condition is not a spiritual attack be is done to the

failure of the pancreatic beta cells to produce insulin or decreased sensitivity to insulin called

insulin resistance. He was told that the disease cannot be cured but it can be controlled.

SEVENTH TO EIGHT (12-9/11 – 13/9/11)

Mr. R.B.K’s random blood sugar level was 15.6mmol/L and 8 units of soluble insulin was

administered. He was reminded of the diet and exercise. He was made aware that the insulin

should be taken 30 minutes before taking his meal. The vital signs were checked and recorded

tablet diclofenac100mg bd x 6 days was administered.

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On the 13/9/11, the random blood sugar level dropped to 10.0mmol/L. he was reviewed by the

doctor and asked to prepare to be discharged. He was taught how to care for hands and feet, skin

and nails. He was told to bath twice a day with mild soap and warm water and gently rub the skin

lotion. He was asked to protect the hands when handling hot items and also advised to examine

the feet especially the heels and between the toe, for sores, cut, and cracks blisters and over

grown nails.

He was encouraged to use foot wear that fit well and should avoid tight and pointed shoes. He

was to cut hi nails across using nail dipper. The use of blade to cut was discouraged. He learnt a

lot and promised to abide by what he had been tonight.

NINTH DAY OF ADMISSION (14/9/11)

The random blood sugar level was 6mmol/L. the doctor reviewed and discharged him because

the blood sugar level had reduced and he looked healthy. The soluble insulin was discontinued:

injection insulin mixtard and tablet metformin 500g tid x 15 days were prescribed to be taken

home. The bills were prepared and because of the National Health Insurance Scheme (NHIS), he

did not pay anything. The relative and patient were reminded of the education on diet,

exercising, drug the therapy and self monitoring. He was advised to come for regular check-up in

every 2 weeks, but there should be any change in hi health he should report immediately. He was

finally encouraged to visit the diabetic clinic every Thursday for more education on his illness.

At 10:30am, he was escorted to the hospital gate and the left.

PREPARATION OF THE PATIENT/FAMILY FOR DISCHARGE AND

REHABILITATION

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Preparation of Mr. R.B.K and his family toward discharge commenced on the day of admission.

They were educated on the cause, sign and symptoms and management of diabetes mellitus. He

was advised to avoid herbal treatment which can lead to complication to the disease. The patient

was told to live a healthy life by having enough rest and sleep and exercising which should not

be strenuous. They were encouraged to have regular check-ups and report change in her

condition. He was told to have a regular supply of insulin mixtard. He was advised to continuous

his daily activities or work.

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FOLLOW-UP/HOME VISITS

Home visit is made to the client’s own environment (home). It helps in the education,

supervision and continuity of care of the patient. It also gives the nurse the chance to see the real

situation of the client at home.

FIRST HOME VISIT

Whilst on admission, permission was sought from Mr.R.B.K to visit his home. On the 9 th

September 2011, the first visit was made to the house in the company of his sister. This was done

to get acquainted with the environment, to identify healthy problems in the community and give

education when necessary; it also enables the nurse to know the progress of health after

discharge.He stays at Effia Kuma new site in a family house, with his sister. He occupies a flat in

the house. The house is built with cement and block and roofed with aluminum sheet. It is

designed with different colours of bricks and has a summer hut on top of it. The rooms are

spacious and well arranged to keep it airy. Each room has its own bathroom and toilet. The

source of light is electricity and water I pipe-borne. They were given a brief education on

Mr.R.B.K’s condition and reassured that with treatment, he would soon be discharged. After the

education, permission was sought to leave. A promise was made to call on them again after his

discharge.

