TRIBHUVAN UNIVERSITY

INSTITUTE OF MEDICINE
BIRATNAGAR NURSING CAMPUS

CASE STUDY REPORT

ON
UNCONTROLLED TYPE 2 DIABETES MELLITUS
SUBMITTED TO: SUBMITTED BY:
Respected madam Lawoti limbu
Mrs. Sarswati Basnet Roll:07
B.sc. Nursing 2nd year C BSC 2nd Year 1th Batch

Date of submission: 2079/01/

1
 ACKNOWLEDGEMENT

I have prepared the case study on “uncontrolled diabetes mellitus” during my 4 th week of adult
health nursing Practicum posting on medical and surgical ward. As per the requirement of
curriculum of Bachelor of Nursing Science Second year, during my posting I have tried my best to
gather and interpret the information and provide care and face the challenges regarding the topic and
compare it in theoretical as well as practical aspect in hospital setting. This case study is possible
only because of the guidance, support, supervision and co-operation of several personalities to whom
I am heartfully thankful. First of all I would like to express my heartfelt gratitude to our respected
ma’am Sarswati basnet and student teacher sister for continuous monitoring, supervision, guidance
and encouragement throughout the entire period of my case study.
I am glad in expressing my grateful thanks to all of my BSC 2 nd year teachers, library staffs of
Nursing Campus Biratnagar for their help , kind co-operation, encouragement and valuable
suggestions.
I am equally thanking to my colleagues, senior as well as juniors and also thankful to my patient and
his visitors for providing the necessary information so kindly and co-operatively.
I would like to express my special thanks to the Koshi Zonal Hospital, staffs and doctors who
encouraged and provided me opportunity to practice in real situation.

LAWOTI LIMBU
BSC 2nd YEAR , 1st BATCH

2
CONTENTS

SN TOPIC PAGE NO
1. BACKGROUND 4
2. OBJECTIVES 5
3. HISTORY TAKING 6-10
4. PHYSICAL EXAMINATION 11-19
5. DEVELOPMENTAL TASK OF MIDDLE ADULTHOOD 19-20
6. DISEASE PROCESS AND DRUG PROFILE 20-37
7. APPLICATION OF NURSING THEORY 38-39
8. NURSING CARE PLAN 40-44
9. SPECIAL GADGETS USED IN PATIENT 44
10. DIVERSIONAL THERAPY USED IN PATIENT 45-46
11. DAILY PROGRESS NOTE 46-47
12. DISCHARGE PLANNING AND TEACHING 47-49
13. ACTION TO MINIMIZE STRESS OF ILLNESS AND 49-50
HOSPITALIZATION
14. WHAT I LEARNT FROM MY CASE STUDY 50
15. SUMMARY 51
16. REFERENCES 52

3
BACKGROUND

This case study report on “ Uncontrolled Diabetes Mellitus” is prepared as a Partial fulfillment of
Bachelor of Nursing Science Curriculum of 2nd year ,Adult Nursing Practicum.

The BSC curriculum of the Institute of Medicine demands a case study on a patient having a major
problem or disease condition and applies the concept of nursing theory. Hence, this case study report
is developed during my 4th weeks clinical practicum period in Medical/ Surgical unit at Koshi Zonal
Hospital.
It aims to enable the BSC students to get through knowledge about the selected case and be able to
apply the concepts of nursing theory following nursing process, providing holistic nursing care
which would bring comfort and relief symptoms of the patient.

4
OBJECTIVES
Every program and function has its own objectives to accomplish the work. Similarly, this case study
also got certain general and specific objectives which are as follows:

GENERAL OBJECTIVES
At the end of the 4th week of clinical practicum of Medical Surgical Nursing at Koshi Zonal Hospital,
I will be able to do a case study and provide holistic care for patient by applying the concepts of
nursing theory.

SPECIFIC OBJECTIVES
• To identify the problem and find out the possible solutions of their problems.
• To select one patient and to anticipate physical and psychological problems and needs during care
of patient.
• To get full information about the patient.
• To provide care according to the need of the patient.
• To upgrade the knowledge of disease, its treatment, prognosis, complications, prevention and skills
of managing them and comparing with patient.
• To minimize patient’s stress of illness and hospitalization.
• To give informal teaching to the patient and visitor about promotion, prevention and maintenance
of the health of patient and assist towards selfcare.
• To collaborate with patient and visitors in discharge planning.
• To formulate a systematic case study report using standard measure.

5
 HISTORY TAKING

1. BIODEMOGRAPHIC DATA:
FULL NAME :Jay Narayan chaudhary
AGE: 46Years
SEX: Male
ADDRESS :-Barjugaupalika Morang, Nepal, currently in Biratnagar karagar
RELIGION : Hindu
CASTE/ETHNIC GROUP :
MARITAL STATUS :Married
OCCUPATION : Driver
LANGUAGE SPOKEN : Nepali, Hindi
ECONOMIC CLASS: Middle class
EDUCATIONAL LEVEL: Literate
WARD/BED NO: Male Medical Ward/185
DIAGNOSIS: Uncontrolled Diabetes Mellitus
DATE OF ADMISSION:2079-12-26 at 1:30pm
SOURCE OF HISTORY: Patient , Patients chart, and Wife
ATTENDING DOCTOR : DR.
DATE OF DISCHARGE :
HOSPITAL STAY : DAYS

2. CHIEF COMPLAIN:
Patient says I have excessive thirst , occasional headache, burning and tingling sensation of feet since
1month and infected wound on right foot since 7 days .

3. HEALTH HISTORY:
1. PRESENT HEALTH PROBLEMS
Patient is a known case of Type 2 Diabetes Mellitus since 3 years . He is admitted to Male Medical
Ward from Emegency with the chief complain of excessive thirst , headache, burning sensation of
feet since 1 month and infected wound on right foot since 7 days .

6
Problem: excessive thirst, occasional headache , burning sensation of feet , infected wound on right
foot and increased blood glucose level (520 mg/dl) at a time of admission .
Onset: since 7 days
Frequency: Intermittent
Duration: continously
Severity: mild to moderate
Alleviating factors(decreasing factor): after taking regular oral hypoglysemic drug
Aggravating factors(increasing factor): inactivity, specially at night and morning time
Current medication:
Inj. Clavum x 1000mg x IV x BD
Inj. Ornidazole x 500mg x IV x BD
Inj. Rabeloc x 20mg x IV x BD
Inj. R Insulin 14U With 10 meq Kcl with 500 ml Normal saline 3 pint over 24 hrs respectively
Traditional healer prescription: No
Medical Healer prescription: No
Self-prescription: No

4. PAST HEALTH PROBLEMS:

Past illness and treatment:-
Previous hospitalization: Yes,
Surgeries: No
Allergies including clinical exposure: No
Injury and Accidental history: No
Special treatment (Blood transfusion etc): No
Any medication used (what for? How long? How regular?):
Any adverse drug reaction: No
Drug allergy:Not known till now
Immunization history: Covid vaccine
Any childhood illness(measles, polio, malnutrition etc): No

5. FAMILY HISTORY:
Type of family: Nuclear
No of family member: 5
7
Care giver and support system: Son, daughter and wife
History of chronic illness (include diabetes mellitus , Hypertension
cancer, psychiatric illness, renal disease, cardiac disease etc): Present, Diabetes
History of recent death in the family (cause if any): No
History of any communicable disease in the family: No
Drug abuse history: No

6. PERSONAL HISTORY:
Dietary habit
No of meal taken: 2 times a day
Meal timing: Daal + rice + curry, 7pm: Daal+ rice +curry
Nutritional pattern:daal ,roti, rice, vegetables , water
Food like: roti , meat , milk, fruits etc
Food dislike: none
Food allergy: none
Personal care habits
Smoking \Alcohol \chewing tobacco: No any
Religious habit: occasionally visit Temple
Exercise pattern: No any specific exercise patters, walking inside prison occasionally
Brushing\Bathing(how often): brushes teeth once a day and baths everyday.
Elimination habit: frequency of urination ( 10-12) times a day and bowel pattern regular.
Rest and sleep habit: sleeps 6-8hrs/day
Recreational habit: reads newspaper, listening to songs , watch TV
Work pattern:he doesn’t perofrm any work as he is in prison

7. SOCIO ECONOMIC AND ENVIRONMENTAL HISTORY:

House :
Type and location: cemented ground floor house in Barjugauoalika
Adequacy of privacy: maintained
Kitchen: separate
Own or rented: own
Adequacy of lighting, ventilation: well- ventilated and good lighting

8
Sources of drinking water: Handpump
Types of fuel used for cooking: LPG Gas + firewood
Type of latrine: Water sealed latrine
Drainage system: Closed drainage
Waste Disposal system: Burning as well as composting
Environmental pollution: keeps environment clean
Kitchen garden: Available, grow vegetables on their own.
Presence of files /mosquitoes\rodents: Rats, mosquitoes and flies present
Pets in home: No
COMMUNITY
Frequency and nature of social contact: no contact as patient is in prison since past 10 months Family
members accessibility of health services: visits to the government hospital as well as private clinic.
Availability of local resources: available.
Frequency of attendance at religious and secular meeting or events: sometimes
Social support: available
8. PSYCHO SOCIAL HISTORY:
Any psychological stressors present: No
Family relationship: Good relation with the family members
Client position in the family: Respected member of family ,head of family
Recent family crisis or change: No any
Memory problem: No
9. CULTURE OR TRADITIONAL HEALTH PRACTICE:
Self medication or home remedies :Yes , sometimes
Preferring to visit traditional healer or seek medical help: Yes, sometimes
Client's belief about health and illness: he believes that disease is due to
imbalance in the bodily functions and good heath can be maintained by following
healthy habits.
Client's perception of current health problem from religious aspect: he does
believe in religious aspects of health.

