BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

A study on the case of MRS.LV diagnosed with Type 2 Diabetes Mellitus

SUBMITTED BY: BSN-3C Group#1 SUBMITTED TO:

Alipio, Joana Marie E. LEVEL THREE INSTRUCTORS
Amado, Erika Patricia B.
Antonio, Sunshine V.
Arnedo, Mari Fe
Balgos, Ana Margarita M.
Baltazar, Alona N.
Bautista, Jenna V.
Belizario, Marjorie Anne M.
Cabral, Romeo A.
Cuanico, Dea Karell F.
Matsuoka, Miguel

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 I. INTRODUCTION
This case study is all about L.V, a 56 year old patient who diagnose with a Type 2 Diabetes Mellitus along with a urinary tract infection at
Bulacan Medical Center on December 19, 2012, with a chief complain of dizziness, weakness and difficulty in breathing.

Diabetes Mellitus or simply diabetes, is a group of metabolic diseases characterized by increased levels of glucose in the blood
(hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Diabetes has its major classification which varies in cause, clinical
course, and treatment. These are the type 1 DM, type 2 DM, gestational diabetes, and diabetes mellitus associated with other conditions or
syndromes.

Type 2 diabetes mellitus or commonly known as Non- insulin – dependent or an adult onset type described as a relative deficiency of insulin
production and a decreased insulin action and/or increased insulin resistance. It occurs more commonly among people who are older than 30 years
of age and obese although its incidence is rapidly increasing in younger people that is because of the growing epidemic of obesity in children,
adolescence and young adults.

The clinical manifestations are depending on the patient’s level of hyperglycemia. It includes polyuria (increased urination) and polydipsia
(increased thirst) occurs as a result of excess loss of fluid associated with osmotic dieresis. Patient’s also suffers polyphagia (increased appetite) that
is the results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Other manifestations such as fatigue,
weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin and recurrent infections are noted.

Several procedures like fasting plasma glucose, random plasma glucose and glucose level two hours after receiving glucose (2- hour postload)
may indicate an abnormally high blood glucose level which is considered to be the basic criterion for the diagnosis of diabetes. The major goal of the
diabetes treatment is to normalize the insulin activity and blood glucose level to reduce the development of vascular and neuropathic complications
without patient experiencing hypoglycemia: nutritional therapy, exercise, monitoring, pharmacologic therapy and education which are the essential
components of diabetic regimen.

The incidence of diabetes is growing around the world. It is in the top ten leading causes of deaths. Filipinos are not an exemption to this
incidence as more and more Filipinos are affected by the disease. According to the survey conducted by the Philippine Cardiovascular outcome
study on Diabetes Mellitus in 2007 found out that “20.6 percent of adults aged 30 and above were found to be diabetic”. In 1998 only 3.9 percent of

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 Filipinos living in the Philippines had diabetes. On the other hand, the prevalence of diabetes according to the NNHES (National Nutrition Health
Survey) study is 4.8%.

REASONS OF STUDY

The group chose type 2 diabetes mellitus as our case study because aside from it is still fresh in our minds; our group was interested in
studying this. We are willing to do this case to challenge our own minds in analyzing the problem and to enhance our knowledge, as well as to
gain new experiences which could bring new learning’s for the group. This case study will also help the group in understanding the disease
process of the patient. It would also help the group in identifying the primary needs of the patient with a type 2 Diabetes Mellitus. By identifying
such needs and health problems arise the group can now formulate an individualized Nursing care plan for the patient that would address these
needs and problems effectively. Management of the identified problem will help the patient to recover faster and maintain holistic sense of
wellness. This will also equip the group with knowledge, skills and attitude on how to manage future patient with the same disease.

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 II. OBJECTIVES
STUDENT- CENTERED

GENERAL OBJECTIVES

The purpose of this case study is to give the much needed knowledge and awareness to the nursing students who have or might have handled cases of
Type II Diabetes Mellitus associated with Urinary Tract Infection.

SPECIFIC OBJECTIVES
(STUDENT-CENTERED)
KNOWLEDGE:
 To be able to have a better understanding at the case of the patient having a type 2 Diabetes Mellitus and the occurrence of its
signs and symptoms.
 To be able to know the disease process through its pathophysiology.
 To be able to be knowledgeable about the patient drug study.

SKILLS:
 To be able to formulate nursing care plans based on the prioritized health needs of the client.
 To be able to discuss about the pathophysiology of the disease process.
 To be able to familiarize on the aggravating factors and specific interventions to prevent complications of Type 2 diabetes
Mellitus

ATTITUDE:
 To be able to change any misconception about the said disease of the patient.
 To be able to develop awareness in the proper care management for type 2 diabetes mellitus.
 To be able to serve our future client’s with a higher level of holistic understanding as well as individualized care.