SECOND HOME VISIT

On the 17th September, 2011, a visit was made to the house after discharge. On arrival to the

house, the sister had visited him and was in the kitchen preparing food. They were happy and

quickly provided seat. Greetings were exchanged and an opportunity was taken to educate them

more on the disease. They were told that the diabetes mellitus disease is a hereditary disease and

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that it can be controlled by ensuring complete bed rest, exercising, maintaining good nutritional

state to raise the blood glucose level. The need to report early signs of hypoglycemia, regular

check-0ups at the diabetic clinics and to take in more fluids and fruits to regulate blood volume

for circulation and finally the management of diabetes mellitus. After, the education, they asked

a lot of questions which were answered but emphasis were made on the attendance to the

diabetic clinic, for more information. They were very grateful for the education and the sister

was asked to encourage Mr.R.B.K’s to complete the drug regimen. They also expressed gratitude

for the care given to his during hospitalization. A promise was made to visit again and was bid

good bye.

THIRD HOME VISIT

On the 21st September, 2011, another visit was made to his house. It was a surprised visit

because they were not aware of the visit. The purpose of the visit was given to know how he was

faring. A warmth welcome and seat was provided. He was asked about the review and his

condition. Mr.R.B.K was asked to continue with his medications and follow as instructions. The

patient followed all management about the disease like exercising every morning before taking

his bath, the kind of food he eat and monitoring of his self well.

Gratitude and appreciation to Mr.R.B.K and family were expressed and thanked for their co-

operation throughout the care. Mr.R.B.K and family were told that, it was the last home visit

and that another visit would be made some time when school activities are over (vaca

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 CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT/FAMILY

Evaluation is an ongoing process carried out at every step in the nursing process. It helps the

nurse to know the effectiveness of the care rendered to the patient.

The evaluation covers the following;

1. Statement of evaluation

2. Amendment of nursing care plan for partially met or unmet outcome criteria objective

3. Termination of care

STATEMENT OF EVALUATION.

Mr.R.B.K received competent nursing care throughout his stay on the ward.

On the 5th of September 2011, objectives were set that;

- Patient will assume normal sleep partern within 72 hours

- Patient will have normal fluid volume within 2 day

- Patient will attain normal fluid and electrolyte balance within 2 days

With effective nursing care as stated in the care plan, goals were fully met within the stated

hours.

Also on the 6th of September 2011, two other objectives were set;

- The patient will attain physical body comfort within 3 day

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- The patient will attain free bowel movement within 72 hours

On 7th of September 2011, another objective was set;

- The patient will be free from infection

On 8th of September 2011, another objective was set;

- Patient will attain a fair knowledge of condition, (diabetes mellitus) its complication and

management 3 day

Lastly On 9th of September 2011, an objective was set;

- The patient will maintain normal nutritional pattern within 3 days.

AMENDMENT OF NURSING CARE PLAN

This is where goals that were partially met are amended. After nursing Mr.R.B.K, suing the

individualized nursing care approach, all of the goals and objective were fully met within the set

time.

TERMINATION OF CARE

Termination of care is one of the most difficult and important phase in the nurse patient

relationship because of the reality of separation. This is when the care rendered to patient and

family is brought to a successful end. During the period of interaction, Mr.R.B.K and relatives

were made aware that the care will continue in the house after discharge, but it will be

terminated gradually as the home visit will not be regular as done earlier. The interaction

between the nurse, Mr.R.B.K and relatives, began on the day of admission, 5th September, 2011

and ended on 21st September 2011, during the last home visit after discharge. Mr.R.B.K and

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family members were thanked for their co-operation and understanding whiles they also

expressed their sincere gratitude and appreciation for all the time spent with them even though

they felt a little sad about the termination of care.

SUMMARY AND CONCLUSION

Mr.R.B.K; a 31 year old man was the patient on which this care study was written. He was

admitted to the male ward of EffiankwantaRegional Hospital with the diagnosis of diabetes

mellitus. Good interpersonal relationship established with the patient and family, helped to

identify certain health problems. The patient was reviewed by the doctor and medications were

prescribed for the treatment of the condition. With the involvement of the patient and family,

effective and efficient medical and nursing care were given to him, which led to her speedy

recovery and discharged. Home visit and follow ups were made to assess the patient’s condition

and how he was coping with the environment in the home, where health education was given to

the patient and family. In all, this patient and family care study has broadened my knowledge on

diabetes mellitus, it causes, signs and symptoms, complications, as well as it management. It has

help to put into practice all that have been taught at school and on the ward.

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SINATURIES

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