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FAMILY TREE

SN INDICES

1. FEMALE

2. MALE

3. FEMALE
DEAD

4. MALE
DEAD

5. PATIENT

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PHYSICAL EXAMINATION
A. Systemic Examination
Clinical Measurement
a. Blood pressure: 120/60 mm of Hg
b. Pulse:80 beats/min
c. Respiration: 22 breaths/min
d. Temperature: 98.0F
e. Height: 5 feet and 7 inch
f. Weight: 54kg
g. BMI:18.6 kg/m2
B. General Appearance and Mental status
• Body build: Well- built body
• Nutritional status: Appears well-nourished
• Posture and gait on standing, sitting and walking: normal, walk
Straight , stands erect in position
• Grooming status: appears well-groomed
• Hygienic condition: maintained , good hygiene, clean clothing and
bedding.
• Facial expression: active and tensed regarding illness
• Note body and breathe odor: No foul smelling
• Sensory aid devices: Not used
• Assess client attitude: Appropriate , co-operative
• Assess for mood, memory, judgment, thought, quality, quantity of
speech and appropriateness of the client response:
Normal,appropriate and clear voice.

Head
1. Skull and face
Inspect skull and face for;

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• Evenness of hair growth: even distribution , black hair and slightly grey hair present
• Hair thickness or thinness: black , grey and thin hair present
• Hair texture :smooth hair, oil used.
• Presence of infection or infestation: None
• Injury, abrasion, masses and scar: No any
• Skull shape, size and symmetry: Symmetrical in shape and size
• Scalp colour: whitish- brown
• Facial features: Symmetrical ,appropriate
• Eyes for hollowness, swelling: No papilledema and periorbital swelling
• Symmetry of facial movement: Symmetrical movement
• Facial skin:slightly wrinkle present.

Palpation
• Nodules or masses and depression: No
2. Eyes and Vision
Inspection and palpation
• Eyebrows for hair distribution and alignment, skin quality and movement :
Normal equal hair distribution and normal eye movement
• Eyelashes for evenness of distribution and direction of curl: Equal hair
distribution, entropion and ectropion not present
• Eyelids for surface characteristics, ability to blink: normal blinking
• Bulbar and Palpebral conjunctiva color, texture and presence of lesions: No any
signs of anemia and jaundice, and no any lesions, dark pink in color, moist.
• Lacrimal gland for edema and tenderness: No any edema and tenderness present
• Lacrimal sac and nasolacrimal duct: Normal
• Presence of discharge: no any discharge present, no signs of infections
• Tears production: Normal and spontaneous
Assess for;
• Cornea and corneal reflex: Corneal reflex Present in bilateral eyes.
• Pupils size: Normal in both eyes.
• Consensual reaction to light: Present, equally reactive to light.
• Near vision and distance vision: Normal in both eyes.

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• Peripheral vision: Normal
• Lens opacity: Not present

• Oculomotor muscle movement: Normal conjugate movement of the eyes in

each direction, no any deviations noted.
3. Ears and Hearing
Inspection
• Auricles for skin color: Dark - Brown
• Symmetry of size : Symmetrical, outer canthus of eye crosses 1/3rd of pinna
• Injury, scar, abrasions and nodules: Not present
• Ear canal for presence of wax and discharge: Slightly discharge present
Assess for;
• Clients response to normal voice tones: Normal response to normal voice
• Auricles for texture, elasticity and areas of tenderness: Normal texture, elasticity
and no any tenderness present
Palpation
• No any complain of pain at tragus and mastoid process
• Pre and post auricular, sub-mandibular and sub-mental lymph nodes: No
swelling and tenderness
4. Nose and sinuses
Inspection
• External nose deviations in shape:

✓ Shape and size: Symmetrical, normal shape and size

✓ Color : Dark-Brown, normal tone of color

✓ Flaring : No nasal flaring present

✓ Discharge from the nares: not present

✓ Nasal septum: Not deviated nasal septum

• Patency of both nasal cavity: Patent, no any obstruction
• Presence of redness, swelling : not present
Palpation
• External nares for tenderness, masses and displacement of bone and cartilage: Not
present
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• Maxillary and frontal sinuses for tenderness: No swelling and tenderness,sinusitis
not present
• Smell: Normal sense of smell
5.Mouth and oropharynx
Inspection
• Outer lips for symmetry, color and texture: Symmetrical, dark pink color and dry
lips present.
• Inner lips and buccal mucosa for color, moisture and the presence of lesions:
Pink colour , dry mucous membrane, no any lesions
• Teeth and gums for color, condition and quality: dark black colour gum and teeth,
no gum bleeding and swelling , dental caries present on upper 2nd molar
• Artificial teeth: None
• Tongue for position, color and texture: Midline position, dark pinkish brown in
color
• Tongue movement: Normal
• Presence of papillae: Normal
• Salivary duct opening for any swelling or redness: Not present
• Hard and soft palate for color, shape and presence of bony prominences: Normal
• Tonsil for color, discharge and enlargement: Pink throat, no swelling of tonsils
• Taste: Present
6 .Neck
Inspection
• Skin color:Dark- Brown and uniform colour all over the neck
• Neck muscle for scar, injury, abrasions, abnormal swellings or masses: Not present
• Head movement: Normal, no stiffness
• Assess muscle strength: Normal, no weakness
• Thyroid gland: Not visible
• Jugular vein for distention: Not distended
Palpation
• Entire neck for enlarged lymph nodes: Not enlarged
• Carotid pulse for its rhythm, regularity : Normal rhythm and regular pattern
• Thyroid gland for smoothness, enlargement or nodules: Not enlarged

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D. Thorax and Lungs and Heart
1. Posterior Thorax
Inspect for;
• Shape and symmetry of the thorax : Bilateral symmetric thorax, centrally located
sternum
• Spinal alignment: Normal
• Scar, injury, abrasions and lesions: Not present
Palpation;
• Respiratory excursion: Equal chest movement , no chest retraction
• Vocal fremitus: Equal vibration on both sides, tactile fremitus present
Percussion : Deep resonant sound heard over the lungs
Auscultation;
• Normal breath sound.
2. Anterior Thorax
Inspection
• Breathing pattern: expiration>inspiration
• Bilateral chest movement: Present
• Intercostal retraction: Not present
• Skin color, injury, scar, abrasions: Dark- Brown, no any scar, injury
Palpation
• Respiratory excursion: Equal chest movement
• Tactile fremitus: Equal vibration on both sides
Percussion
• Deep resonant sound heard over the lungs
Auscultation
• Normal breath sound present
3. Heart
• Heart sound were auscultated over the aortic, pulmonic, tricuspid and mitral:
Normal heart sound (lub-dub)
• Apical heart sound equal to radial pulse
4. Breast and Axillae
Inspection

15
• No any enlargement of breast tissue.
• Areola for size, shape, symmetry, color and any masses or lesions: Dark areola
with equal shape and size, and no any masses .
E. Abdomen
Inspection
• Skin integrity: Intact skin integrity
• Color: Dark-Brown
• Elasticity: Normal
• Scar: Not present
• Injury, abrasions or nodules: not present
• Abdomen for shape and symmetry: Flat shaped
• Abdominal distention: Not present
• Vascular pattern: Not present
Auscultation;
• Bowel sounds: Normal bowel sounds (clicks and gurgling), 15 times during 1 minute
Percussion;
• Scattered areas of tympany and dullness
Palpation :
• Liver ; Not palpable
• Kidneys : Not palpable
• Spleen : Not palpable
• Bladder not palpable
• Groin : On palpation over groin area
F. Upper limbs
Inspection
• Skin

✓ Color: Dark-Brown with equal hair distribution.

✓ Elasticity: slightly less elasticity due to dehydration.

✓ Abrasions: Not present

✓ Injury, scar: Not present

✓ Vascular pattern: Not present

• Nail
16
✓ Shape: Normal

✓ Color: Normal

✓ Tissue surrounding nails: Intact

✓ Capillary refill: Normal i.e., 0.3 sec was found

• Muscle and tendons for contracture: Not present
• Tremors of the hands and arms: Not present
• Bone for deformities: Not found
• Joint for swelling, range of motion: No any swelling and absence of range of motion in right foot
due to presence of wound and in other part normal.
Palpation;
• Pulse: Normal and regular
• Muscle strength: Good pull, push, flexion and extension
• Bones for oedema or tenderness: Present on left foot
Reflexes:
• Biceps reflex; Present
• Triceps reflex: Present
• Brachio- radialis reflex: Present
G. lower limbs
Inspection
• Skin

✓ Color: Dark- Brown

✓ Elasticity: Normal, no signs of dehydration

✓ Abrasions, injury, scar: Presence of infected wound on right foot .