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 (CLIENT-CENTERED)
GENERAL OBJECTIVES
This case study implies knowledge and awareness to people who have or might be at risk of the said disease regarding it’s fatality and
detection.

 SPECIFIC OBJECTIVES

KNOWLEDGE:
 To be able to impart knowledge regarding type 2 Diabetes Mellitus.
 To be able to determine signs and symptoms and its complications.
 To be able to familiarize on the appropriate interventions with its rationale to improve patient’s condition.

SKILLS:
 To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own.
 To be able to explain the different factors that may cause type 2 diabetes mellitus and its danger.
 To be able to participate in her plan of care.

ATTITUDE:
 To help the patient in motivating her to continue the health care provided by the health workers.
 To be able to complies with the treatment protocol and prevention strategies.
 To be able to identify different measures to prevent further aggravation of the condition.

III. NURSING ASSESSMENT

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 A. Biographic Data

Name: Client LV
Address: Poblacion San Ildefonso Bulacan
Gender: Female
Birthday: October 12, 1956
Age: 56 years old
Civil Status: Married
Religion: Roman Catholic
Educational Attainment: College Undergraduate - Accountancy
Date of Consultation: March 5, 2013
Admitting Diagnosis: Type 2 Diabetes Mellitus
Final Diagnosis: T/C DKA, Type 2 Diabetes Mellitus

B. Chief complaint: “Nahihilo kasi ako, tsaka nanlalata nahihirapan pa akong huminga” as verbalized by the client.

C. History of Present Illness

Prior to consultaion, the client was experiencing weakness and she stated that she feels tired easily doing some household chores. The night before
she decided to go to hospital, she experienced difficulty of breathing and weakness, which cause her inability to sleep. On the following day at 7:00AM, she
seeks consultation at Bulacan Medical Center.

In the Out Patient Department the patient was diagnosed already of Type 2 Diabetes Mellitus and did an initial assessment with positive weakness
and pale, hyperlycemia with a blood pressure of 130/60, Respiratory rate of 29cpm, and pulse rate of 107bpm. Part of the confirmation of the disease, the
following test was requested to be done such as Capillary Blood Glucose and certain blood test.

Upon seeing the patient last March 5, 2013, he was able to communicate to us, has no manifestation of hyperglycemia nor hypoglycemia. During
our clinical rotation we seen our client with the following drugs Humulin 70/30, Lantus 16 units, VAsalat 10mg, Micardis Plus 80mg and Catapress her blood
pressure reaches 150.

D. Past Health History

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 According to the client, he experienced common diseases like fever, cough and colds. She also had Urinary Tract infection last December and was
given medication like Bactrim Forte. According to client she was also confined in the ICU for 1 week because of hyperglycemia associated by hypertension.
He is also a hypertensive patient.

E. Family Health History

According to the patient, her family has a history of Asthma, diabetes Mellitus and Hypertension on the paternal side.

F. Functional health pattern

 Health Perception – Health Management Pattern

With Diabetes Mellitus

According to the client she feels ill and weak whenever her sugar level increased. She
also added that she feels sad because she wasn’t able to do things that he used to do
before like doing chores in a longer period of time but the client has a positive
outlook in life, she stated that “kahit na may diabetes ako at maraming bawal,
pagpapatuloy ko ang aking buhay”.

 Nutritional-Metabolic Pattern

With Diabetes Mellitus

BREAKFAST LUNCH DINNER TOTAL INTAKE
March 2, 1 bowl 1 pc. Of fish 1 pc. Of fish Approximately:
2013 Lugaw(275ml) fillet fillet 1050mL
1 cup ¼ cup of rice ½ cup of rice
tea(250mL) 1 glass of 1 cup
water(250ml) tea(250mL)
March 3, 1 bowl of ½ bowl of ½ bowl of Approximately:
2013 lomi(275mL) binagoongang binagoongang 1350mL

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 1 glass of baboy(150mL) baboy(150mL)
water(250mL) ½ cup rice 1 cup rice
1 glass of 1 glass of
water(250mL) water(250mL)
1 pc Indian
mango
March 4, ½ bowl of ½ cup of rice 1 sachet of Approximately:
2013 Quaker ½ serving of skyflakes 1325mL
oats(125mL) adobong 1 cup
1 glass of manok tea(250mL)
water(250mL) 1 glass of
water(250mL)

According to the client she has restriction on his diet. If we noticed her intake in the span of 3
days, she limits her carbohydrates intake as well as fat intake. She also added that she was also
limiting herself in eating sweet foods. Our client stated that she drinks a lot everyday
approximately 1 ½ liters, she verbalized “uhaw na uhaw ako palagi”. According to the
approximate Total intake per day it is normal, because the normal Total intake is 2500mL per
day. And in the 72-hour diet recall it is shown that her intake is minimal, compare to her
statement prior to her condition.