✓ Vascular pattern: Not present

✓ Oedema: Present on left foot

• Nail

✓ Nail plate shape: Normal

✓ Color: Normal

✓ Tissue surrounding nails: Intact

✓ Capillary refill: Normal

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• Muscles and tendons for contracture: Not present
• Bone deformities: Not present
• Joint for swelling: Not present
• Range of motion: Absent on Right foot related to presence of wound
Assess for;
• Peripheral leg veins for sign of phlebitis: Not present
Palpation
• Pulse: Normal
• Muscle strength: Normal
• Bones for edema or tenderness: Not present
• Calf vein for varicose veins: Not present
Reflex
• Patellar reflex: Present
H. Genitalia
While asking the patient
• Pubic hair distribution: Normal
• Skin of the pubic areas for inflammation, swelling and lesions: no present
• Burning and frequent micturition: Not present
• Discharge and bleeding: Not present
I.Anus
While asking
• No any cracks, lesions, or bleeding.
SUMMARY OF PHYSICAL EXAMINATION:.
History taking and physical examination helps to reveal information about the patient.
They are the tool in obtaining subjective and objective data and thus help to assemble
information about patient.
After performing history taking and physical examination following things were
found:

a. Patient economic condition was average but cooperative.

b. Patient belonged to middle class family.
c. Patient was in prison since 10 months in the case of murder

18
d. Patient looks neat and clean, well groomed.
e. Dental carries on upper 2nd molar teeth is present.
f. Pulse rate, respiration rate are normal and B.P. is increased to 120/60 mm of hg
g. He is anxious regarding his disease and treatment
h. Nutritional status- well nourished, BMI was 18.6 kg/m2
i. dry skin, lips and mucus membrane
j. Patient had infected wound ( Diabetic foot ) on right foot and presence of edema on left foot
k. no any significant abnormality found in any specific body part

DEVELOPMENTAL TASK OF MIDDLE ADULTHOOD

Middle adulthood starts at the age of 46 and ends at 65 years. This is the period of physiological
changes that are gradual and inveitable; although physical growth has stopped he/she continues to
mature emotionally. In this period he or she has obtained personal achivements and socioeconomic
stability. He or she enjoys the role in assisting other young people or children, this is the time of
helping aging parents progress through the later years of life. The middle aged adults use their leisure
time in creative work and get satisfaction from his/her own work.

PHYSIOLOGICAL DEVELOPMENT
Major physiological changes occurs during 45-65 years of age. The changes in physical appearance
and functions vary from person to person .The most visible changes are grey hair, loss of hair,
wrinkling , body metabolism which begins to slow down due to lack of exercise. There is weight
gain, with excess fat deposition especially around waist and abdomen. Presbyopia is common in
middle adulthood.

COGNETIVE AND PSYCHOLOGICAL DEVELOPMENT

Middle aged adults are able to learn new skills and information. Some adults prepare themselves for
new education, career and vocational training. The cognitive function changes when they become
seriously ill or have trauma.
The psychosocial changes in middle age are due to children moving away from home, divorce and
death of spouse. The change may cause stress and affect the health of an individual.

SEXUALITY
There is decreased level of androgen which may cause climacteric changes in male. Due to the
hormonal changes in both male and female, middle aged adult experience changes in erection and
decreased repeated orgasm.
As my patient is 46 years old, he falls in the stage of middle adulthood. The core task of this stage is
generativity vs stagnation .
Following are the developmental task of middle adulthood,
Comparision of developmental task of middle adulthood according to ‘Havighrust’ with my patient
BOOK PICTURE PATIENT PICTURE

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 Achieving adult civil social responsibility Was not able to achive civic social
responsibility as he was in prison since 10
months
Helping teenage children become happy and He helped the teenage children to become
responsible adult responsible and happy adults all his children are
well established in their carrier and are adult.
Developing leisure activity Sometimes he used to read newspaper, watch
TV and listen music during leisure time
Establishing and maintaining as standard of Was not able to maintain as standard of living
living as he is not involved in any income generating
activity
Relating to one’s spouse as a person Relates ones spouse as a person
Accepting and adjusting to physiological Accepts and adjusts to physiological changes of
changes of middle age middle adulthood in a positive way
Adjusting to aging parents No aging parents as they both were expired

ANATOMY: The pancreas is an elongated, tapered organ located across the back of the belly,
behind the stomach. The right side of the organ—called the head—is the widest part of the organ and
lies in the curve of the duodenum, the first division of the small intestine. The tapered left side
extends slightly upward—called the body of the pancreas—and ends near the spleen—called the tail.

The pancreas is made up of 2

types of glands:

 Exocrine. The exocrine
gland secretes digestive
enzymes. These
enzymes are secreted
into a network of ducts
that join the main pancreatic duct. This runs the length of the pancreas.
 Endocrine. The endocrine gland, which consists of the islets of Langerhans, secretes
hormones into the bloodstream.

Functions of the pancreas :The pancreas has digestive and hormonal functions:

 The enzymes secreted by the exocrine gland in the pancreas help break down carbohydrates,
fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct
into the bile duct in an inactive form. When they enter the duodenum, they are activated. The
exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum. This
is the first section of the small intestine.
 The main hormones secreted by the endocrine gland in the pancreas are insulin and glucagon,
which regulate the level of glucose in the blood, and somatostatin, which prevents the release
of insulin and glucagon.

DISEASE PROFILE
DEFINATION
• Diabetes is a group of metabolic disease characterized by elevated level of glucose in the
blood (hyperglycemia)resulting from defect in insulin secretion, insulin action or both
(American Diabetes Association , Expertes committee on the diagnosis and Classification of
Diabetes Mellitus)

20
 EPIDEMOLOGY
 Approximately 537 million adults (20-79 years) are living with diabetes in world

 3 in 4 adults with diabetes live in low- and middle-income countries

 Almost 1 in 2 (240
million) adults living with
diabetes are undiagnosed

 Diabetes caused 6.7 million

deaths
 541 million adults are at
increased risk of developing
type 2 diabetes
SOURCE: IDF
Diabetes Atlas
10th Edition 2021 
th
 In 2019 diabetes was the 9
leading cause of death with an
estimated 1.5 million deaths
directly caused by diabetes
(WHO)

• 90 million adults (20-79) are

living with diabetes in the IDF South-East Asia (SEA) Region in 2021. This figure is
estimated to increase to 113 million by 2030 and 152 million by 2045.

• 47 million adults in the IDF SEA Region have Impaired Glucose Tolerance (IGT), which
places them at increased risk of developing type 2 diabetes

• Diabetes was responsible for 747,000 deaths in the IDF SEA Region in 2021. 

Source: IDF Diabetes Atlas 10th Edition 2021
In context of Nepal
• DM death in Nepal reached 6,555 or 3.94% of total deaths, Nepal rank #62 in world (WHO
2018)
• The estimated prevalence of type 2 DM in Nepal is 8.4% in 2021

CLASSIFICATION

1. Type 1 Diabetes Mellitus(Insulin Dependent Diabetes Mellitus or Juvenile Diabetes)

2. Type 2 Diabetes Mellitus(Non-Insulin Dependent Diabetes)
3. Gestational Diabetes Mellitus
4. Other Types
• Pre diabetes

• Latent Autoimmune Diabetes of adult (LADA)

TYPE 2 DIABETES MELLITUS

• Also known as Non-Insulin dependent Diabetes Mellitus or adult-onset Diabetes

• It result from Insulin resistance, a condition in which cells fails to use Insulin properly, or
when the body is able to produce some Insulin, but not enough for it to function properly
• This type of Diabetes is more common and accounts for 85-95% of all people with Diabetes
21
 • It mainly appears in people over the age of 40 years
• Uncontrolled Diabetes is a state in which your blood sugar levels are consistently above
180mg/dl even with the treatment ,which can lead to life threatening complication such as
heartattack or stroke
• Chronically high blood sugar levels can damage nerves, blood vessel and vital organs

RISK FACTORS
MODIEFIABLE PATIENT NONMODIEFIABLE PATIENT PICTURE
(BOOK PICTURE) PICTURE (BOOK PICTURE)

Physical inactivity Present History of gestational Not present

diabetes
Obesity Not present Race/Ethnicity Not present
(African ,American)
Hypertension Not present Age over 45 years Present

Alcohol intake Not present Family history of DM Not present

High Present
cholesterol,triglyceride

PATHOPHYSIOLOGY

Genetic Insulin resistance Acquired

Glucose cannot be taken up by different organ tissue which leads to increase blood glucose level

Stimulates beta cell of pancreas to produce more insulin

Hyperinsulemia

Compensiated resistance

Beta cell failure

Impaired insulin secretion

22
Increased hepatic Increased GI glucose absorption Glucose
production

Type 2 Diabetes Mellitus

CLINICAL FEATURES

BOOK PICTURE PATIENT PICTURE

Polyuria(frequency of urination) Present

Polydipsia(increased thirst and fluid intake) Present

Polyphagia(increased hunger) Present

Sudden weight loss Not present

Tingling and numbness in hands and feets Occassionally present with burning sensation
Constant fatigue Present
Soreness and wound that takes long time to heal Present
Skin infections Not present
Cramps Present (leg cramps)
Dry skin, lips and mucus membrane Present

DIAGNOSIS
1. History taking
2. Physical examination
3. Finger stick glucose test
4. Blood plasma glucose level
5. Oral glucose tolorence test
6. Glycosylated haemoglobin
7.
IN MY PATENT
• History taking,Physical examination ,finger stick blood glucose, Glycated
haemoglobin , fasting and post Prandial blood glucose, urine for acetone , Uric
acid was done
• Others: ECG, Complete blood count, liver function test , Renal function test and
lipid profile was done

INVESTIGATIONS VALUES

Lab investigation Patient value Normal value

Hemoglobin 12.2 gm/dl (11-18)gm/dl
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Total WBC count 7900/mm3 (4-11 x 10)/ mm3
Differential WBC count
Neutrophils 77% (40-45)%
Lymphocytes 20% (20-45)%
Eosinophils 01% (1-4)%
Monocytes 02% (0-6)%
Basophils 00% (0-1)%

RBC 4.62 million/mm3 (4.0-6.5)million/mm3

Platelates 243000/mm3 (150-500 x 100)/mm3
Bilirubin-T 045 mg% (0.4-1.0)mg%
Bilirubin-D 0.21 mg% Upto 0.4 mg%
Alk ptase 51. 14mg% ( 53-128) U/L
SGOT 32 U/L (5.0- 40.0) U/L
SGPT 24 U/L (5- 35) U/L
Blood sugar fasting 500 mg/dl (60-110)mg/dl
HbA1c 14.2 % <6.5%
Urea 23 mg% (20-40)mg%
Serum creatinine 0.44 mg% (0.4-1.4)mg%
Sodium 139 mmol/l (135-155)mmol/l
Potassium 4.3 mmol/l (3.5-5.5)mmol/l
Protein 6.7 gm% 6-8gm%
Albumin 2.9 mg% (3.4 – 4.8)mg%
Urine for Acetone Negative
Uric acid 2.05mg% ( 2-7)%

DAILY BLOOD SUGAR VALUE

Date Investigation name Patient value Normal value

2078/11/25 Blood sugar fasting 225mg/dl (60-110)mg/dl
Blood sugar post prandial 450mg/dl <150mg/dl
2078/11/26 Blood sugar fasting 308mg/dl (60-110)mg/dl
24
 Blood sugar post prandial 512mg/dl <150mg/dl
2078/11/27 Blood sugar fasting 282mg/dl (60-110)mg/dl
Blood sugar post prandial 425mg/dl <150mg/dl
2078/11/28 Blood sugar fasting 212mg/dl (60-110)mg/dl

 Urine for acetone was negative and ECG was normal

FINGER STICK DAILY GRBS MONITORING VALUE

Date Before Before lunch Before dinner At bed time

breakfast
2078/11/26 - 500mg/dl 475mg/dl 412mg/dl
2078/11/27 416mg/dl 444mg/dl 451mg/dl 437mg/dl
2078/11/28 250mg/dl 462mg/dl 252mg/dl 362mg/dl
2078/11/27 222mg/dl 350mg/dl 381mg/dl 338mg/dl
2078/11/29 231mg/dl - - -

MANAGEMENT
There are five component of diabetes management :

BOOK PICTURE PATIENT PICTURE

Nutritional management Done

Exercise Not done
Monitoring(Blood glucose level) Done(BBF,BL,BD,HS)
Pharmacological therapy Done

• Rapid acting insulin( Inj Regular

insulin)

Education Done

1) NUTRITIONAL MANAGEMENT :

 A healthy diet is key to controlling boood sugar levels and preventing diabetes complications.
Eat a consistent, well balanced diet that is high in fiber, low in saturated fat, and low in
concentrated sweets.
 A consistent diet that includes roughly the same number of calories at about the same time of
day should be taken and this helps health care professional prescribe the correct dose of
medication or insulin.

25
 A healthy diet also helps to keep blood sugar level and avoids excessively high or low blood
sugar level, which can be dangerous and life threatening .

2) EXERCISE :

 Reglular exercise, in any form, can help reduce the risk of developing diabetes.
Activity can also reduce the risk of developing complications of diabetes such as heart
disease, stroke, kidney failure, blindness, and leg ulcers.
 As little as 20 minutes of walking three time a week has a proven beneficial effect.
Any exercise is beneficial; no matter how easy or how long, some exercise is better
than no exercise.
 If the patient has complications of diabetes (such as eye, kidney, or nerve problems),
they may be limited both in types of exercise, and amount of exercise thy can do
without worsening their condition. Consult your health care provider before starting
any exercise program.

3) MONITORING :

 Check the blood sugar level frequently, at least before meals and at bedtime, then
record the results and at bed time, then record the result in a chart.
 The chart should also include the recording of insulin or oral medication doses and
times, when and what the patient ate, and any significant events of the day such as
high or low blood sugar levels and how they treated the problem
 A daily and regular blood sugar monitoring is valuable to the health care professional
in evaluating how the patient is responding to medication, diet, and exercise in the
treatment of diabetes.

4) PHARMACOLOGICAL THERAPY :

 Many different types of medication are available to help lower the blood sugar level
in people with type 2 diabetes. Each type works in a different way. It is very common
to combine two or more types to get the best effects with fewest side effects.

 Pharmacological therapy used in my patients:

 At 2078/12/27
 Inj. Clavum x 1.25 gm x IVx BD
 Inj. Ornidazole x 500mg x IV x BD
 Inj. Rabeloc x 20mg x IVx BD
 Inj. Regular. Insulin x 40 unit with 10 meq kcl with Inj. 500 ml x Normal saline x 3 pint over
24 hrs.

 At 2078/11/28, Inj. Insulin unit was changed to;

 Inj. Regular. Insulin 14 unit with 10 meq kcl with Inj . 500 ml normal saline x 3 pint over 24
hrs respectively

26
  At 2078/11/29, Inj. Insulin was not changed .

EDUCATION :

 Education about diabetes and its treatment is essential in all type of diabetes;
 When the patient is diagnosed with diabetes for the first time, patient should be provided
teaching about their condition, treatment and everything they need to know to care for them
on daily basis.

PROGNOSIS OF TYPE 2 DIABETES MELLITUS

By the time they’re diagnosed, 50% of people with type 2 diabetes already show signs of
complications. These complications may begin 5-6 years before diagnosis, while the diabetes itself
may start 10 years or more before the clinical diagnosis is made.

CVD is a major cause of death and disability in people with type 2 diabetes, accounting for 52% of
fatalities in this group. People with type 2 diabetes have a two-fold increased risk of stroke within the
first five years of diagnosis compared with the general population.

Other possible complications include:

 Kidney disease. Diabetes is the single most common cause of end-stage kidney disease and
about one in three people with type 2 diabetes develop overt kidney disease. Kidney disease
accounts for 11% of deaths in people with type 2 diabetes.

 Depression. The prevalence of depression is approximately twice as high in people with

diabetes as it is in the general population.

 Neuropathy (nerve damage). Damage to the nerves that transmit impulses to and from the
brain and spinal cord to the muscles, skin, blood vessels and other organs may affect up to
50% of people with diabetes. It can also cause erectile dysfunction and chronic pain.

 Limb amputation. Diabetes is the most common cause of lower-limb amputation. About one
in every 20 people with diabetes will develop a foot ulcer in any given year and more than
one in ten foot ulcers result in the amputation of a foot or leg. Up to 70% of people die within
five years of having an amputation as a result of diabetes.

Life expectancy is reduced, on average, by up to 10 years in people with type 2 diabetes.

COMPLICATIONS
 CHRONIC COMPLICATION:
1. Diabetic Retinopathy:leading cause of blindness in adult
2. Diabetic Nephropathy:leading cause of end stage renal failure disease
3. Diabetic Neuropathy:leading cause of non traumatic lower leg amputation
4. Stroke:2-4 fold increase in cv mortality and stroke
5. CV disease:8 out of 10 individual with diabetes die from cv events

 ACUTE COMPLICATION
1. Hyperosmolar hyperglycemic non ketotic syndrome

NURSING MANAGEMENT

27
 NURSING ASSESSMENT :
 History taking :dietary history, eating habits, use of tobacco, alcohols and pescribed
over the counter medications, lifestyle psychosocial and economic factors that may
affect diabetic treatment, effect of diabetes or its complication on functional status.
 Physical examination : assess; blood pressure, BMI, perform foot examination,
nervous system, mouth and visual examination
 Laboratory examinations : HbA1c, blood sugar fasting & post prandial, lipid profile, serum
creatinine level, urine for acetone, ECG.
 Asser for signs of hyper and hypoglycemia
 Assess for complication or risk for developing complication

NURSING DIAGNOSIS :

 Altered nutrition more than body requirement related to increased hunger and eating
habit
 Altered blood glucose level related of physical inactivity , imbalanced diet and
impaired insulin secretion
 Risk for infection related to high glucose level (520 mg/dl) as evidenced by disrupted
epidermis and elevated WBC , Neutrophils ( 77 % )

 Delay wound healing related to disease condition and poor peripheral circulation
 Activity intolerance related to poor glucose control and diabetic foot

NURSING INTERVENTION :
For nutrition:
 Assess dietary pattern and eating habits
 Explore techniques to explore eating behavior
 Advice the importance of individualized meal planning and techniques of meal
planning with patient
 Encourage patient of take high fiber diet, non starchy vegetables, low protein and
carbohydrate diet.
 Limit the intake of fatty foods and take low salt diet.

For maintaining blood glucose level:

 Help patient to identify, select , participate in energy expending activities
 Perform regular blood glucose monitoring
 Explain the importance of exercise in maintaining body wright and teach simple
exercise
 Encourage the patient to perform daily exercise at least 20min
 Instruct patient to take all medication regurarly.