 Elimination Pattern

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 With Diabetes Mellitus
URINATION BOWEL ELIMINATION
FREQUENCY COLOR/ DISCOMFORT FREQUENCY COLOR
TRANPAREN
CY
March 9times(appr Dark Yellow NONE once NOT
2, ox. 625mL) RECALL
2013
March 6times(appr Dark Yellow NONE once NOT
3, ox. 530mL RECALL
2013 per shift)
March 8times(appr Dark Yellow NONE once NOT
4, ox.600) RECALL
2013

 Sleep – Rest Pattern

The client’s frequency of urination isWith

increase because
Diabetes of her condition; she verbalized
Mellitus
“ihi ako ng ihi”. The
According color
to the of her
client sheurine
sleepsvaries on the she
at 2:00AM, drugs that she “nahihirapan
verbalized was taking and
akong
according
kunin yung totulog
the client
ko ba,the odor
kaya of her urine
nanunuod wasako
na lang like ng
a smell of medications.
tv, pero kapag natulog na ako
tuloy-tuloy na” and she wakes up at 6:00 in the morning. She doesn’t take nap
because she is busy watching television.

 Activity – Exercise Pattern

With Diabetes Mellitus

According to the client, she was unable to do the things she usually does

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 because of her condition. Now that she has diabetes mellitus she gets easily
tired and feels weak.

0- FEEDING 0- BED MOBILITY

0- HOME MAINTENANCE 0- BATHING
0- DRESSING 0- COOKING
0- TOILETING 0- GROOMING
N/A- SHOPPING 1- GENERAL MOBILITY

LEGEND:
Level 0- Full self Care
Level I- Requires Use of Equipment
Level II- Requires assistance or supervision from another person
Level III- Requires assistance from another person and device
Level IV- Is Dependent and doesn’t participate

 Role – Relationship Pattern

With Diabetes Mellitus

The Client feels sad and happy. Sad because she was not able to things that may
trigger her condition and happy because her family is very supportive and concern
about her present condition.

 Cognitive-Perceptual Pattern

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 With Diabetes Mellitus
She is normal in cognitive pattern. In terms of perceptual pattern she rated her
condition as 8 out of 10(10 being the highest and 1 is the lowest). The client was also
diagnosed before having an early cataract related to DM retinopathy.

 Coping/Stress Tolerance Pattern

With Diabetes Mellitus

The client stated that she feels good when he see and feel the presence of her
family in the hospital.

 Self Perception/Self Concept Pattern

With Diabetes Mellitus

According to her, she became a stronger person because of his faith in God and she
was more motivated to do follow the proper regimen for diabetes mellitus.

 Sexuality/ ReproductivePattern

With Diabetes Mellitus

We don’t ask about this topic to him.

 Value – Belief Pattern

With Diabetes Mellitus

According to the client her faith in God increase and the only person that she
could ask for help is God.