For activity intolerance:

 Assess patients tolerance and response to activity
 Assess the patients functional ability to perform activity
 Encourage patient to plan exercise in regular basis each day
 Identify activities that leads to fatigue and avoid it

28
  Encourage patient to eat carbohydrate snacks before exercising to avoid
hypoglycemia
 Advice patient to avoid prolonged strenuous exercise and avoid exercise if blood
glucose level is >250md/dl.
For infection prevention:
 Assess patient skin for any damaged tissue , swelling and redness
 Provide clean environment, change bed sheet everyday
 Encourage the patient to take proper antibiotic therapy
 Encourage the patient to maintain personal hygiene
 Assess the patients blood WBC count for determining infection

DRUGPROFILE

Inj. CLAVUM

GENERIC AND PROPRIETARY NAMES- Amoxicilin + Clavulanate

ACTION- It inhibits the synthesis of bacterial cell wall by binding to one or more of the penicillin
binding protein which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in
bacterial cell walls, thus inhibiting cell wall bio- synthesis.

CLASSIFICATION- Beta – lactamase inhibitors

PREPERATION- It is usually available in the form of tablets , dry syrup and injections such as :

Amoxicilin 500mg + Clavulanic acid 125 mg tablet

Amoxicilin 200mg + Clavulanic acid 28.5 mg dry syrup

Amoxicilin 1000mg + Clavulanic acid 200mg vial

USUAL DOSE

By mouth : Adult and children over 12 years : 250 mg tds and doubled in severe infection

Children under 1 years : 20 mg / kg daily in 3 divided doses.

INDICATIONS

 Intra abdominal infections , Gynecological infections

 Respiratory tract infections , Otitis media ,
 Surgical prophylaxis , Dental infection , Urinary tract infection

CONTRAINDICATIONS

 Hypersensitivity to penicillins , severe renal disease , dialysis , jaundice

PRECAUTIONS

 Pregnancy (B) ,breastfeeding , neonates ,hypersensitivity to cephalosporins , asthma , colitis

COMMON SIDE-EFFECTS

29
  GIT : Nausea , vomiting, diarrhoea , pseudomembranous colitis
 SKIN : Urticaria, angioedema , exfoliative dermatitis , stevens Johnson syndrome
 LIVER : Liver dysfunction , elevation in AST , ALT , alkaline phosphate
 BLOOD : Hemolytic anemia , thrombocytopenia , neutropenia
 MISCELLANEOUS : Convulsion , Vaginal candidiasis , serum sickness , vasculitis
 SYST : Respiratory distress , superinfection

INTERACTIONS

 INCREASE : amoxicillin levels – probenecid

 INCREASE : anticoagulant effect – warfarin
 INCREASE : skin rash – allopurinol
 DECREASE : action of oral contraceptives

PHARMACOKINETICS

PO: Peak 2 hr , duration 6-8 hr , half life 1- 1 hr , metabolized in liver , excreted in breast milk ,

removed by hemodialysis

 NURSING CONSIDERATIONS

 Medicine can give without regard to food , instruct patient chews or crush chewable tablet
before swallowing .
 The oral suspension is stable for 14 days after reconstitution at either temperature .
 Be alert for super infection as increased fever , onset of sore throat

PATIENT TEACHING

 To take as prescribed , not to double dose .

 All aspects of product therapy : to complete entire course of medication to ensure organism
death ( 10 – 14 days ) ; that culture may be taken after completed course of medication.

Inj. ORNIDAZOLE

Generic Names & Brand Names

amlodipine besylate

Norvasc, amtas, amlod

Pregnancy Category ‘C’

Drug classes

 Calcium channel-blocker
 Anti anginal drug
30
  Antihypertensive

Mechanism of action

Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells;
inhibits transmembrane calcium flow, which results in the depression of impulse formation in
specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse,
depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral
arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and
in patients with vasospastic (Prinzmetal’s) angina, increased delivery of oxygen to cardiac cells.

Indications

 Angina pectoris due to coronary artery spasm (Prinzmetal’s variant angina)

 Chronic stable angina, alone or in combination with other agents
 Essential hypertension, alone or in combination with other antihypertensives

Contraindications and cautions

 Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus
syndrome, heart block (second or third degree), lactation.
 Use cautiously with CHF, pregnancy.

Available forms

Tablets—2.5, 5, 10 mg

Dosages

ADULTS

Initially, 5 mg PO daily; dosage may be gradually increased over 10–14 days to a maximum dose of
10 mg PO daily.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC IMPAIRMENT

Initially, 2.5 mg PO daily; dosage may be gradually adjusted over 7–14 days based on clinical
assessment.

Pharmacokinetics

Route Onset Peak

Oral Unknown 6–12 hr

Metabolism: Hepatic; T1/2: 30–50 hr

Distribution: Crosses placenta; may enter breast milk

Excretion: Urine
31
Adverse effects

 CNS: Dizziness, light-headedness, headache, asthenia, fatigue, lethargy

 CV: Peripheral edema, arrhythmias
 Dermatologic: Flushing, rash
 GI: Nausea, abdominal discomfort

Interactions

Drug-drug

 Possible increased serum levels and toxicity of cyclosporine if taken concurrently

Nursing considerations

Assessment

 History: Allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome,

heart block, lactation, CHF
 Physical: Skin lesions, color, edema; P, BP, baseline ECG, peripheral perfusion,
auscultation; R, adventitious sounds; liver evaluation, GI normal output; liver and renal
function tests, urinalysis

Interventions

 WARNING: Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug
to therapeutic dose; use special caution if patient has CHF.
 Monitor BP very carefully if patient is also on nitrates.
 Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-
term therapy.
 Administer drug without regard to meals.

Teaching points

 Take with meals if upset stomach occurs.

 You may experience these side effects: Nausea, vomiting (eat frequent small meals);
headache (adjust lighting, noise, and temperature; medication may be ordered).

Report irregular heartbeat, shortness of breath,

Drug Name; TAB MEDOMOL

Generic Name: acetaminophen (N-acetyl-p-aminophenol)

Brand Name:

 Oral: Aceta, Apacet, Atasol (CAN), Genapap, Genebs, Liquiprin, Mapap, Panadol, Tapanol,
Tempra,Tylenol

Classification: Antipyretic, Analgesic (nonopioid)

Pregnancy Category ‘B’

32
Dosages

ADULTS

PO, 1,000 mg tid to qid. Do not exceed 4 gm daily

Therapeutic actions

 Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to

cause vasodilation and sweating, which helps dissipate heat.
 Analgesic: Site and mechanism of action unclear.

Indications

 Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding

diatheses, upper GI disease, gouty arthritis
 Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically
significant antirheumatic and anti-inflammatory effects)
 Common cold, flu, other viral and bacterial infections with pain and fever
 Unlabeled use: Prophylactic for children receiving DPT vaccination to reduce incidence of
fever and pain

Adverse effects

 CNS: Headache
 CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for
several weeks or when doses of 4 g/day are ingested for 1 yr
 GI: Hepatic toxicity and failure, jaundice
 GU: Acute kidney failure, renal tubular necrosis
 Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria;
neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia
 Hypersensitivity: Rash, fever

Contraindications

 Contraindicated with allergy to acetaminophen.

 Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

Nursing considerations

Assessment

 History: Allergy to acetaminophen, impaired hepatic function, chronic alcoholism,

pregnancy, lactation
 Physical: Skin color, lesions; T; liver evaluation; CBC, LFTs, renal function tests

Interventions

 Do not exceed the recommended dosage.

 Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if
continued fever, severe or recurrent pain occurs (possible serious illness).
 Avoid using multiple preparations containing acetaminophen. Carefully check all OTC
products.
33
  Give drug with food if GI upset occurs.
 Discontinue drug if hypersensitivity reactions occur.
 Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should be available
as a specific antidote; basic life support measures may be necessary.

Teaching points

 Do not exceed recommended dose; do not take for longer than 10 days.
 Take the drug only for complaints indicated; it is not an anti-inflammatory agent.
 Avoid the use of other over-the-counter preparations. They may contain acetaminophen, and
serious overdosage can occur. If you need an over-the-counter preparation, consult your
health care provider.
 Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding
patterns

 swelling of the hands or feet, pronounced dizziness, constipation

INJ REGULAR INSULIN

GENERIC NAME: REGULAR INSULIN
BRAND NAME: Humalin R, Novolin R, Humulin R U-500
CLASS: Anti diabetics, short acting insulin
Mechanism of action

The desired and beneficial action of insulin is:

 Insulin replaces endogenous insulin. It is the only parenteral antidiabetic agent available for
exogenous replacement of low levels of insulin. It reacts with the receptors of the cells to
facilitate transport of various metabolites and ions across cell membranes and stimulates the
synthesis of glycogen from glucose, of fats from lipids, and of proteins from amino acids.

Indications

Insulin is indicated for the following medical conditions:

 Treatment of type 1 diabetes

 Treatment of type 2 diabetes when other agents have failed
 Short-term treatment of type 2 diabetes during periods of stress
 Management of diabetic ketoacidosis, hyperkalemia, and marked insulin resistance

Pharmacokinetics

Here are the characteristic interactions of insulin and the body in terms of absorption, distribution,
metabolism, and excretion:

Route Onset Peak Duration

Regular 30-60 min 2-4 h 6-12 h

Contraindications and Cautions

The following are contraindications and cautions for the use of insulin:

34
  No contraindications as it is a replacement hormone. However, close monitoring is needed
among pregnant and lactating women to adjust the dose accordingly. It is the drug of choice
for management of diabetes during pregnancy.
 Insulin does enter breast milk but it is destroyed in the GI tract and does not affect the
nursing infant.
 Insulin-dependent mothers may have inhibited milk production because of insulin’s effects
on fat and protein metabolism.

Adverse Effects

Use of insulin may result in these adverse effects:

 hypoglycemia and ketoacidosis

 local reactions at the injection site (lipodystrophy).

Interactions

The following are drug-drug interactions involved in the use of insulin:

 MAOIs, beta blockers, salicylates, alcohol. Increased glucose reduction

 Beta blockers. Blocking the SNS also blocks many of the signs and symptoms of
hypoglycemia, hindering the patient’s ability to recognize problems.
 Various herbal therapies (juniper berries, ginseng, garlic, fenugreek, coriander,
dandelion root, celery). Increased risk of developing hypoglycemia.  

Nursing Considerations

Here are important nursing considerations when administering insulin:

Nursing Assessment

These are the important things the nurses should include in conducting assessment, history taking,
and examination:

 Assess for contraindications or cautions (e.g. history of allergy, pregnancy, etc.) so that
appropriate monitoring and dose adjustments can be completed.
 Perform a physical assessment to establish a baseline before beginning therapy.
 Assess skin lesions; orientation and reflexes; bloodpressure, pulse, respiration and
adventitious breath sounds which could indicate a response to high or low glucose levels and
potential risk factors in giving insulin.
 Inspect skin areas that will be used for injection; note any areas that are bruised, thickened, or
scarred, which could interfere with insulin absorption and alter anticipated response to insulin
therapy.
 Obtain blood glucose levels as ordered to monitor response to insulin.
 Assess activity level, including amount and degree of exercise which can alter serum glucose
levels and need for these drugs.
 Monitor the results of laboratory tests, including urinalysis, for evidence of glucosuria.

Nursing Implementation with Rationale

These are vital nursing interventions done in patients who are taking insulin:

35
  Ensure that patient has dietary and exercise regimen and using good hygiene practices to
improve the effectiveness of the insulin and decrease adverse effects of the disease.
 Monitor nutritional status to provide nutritional consultation as needed.
 Gently rotate the vial containing the agent and avoid vigorous shaking to ensure uniform
suspension of insulin.
 Rotate injection sites to avoid damage to muscles and to prevent subcutaneous atrophy.
 Monitor response carefully to avoid adverse effects.
 Always verify the name of the insulin being given because each insulin has a different peak
and duration, and the names can be confused.
 Use caution when mixing types of insulin; administer mixtures of regular and NPH insulins
within 15 minutes after combining them to ensure appropriate suspension and therapeutic
effect.
 Store insulin in a cool place away from direct sunlight to ensure effectiveness. Pre drawn
syringes are stable for 1 week if refrigerated.
 Monitor patient’s food intake and exercise and activities to ensure therapeutic effect and
avoid hypoglycemia.
 Monitor patient’s sensory losses to incorporate his or her needs into safety issues, as well as
potential problems in drawing up and administering insulin.
 Provide good skin care and foot care, to prevent the development of serious infections and
changes in therapeutic insulin doses.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to report to enhance patient
knowledge and to promote compliance.   

Evaluation

Here are aspects of care that should be evaluated to determine the effectiveness of drug therapy:

 Monitor patient response to therapy (stabilization of blood glucose levels).

 Monitor for adverse effects (hypoglycemia, ketoacidosis, injection-site irritation).
 Evaluate patient understanding on drug therapy by asking the patient to name the drug, its
indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.

INJ LANTUS

Generic name : Insulin glargine

Brand name: Basaglar, lantus, Rozvoglar

Class: Antidiabetic, long acting insulin

Mechanism of action:Promoting movement of sugar from blood into body and also stops
sugar production in liver. Insulin glargine is manmade insulin that mimic the action of basal
insulin in body. It is longacting insulin and duration is extended upo 30 hours and is usually
used once a day

Indication: it is used to achive glycemic control in adults and pediatrics with type1 and type2
diabetes mellitus

Contraindication: hypoglycemia, hypokalemia, liver problem, decreased kidney function

Pharmacokinetics:
36
Onset- 4-6 hours; Peak- peakless at it works in same concentration throughout the whole
duration ; Duration- 24-36 hours

Sideffects: headache, hunger, weakness ,sweating, tremors, irratibility, rapid breathing,

trouble concentrating.

NURSINGCONSIDERATION

o It should be best stored at the temperature of 2-8 degree celsisus in the refrigerator but
should not be frozen
o Warm the vial before injecting
o Give dose 15 to 30 min before meal
o Local tissue atropy (lipodystrophy) can be prevented by rotating the site of injection
and using same site no more frequently than once every 4 weeks
o Instruct patient about importance of monitoring perodic blood sugar
o Instruct the patient about the symptoms of hypoglycemia.

37
APPLICATION OF NURSING THEORY RELATED TO SELF CARE
DEFICIT:

Dorothea E. Orem began her nursing career in the early 1930s after receiving her RN diploma
from Providence Hospital School of Nursing, Washington DC. In 1939, she received her BS
in
nursing and in 1945, her MS in nursing education from Catholic University of America,
Washington DC. Orem first published her concept of nursing as providing for an individual’s
self-care in 1959 in “Guides for developing curricula for the Education of Practical Nurses”,
a
government publication. In 1971, she further developed her ideas of focusing on the
individual inNursing : concepts of practice. In 1980 and 1985 she refined and explained her
ideas to include self-care of families, groups, and communities; the fourth edition of her book
was published in 1990. Dorothea Orem’s theory consists of three related theories; self-care,
self-caredeficit and nursing system, collectively referred to as Orem’s General Theory of
Nursing.

⦿ THEORY OF SELF CARE:

Theory of self-care is based on the concepts of self-care, self-care agency, self-care
requisites,
and therapeutic self-care demand. This theory promotes the goal of self-care.

⦿ THEORY OF SELF CARE DEFICIT:

This theory explains when nursing is needed and explains how people can be helped through
nursing. Self-care arises when the selfcare agency cannot meet self-care requisites or when a
patient cannot administer self-care. Self-care deficit necessitates nursing to meet the self-care
requisites through five methods of help: acting or doing for, guiding, teaching, supporting and
providing an environment to promote the patient’s ability to meet current or future demands.

⦿ THEORY OF NURSING SYSTEM:

Theory of nursing system refers to actions a nurse takes to meet a patient’s self-care
requisites. It is determined by the patient’s self-care requisites and self-cares agency. It is
composed of three systems- wholly compensatory, partly compensatory and supportive
educative system.
In my case, I have applied both partly compensatory and supportive educative system.
• Partly compensatory: my patient along with me performed activities to achieve desired self-
care goals. My patient was able to do some self-care measures but needs nursing assistance to
meet others. It gave a give and take relationship between the nurse and the patient.
• Supportive and educative system:
From 3rdday, I started supportive and educative system.
I used many resources and educational tools to teach the patient and the family members to
accomplish the tasks. It indicates that my patient contributes mostly in his or her self-care and
nurse is merely to monitor and regulate the patient’s self-care. My patient accomplishes self-
care and regulates the exercise and development of self-care agency. The patient was able to
perform or can able to perform, required measures of therapeutic self-care but cannot do so
without assistance. The patient can meet the self-care care requisites but needs help in
decision making, behavior control or knowledge acquisition.

❖ THEORY APPLICATION
According to Orem, Nursing has its special concern; the individual need for self-care action
and the provision and management of it on a continuous basis in order to sustain life and
health,
recover from disease or injury and cope with their effects”.
38
 Orem’s approach to the nursing process presents a method to determine the self-care deficits
and then to define the roles of the person or the nurse to meet the self-care demands of an
individual.

ASSESSMENT:
Basic conditioning factors: Age/gender, healthstatus, developmental state,socio cultural
orientation, healthcare system ,family system, pattern of living, environment, source of
income was assessed

NURSING DIAGNOSIS:

 Altered blood glucose level related to physical inactivity, imbalanced diet and impaired
insulin secretion
 Fluid volume defecit releted to osmotic diuresis from hyperglycemia
 Activity intolerance related to poor glucose control
 Knowledge defecit related to disease process and treatment regimen
 Risk for impaired skin integrity related to decreased sensation and circulation to lower
extremitis