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IV. GROWTH AND DEVELOPMENT
Freud's Psycho-sexual
Theory
STAGES GENITAL
Puberty-Death
During final stage, the
individual develops a strong
sexual interest in the
opposite sex. This stage
begins during puberty but
DEFINITION last throughout the rest of
person's life.
The client was successfully
met the psychosexual stage
not only because she was
able to have children with
RESOLUTION her husband but also in
genital stage affords the
person the ability to
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Erickson's Psycho-social
Theory
Generativity vs. Stagnation
Middle Adulthood: 35 to 55 or 65
Adults need to create/nurture
things that will outlast them,
often by having children/creating
a positive change that benefits
other people. Success leads to
feelings of usefulness and
accomplishment, while failure
results in shallow involvement in
the world.
The client achieves this stage
because she knows that she gave
back to the society through
raising her children and being
productive as being a mother to
her children.
Piaget’s Theory of Cognitive
Formal Operational
12 - Adulthood
Can think logically about abstract
propositions and test hypothesis
systematically, becomes with
hypothetical future and ideological
problems.
The client thinks rationally and
logically. As a mother and wife she
was able to solve the problems by
communicating to her children and
husband.
Kohlberg’s Theory of
Moral
Post Conventional
-Universal Ethics Orientation
Few people operate at this
stage all the time. It is based
on abstract reasoning and the
ability to put oneself in other
people's shoes. At this stage,
people have principled
conscience and will follow
universal ethical principles
regardless of what the official
laws and rules are.
She lives autonomously and
defines the moral personal
identification with group
values and principle that are
universally agreed on the
considers appropriate that for
life. She makes decision
 confront and resolve her
remaining psychosexual
childhood conflicts.
V. THEORY
THEORY THEORIST DESCRIPTION
A health promoting behavior is an
1. Health Promotion Model Nola J. Pender end point or action outcome directed
toward attaining positive health
outcomes such as optimal well being,
personal fulfillment, and productive
living.
2. Self-Care Deficit Theory Dorothea E. Orem The central idea of the theory of
of Nursing self-care deficit is that the
requirements of persons for nursing
are associated with subjectivity of
mature and maturing persons to
health-related or health care-related
action limitations
3. Core, Care and Cure Lydia Hall Focusing on the notion that centers
Model around three components of Care, Core
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according to what her
conscience dictates.
APPLICATION OF THEORY TO
THE PATIENT
Health Promotion Model can help the client
to attain positive health outcomes by eating
of healthy diet, exercise regularly, managing
stress, gaining adequate rest, spiritual
growth and building positive relationships.
In this theory suggests that patients recover
quicker and more effectively when they are
allowed to meet their own basic needs, such as
eating, grooming, and using the restroom.
We use it as a guide to provide care and to help
client to attain self-care.
We use this theory as a guide for our care
plan to the client because the major purpose
 and Cure. Care represents nurturance
and is exclusive to nursing. Core
involves the therapeutic use of self and
emphasizes the use of reflection. Cure
focuses on nursing related to the
physician’s orders. Core and cure are
shared with the other health care
providers.
of care is to achieve an interpersonal
relationship with the individual that will
facilitate the development of the core. Client
is composed of body, pathology, and person.
People set their own goals and are capable of
learning and growing.

 PHYSICAL ASSESSMENT
ASSESSMENT TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/INTERPRETATION

GENERAL APPEARANCE

BODY BUILT INSPECTION Proportionate, varies with lifestyle Proportionate ( mesomorph ) Normal

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 POSTURE INSPECTION Not on an Erect posture Not on an erect posture Normal

OVER-ALL-HYGIENE INSPECTION Clean and neat appearance Clean and neat appearance Normal

BODY AND BREATH INSPECTION No body and breath odor No body and no breath odor Normal
ODOR
SIGNS OF DISTRESS INSPECTION No signs of distress Weak in appearance Deviation from Normal due to
aging

OBVIOUS SIGN OF INSPECTION No signs of illness or disease Obvious signs of illness or disease Deviation from Normal due to
HEALTH OR ILLNESS the presence of the disease.

MENTAL STATUS

LEVEL OF INSPECTION Conscious and coherent Conscious and coherent Normal

CONSCIOUSNESS
ORIENTATION INSPECTION Oriented to time, place, situation Oriented to time, place, situation Normal

BODY PART TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

INTEGUMENTARY INPECTION Uniform in color, no presence of edema ,no Dry skin and there’s presence of skin Deviation from Normal due to
a.) SKIN skin lesions, normal temperature, long skin pigmentations on the body hydration status & melatonin
PALPATION
turgor, dry skin deficiency of the client.

b.) NAILS INSPECTION Convex curvature about 160°, smooth in
texture, have an intact epidermis tissue
PALPATION
surrounding the nails, less than 4 sec.
returning to its normal color (pink) when
Convex curvature about 160°, smooth in Deviation from Normal due to
texture, have an intact epidermis tissue decrease of oxygen in the
surrounding the nails, having a normal tissue cells.
blanch test with pale color of nail beds. &

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 performing blanch test presence of dead toe nail.

SKULL INSPECTION Rounded Normocephalic and symmetrical Rounded Normocephalic and symmetrical Normal
with frontal, parietal, and occipital with frontal, parietal, and occipital
PALPATION
prominences, Smooth skull contour prominences, Smooth skull contour

SCALP INSPECTION No presence of dandruff or lesions No presence of dandruff or lesions Normal

PALPATION Smooth Smooth

Color is lighter than facial skin Color is lighter than facial skin

No tenderness No tenderness

HAIR INSPECTION Not Evenly distributed, thin, dry hair Not Evenly distributed, thin, dry hair Normal

FACE INSPECTION Symmetric/slightly asymmetrical facial Symmetrical facial features and Normal
features coordinated facial movements.
Symmetrical facial movements.