NURSING CARE PLAN

39
Altered blood glucose level related to physical inability, imbalanced nutrition and impaired insulin secretion
SN ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL EVALUATION
DIAGNOSIS
1. Subjective data: Altered blood Patient blood 1.Assess general 1.Patients general 1. Provides baseline data My set goal was
patient says I glucose level sugar will be condition of the condition assessed. about patients partially met at
am feeling related to maintained patient physiological condition patient blood
excessive physical within normal glucose was
“thirst and inability, range within 2.Monitor the 2.capillary blood glucose 2.To identify thr maintained at
hunger” imbalanced the period of capillary blood level monitored at BBF, imbalance in blood level of 143-
Objective data: nutrition and hospitalization glucose level at BL, BD& HS glucose levels 250mg/dl(before
Capilary blood impaired regular interval as 3. Daily weight 3.To determine weight meal) within the
glucose level insulin pescribed monitoring was done loss or weight gain period of
increased, FBS secretion 3.monitor daily hospitalization
increased, weight 4.Patient was adviced to 4. To prevent
PPBS decrease carbohydrate hyperglycemia
increased, 4.Advice patient to rich diet like white rice,
HbA1c avoid carbohydrate white breaed,potatos etc
increased like direct sugar in
diet 5.Helps to maintain body
5.Encourage patient 5.Patient was encouraged weight
to perform simple to perform simple
exercise 150min/ week 6.To decrease the blood
exercise daily glucose level
6.Administer insulin 6.Inj rinsulin, inj lantus
therapy and and tab metformin was
oralhperglycemic as administered as 7.To prevent complication
pescribed pescribed by doctor of disease
7.advice the client 7.Patient was adviced to 8.To evaluate the
on the need of continue treatment effectiveness of nursing
regular treatment 8. Patients condition was care provided
8.Reassess the reassessed

patients condition

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Fluid volume deficit related to osmotic diuresis from hyperglycemia
SN ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL EVALUATION
DIAGNOSIS
2. Subjective data: Fluid volume After 8 hours 1.Assess patients 1.general condition of 1.provides baseline My set goal
patient says “I defecit related of nursing general condition patient was assessed information of was fully met
am feeling to osmotic intervention , patients physiologic as after 8 hours
week, always diuretics from patient will state of nursing
2.Monitor orthostatic 2.Orthostatic blood pressure 2.Hypovolemia may
thirsty and hyperglycemia demonstrate intervention
blood pressure changes and pulse rate was be manifested by
having adequate patient was able
and pulse rate
excessive hydration monitored and was hypotension and to demonstrate
urination” 120/70mm of hg and bradycardia. adequate
Objective data 3.Assess skin turgor and 112b/m respsctively. hydration as
Dry skin and mucus membrane 3.Indicated the lelv evidenved by
mucus 3.Patients skin was dry, of dehydration stable vitals and
membreane, rough and mucous good skin
poor skin 4.Monitor input and membrane and lips were dry turgor
turgor, vital output strictly 4.Provide estimate of
sign: 4.Input and output was volume replacement
pulse;112b/m strictly monitored and needs and kidney
5.Encourage patient to charted function
increase fluid volume 5.Helps to overcome
5.patient was encouraged to loss of fluid via urine
increase fluid intake;1 liter
6.Reassess patients
more than daily output 6.Helps to evulate
condition
effectiveness of
6. patients condition nursing intervention
reassessed

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Activity intolerance related to poor blood glucose control
SN ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL EVALUATION
DIAGNOSIS
3. Subjective data Activity Patient will 1.Assess the 1.Level of physical activity 1.Provide baseline My set goal
patient says “I intolerance demonstrate physical activity and mobility of patient was information for was fully met
feel tired during related to poor tolerance to level and mobility of assessed formulating baseline as patient
simple work blood glucose activity by patient nursing goal setting demonstrated
and feels weak” control achiving tolerance to
Objective data: glycemic 2.Perodic capillary blood 2.Helps to determine activity as
Patients control within 2.Perodic blood glucose monitoring was if the patient is verbalized by
bloodglucose the period of glucose monitoring Done hyperglycemic patient and
level increased hospitalization glycemic
FBG;444mg/dl, 3.patient was encouraged 3.Activity and control
patient seems 3.Avoid exercise and to rest and avoid exercise exercise will increase
lethargic and strenou sactivity if when blood glucose level the demand of
tired by his blood glucose is is >250mg/dl glucose in muscles
facial >250mg/dl
expressions 4.patient was encouraged 4.Helps to increase
4.Have the patient to plan activity and rest the tolerence of
perform the activity period and take long time activity.
slowly, in a longer to perform activity with
time with more rest more rest
5.Oral hypoglycemic and 5.Helps to obtain
5.Administer insulin was administered as glycemic control
antidiabetic pescribed
medication as
pescribed
6. patients tolerance level 6. Helps to
6.Reassess patients and activity level assessed determine the
activity level and effectiveness
tolerance ability of nursing
intervena
Knowledge defecit related to disease process and treatment regimen
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SN ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL EVALUATION
DIAGNOSIS
4. Subjective data: Knowledge Patient will 1.Assess the patients 1.Patinets level of 1.provide baseline My set goal
patient says “I defecit related demonstrate level of knowledge knowledge about disease information about was fully met
don’t know why to disease understanding about disease process and treatment was assessed patients as my patient
is insulin used process and of disease and treatment regemin understanding . demonstrated
in me” treatment process and understanding
Objective regemin treatment 2.Focus on patients 1. Patients major 2.Helps to know the of disease
data:Patient was regemin major concern concerns were topic needed to be process and
not willing to within 2 hours focused and cleared discuss treatment
take insulin and regemin as
was frequently 3.Provide calm and 3.Calm and friendly 2. A calm verbalized by
asking why his peaceful environment environment was created to the environment patient
without interruption patient will allow
blood glucose
level is patient to
increasing concentrate
on thing you
are explained

4. Patient was explained about 4.Helps to increase the

4.Explain patient patient level of
disease , it prognosis,possible
about disease process knowledge and
complication and need and
its prognosis and importance of insulin therapy understanding
treatment regimen
5.Patient was explained about
5.Explain the patient sign and symptoms of hyper 5.Helps patient to early
about sign of hyper and hypoglycemia determine and seek
and hypoglycemia help if these sign
occurs
6.Provide patient
information about
insulin therapy 6.Patient was informed about 6.Helpsto increase
insulin therapy, its uses , patient understanding
about insulin therapy
7.Reassess patients technique of administering
43
 level of knowledge used in him
and understanding 7. Patients level of knowledge 7.Helps to evaluate the
and understanding about effectiveness of
disease, treatment regemin was nursing intervention
reassessed

Risk for impaired skin integrity related to decreased sensation and blood supply to lower extremeties
SN ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONAL EVALUATION
DIAGNOSIS
5. Subjective data Risk for Patient will 1.Inspect the body 1.patient entire body skin 1. provide baseline My set goal
Patient says I impaired skin have skin for any impair including foot was information for was fully met at
have burning integrity related maintained ment especially the assessed , there was no any planning care patient skin
and tingling to decreased skin integrity foot area impairment in skin integrity was
sensation in my sensation and during the maintained
feet blood supply to period of during the
Objective data: lower hospitalization 2.Encourage patient 2. Patient was period of
patient had extremities to ambulate encouraged to hospitalization
decreased pedal ambulate twice 2.Helps to increase
pulse atleast fo 10-15 blood circulation to
3.Encourage patient minutes lower extremities
to avoid tight shoes
and shcoks 3.Patient was encouraged to 3.Tight shoes and
avoid tight shoes and shocks shocks can inpair the
4.Encourage patient and wear soft slippers blood flow to feet
to use slippers and
avoid walking bare 4.Pateint was encouraged to 4.Protect feet from
foot wear slippers while walking injury

5.Maintain skin
5. patient was encouragrd to 5.Prevent skin from
hygiene and use take bath daily and clean their breking down and
moisturizer to keep
44
skin soft foot daily and use vasline to protect from skin
keep the moist infections
6.Reassess the
patients condition of 6.Patients condition fo skin 6.Helps to determine
skin was reassessed the effectiveness of
nursing
implementation

45
SPECIAL GADGETS USED IN MY PATIENT
 BP set
 Thermometer
 Pulse Oximeter
 Screen
 ECG machine
 Tuning fork
 Weighing machine
 Measuring tape and watch
 Torchlight and tongue depressor
 Hammer for reflex test
 Glucometer

DIVERSIONAL THERAPY USED IN MY PATIENT

There is arise in stressful situation where there is new adjustment, situation and different
environment. Due to change in environment and disease condition some stress in environment that is
perceived as threatening or damaging to the person’s dynamic equilibrium.
The mind is diverted due to the diversional therapy which is used parallel with medicines for the
treatment of ill persons, in this time an ill person is more concentrated towards his illness.This type
of diversional therapy diverts the concern to another areas than his illness. The following diversional
therapy in patient is used: -
1. Talk Therapy: - It is very simple and effective therapy. Lots of information can be obtained by this
method which find out the causes of stress by exposing patient psychological, social and cultural
views. So, conversation with the patient is needed time to time to find out the views of the patient.
2. Imaginary: - It is very much important to imagine the good movement which is essential for the
patient to relax from the anxiety and improve better sleep and get rid of the problem. I encouraged
my patient to imagine good moment.
3. Distraction: - This method help patient to divert into pleasant situation. This can be done by
listening the music or talking with others. This will ultimately help to make the patient free from
stress he likes to listen music.
4. Others: -
 Good environment with warm atmosphere is very much essential.
 Patient should try to find out the fact than imagination.
 Without giving false reassurance to the patient.
 Patient should participate in the plan of care and he should be given suitable choice.
 For proper safety and security, we should stay with the patient to reduce the fear.
46
 Diseases condition should explain clearly.
 To support the patient for her own coping strategies.

DAILY PROGRESS NOTE OF THE PATIENT

DATE-2078/11/23
Admitted the patient in male medical ward
 Introduction with the patient.
 General condition was assessed.
 Medicines were administered.
 During my shift, his vital signs were: -
T-97.6◦F, P- 92 beats/min, RR-26breaths/min, BP-110/60mm of Hg
Spo 2 :98% in room air.
DATE-2078/11/24
 Assessed the patient’s general condition.
 Monitored vital signs and provided medications.
 History taking was done
 Patients need was assessed by applying Orems self care theory
 Patient was encouraged to perofrm oral caew and take bath
 Change the bedsheet and clothing of patient.
 Baseline investigation was sent as per doctors order (CBC, LFT,RFT,Lipidprofile,Urine for
acetone ECG , and blood sugar fasting and post prandial was sent)
 Revised cardex after round, and GRBS monitoring BBF, BL, BD, HS was started
 During my shift, his vital signs were: -
T-98.2 F, P- 90 beats/min, RR-20breaths/min, BP-100/60mm of Hg
Spo 2 :97% in room air and GRBS was 374 mg/dl

DATE-2078/11/23
 Condition of the patient was assessed.
 Provided medications as instructed and monitored vital signs.
 Took complete history of the patient and performed physical examination
 Kept the patient in comfortable position.
 All blood investigations report were collected, abd blood sugar postprandial was sent
 Routine works were conducted.
 GRBS monitoring done and was 462mg/dl

47
 Encouraged him to take balanced diabetic food.
 Encouraged for oral intake high fiber food.
 During my shift, his vital signs were: -
T-97.8 F, P- 88 beats/min, RR-20breaths/min, BP-110/70mm of Hg
Spo 2 :96%without o 2 .

DATE-2078/11/26
 Patient looked well and chearful
 Routine works were conducted.
 Patient was encouraged to take diabetic diet and techniques of meal planning were discussed and
explained about it.
 Maintained intake and output of patient .
 During my shift, his vital signs were: -
T-98.0◦F, P- 88 beats/min, RR-22breaths/min, BP-120/60mm of Hg
Spo 2 :96%without o 2 .
DATE -2078/11/27
 Assessed the condition of patient.
 Medication was given on time.
 Cardex revised after round
 Health teaching was provided to the patient about need of exercise, nuteitional management, anf
GRBS was monitored and was 222mg/dl
 During my shift, his vital signs were: -
T-98.2◦F, P- 88beats/min, RR-22breaths/min, BP-120/70mm of Hg
Spo 2 :98%without o 2 .

DATE -2078/11/28
 Patient looked well and chearful
 Routine work was completed.
 Gave emotional support to patient
 Patient was discharged after doctors round, and discharge procedure was completed and discharge
teaching was provided, discharge medications were explained to patient
 During my shift, her vital signs were: -
T-98.2◦F, P- 88beats/min, RR-22breaths/min, BP-120/70mm of Hg

48
Spo 2 :97%without o 2 .

Discharge planning and teaching:

DIETARY HABIT
 Intake of adequate amount of fluid and emcouraged to take high fiber containing food, more
starchy vegetables, less protein and carbohydrate containing food. Limit fatty food and daily salt
intake.
 Techniques of meal planning with plate method was discussed with patient
 Encourage to take small frequent meal at least 4 meals per day.
 Low sodium diet and low fat containing diet (too much sodium can increase his bloodpressure).
 Using low fatty products, can take skimmed milk
 Limiting sweets intake.
 Avoid alcohol and smoking.
REST AND SLEEP
 Encourage to have adequate rest and sleep at least 6 to 8 hour, at night and 1-2 hr. as day
nap.
 Avoid any stress.
 Take warm water or skimmed milk at night time to induce good sleep.
 Healthy and peaceful sleep environment.
MAINTAINING PERSONAL HYGIENE
 Body parts should be cleand properly.
 Take shower daily and usw moisturizer to keep skin smooth and soft.
 Oral hygiene should be maintained.
 Keep nail short.
 Frequent mouth gargling to prevent bad odor.
 Use slippers or shoes while walking, do not walk bare foot
EXERCISE
 Do light exercise 150minutes a week (walking, yoga, meditation), and 75 min a week if vigorous
exercise is done
 Deep breathing and coughing exercise to promote easy breathing.
 Avoid exercise if you have blood glucose more than 250mg/dl
 Plan rest and exercise period, any always take carbohydrate diet before exercise to prevent
hypoglycemia, always carry sweets in pocket during exercise
MEDICATION
 Take medicine at right time of right dose according to prescription made by doctors.
49
 contact the healthcare provider if medicine is not helping or have side effect and tell
about allergic to any medicine,
Self administration of insulin injection was demonstrated, and sign of hyper and hypoglycemia was
explained
 immediately visit doctor if,
Sudden loss of consciousness
Weakness, tingling sensation
Sudden trouble speaking.
Sudden severe headache.
SELF CARE
 Provide personal care such as bathing and dressing.
 Wear light and easy clothes.
 Don’t smoke, and don’t allow others to smoke around smoking increases risk.
Deep breathing and coughing exercise to enhance breathing, and relieve stress.
MONITORING
 Patient was encouraged to perform bloodglucose monitoring on daily basis , if not possible at
least once in every 3 months
 Encouraged to perform eye examination, foot examination,lipid profile,ECG every yearly
 Maintain weight weight and blood pressure monitoring in every 3 months and visit dentist
every 6 months

FOLLOW-UP
 Instruct the patient for follow up in advised days or any time if there is any complication
arises.
 While coming in follow-up bring all the documents like discharge slip, investigation
form, medicine slip etc,

ACTION TO MINIMIZE THE STRESS OF ILLNESS AND

HOSPITALIZATION

 Build good rapport with patient and family

 Orientation of ward, staffs, ward routine, hospital rule and regulation
 Gave clear information on disease condition and treatment protocol
 Patients and visitors were allowed to express their feelings, fear and concern about disease
 Each procedure performed on him was fully explained
 Taught patient about relexation techniques and informal health teaching was provided on
various topics

50
WHAT I LEARNT FROM CASE STUDY:
Case study and case report preparation is very good opportunity to sharpen our theoretical
knowledge in practical situation. It enhances our nursing practice by applying different nursing
theorys as well as relating with different disease in detail. It helps in comprehensive study of a
selected client and compare it with book picture. Through my case study I got opportunity to
know: Following are the knowledge gained and learned from this study:
 Diabetes Mellitus, its epidemiology, causes, patho-physiology, clinical
manifestations, diagnostic tests and evaluation, prognosis, complications, treatment and
management in detail.
 Skill for history taking and physical examination.
 Comparison of book picture and real client presentation.
 Different diagnostic tests and procedures and their reference values.
 Drugs in detail as their mode of action, dosage, uses, adverse effects and their nursing
considerations.
 Developmental needs and tasks of the adults and its variation in a disease condition.
 Different types of diversional therapies that can be effective and useful.
 Nursing management of the client in a holistic approach with the application of nursing theory,
nursing process and nursing care plan.
 Skill of recording, reporting and communicating about the client care and progress to the
concerned personnel, may be health care team or the patient party.
 Skill of presenting the case in a concrete and precise way.
Finally, I would like to thank everyone who has put their endeavor to help me gain the
knowledge and skill by conducting this case study.

SUMMARY

Case study is one of the most crucial parts of nursing practice. It is the best way of learning. Case
study is concerned with the individualized care which helps to provide holistic nursing care including
physiological, psychological, social, spiritual and cultural traditional beliefs.
According to the curriculum of BNS 1 st year, a case with diagnosis of Uncontrolled tope 2 diabetes
mellitus was selected for case study. All the essential health history from patient, his relatives was
taken during the case study. Then physical examination was done and recorded. The normal
developmental process of middle adulthood was revised. The collected health history,investigations
report, and outcome of physical examination was reviewed and nursing diagnosis was formulated.
The Orem theory was used for the nursing management of the patient. Complete nursing care was
51
provided to the patient by applying nursing process. During the case study, I also studied about
disease, its etiology, pathophysiology, its sign and symptoms, diagnostic procedure, therapeutic as
well as nursing management from different books and did a comparative study of patient and book.
I maintained good relationship with the patient and his family and they co-operate me as well. I
got an opportunity for comprehensive study and provide holistic quality care. I am contented with the
effort I made to complete this case study. I think both of us, the patient and I are benefited from this
case study.

- PRASANSA POUDEL

REFERENCES :
 Basvanthappa, BT.(2009).Medical Surgical Nursing(2nd ed.): New Delhi:Jaypee Brothers
Medical Publishers pgno:984-1005

 Mandal, G.N.(2013).A textbook of Adult Nursing(2nd ed.): Dillibazar,Kathmandu:Makalu

Publications pgno:352-358

 Hinkle, J. L & Cheever, K .H.(2018).Bruner’s and Suddarth’s Textbook of Medical Surgical

Nursing(13th ed): New Delhi, India, :Wolters Kluwer pgno:1417-1455

 Tuitui, R. (2014). Pocket Book of Drugs(5th ed.): Dillibazar, Kathmandu, : Makalu

Publication pgno:262-263

 Shrestha, H. ,Paudyal, P. & Giri, S.(2019). A Textbook of Medical Surgical Nursing I and
II(4th ed): Kathmandu, Nepal, : Hintage Publishor and distributors pgno:458-464

 Rai, L. (2019). Nursing Concepts and Principles (4th ed.): Chhetrapati, Kathmandu, : Akshav
Publication pgno:352-358

 Thapa, U.(2015). A Textbook of Common Health Problem of Adulthood (3rd ed.): Dillibazar,
Kathmandu, : Makalu Pudblication pgno:94-96

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