EYES

Skin intact. Eyebrows symmetrically aligned. Skin intact. Eyebrows symmetrically

a. Eyebrows INSPECTION Normal
Evenly distributed. aligned. Evenly distributed.

b. Eyelashes Equally distributed and is curled slightly Equally distributed and is curled slightly

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 INSPECTION outward. outward. Normal

Skin is intact Skin is intact

c. Eyelids
NSPECTION No discharge and discoloration No discharge and discoloration Normal

Lids close symmetrically Lids close symmetrically

the cornea.

d. Conjunctiva

Red or pink. Pink in color

e. Cornea
INSPECTION Capillaries sometimes evident. Capillaries sometimes evident. Normal

INSPECTION Transparent, shiny and smooth. Transparent, shiny and smooth. Normal

Details of iris are visible. Details of iris are visible

f. Lacrimal gland,
lacrimal sac and
nasolacrimal
duct INSPECTION No edema or tearing No edema or tearing

PALPATION Normal

g. Pupils

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 Pupil constricts when looking in near objects Pupil constricts when looking in near Normal
and pupil dilates when looking at far objects. objects and pupil dilates when looking at
INSPECTION
far objects.
Non illuminated eye constricts and
illuminated eye also constricts. Non illuminated eye constricts and
illuminated eye also constricts. Normal
PERRLA (pupil equally round and react to
light and accommodation) PERRLA (pupil equally round and react to
light and accommodation)
h. Visual Fields

Normal
The client can see object in the periphery
The client can see object in the periphery
when looking straight ahead.
i. Ocular when looking straight ahead.
movements INSPECTION

Both eyes coordinated.

Both eyes coordinated.
INSPECTION Moves in unison. Normal
Moves in unison.
In parallel alignment.
j. Visual Acuity In parallel alignment.

INSPECTION Both Eyes has a grade of 250

Distance vision:
Deviation from normal due to
20/20 vision on Snellen chart aging and the disease
process.

EARS
a. Auricles INSPECTION Color same as facial skin. Color same as facial skin. Normal

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 Symmetrical

PALPATION Symmetrical Aligned with the outer canthus of the eye

about 10 degrees from vertical.
Aligned with the outer canthus of the eye
about 10 degrees from vertical.

b. External ear Mobile, firm and not tender.

Mobile, firm and not tender.
INSPECTION
The pinna recoils after it is folded.
Absence of cerumen, pus, or blood.
The pinna recoils after it is folded.
Normal
Absence of cerumen, pus, there is no
presence of blood.

NOSE INSPECTION Symmetrical and straight. No discharge or Symmetrical and straight. No discharge or Normal
flaring. flaring.
PALPATION
Uniform color. Uniform color.

No tenderness or lesions. No tenderness or lesions.

Mucosa is pink. Mucosa is pink.

Normal
Clear, watery discharge Clear, watery discharge

Nasal patency: Nasal patency:

Normal
Air moves freely as the client breathes

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 through the nares. Nasal septum intact and in the midline. Normal

Nasal septum intact and in the midline. Air moves freely as the client breathes
through the nares.

Frontal and maxillary sinuses: not tender

Frontal and maxillary sinuses: not tender.

MOUTH
a. Lips and buccal INSPECTION Uniform pink in color Uniform pink in color Normal

mucosa PALPATION Moist, smooth, soft, glistening, elastic Moist, smooth, soft, glistening, elastic
texture texture

Deviation from Normal due to

32 adult teeth Presence of dentures ,Pink gums presence of dentures.
b. Teeth and gums INSPECTION
Smooth and shiny white teeth Moist, firm gum texture
PALPATION
Pink gums No retraction of gums

Moist, firm gum texture

No retraction of gums

Normal

Central position Central position

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 c. Tongue INSPECTION Pink color Pink color

PALPATION Smooth lateral margins Smooth lateral margins

No lesions No lesions

Normal

Moves freely Moves freely

PALPATION No tenderness No tenderness

Normal

d. Mouth floor and INSPECTION Smooth tongue base with prominent veins Smooth tongue base with prominent
roof veins
Normal

e. Hard and soft Soft palate: light pink

INSPECTION Soft palate: light pink
palate
Hard palate: lighter pink, more irregular
Hard palate: lighter pink, more irregular in Normal
in texture
texture

INSPECTION Normal
f. Uvula Uvula in the midline of soft palate
Uvula in the midline of soft palate

INSPECTION
e. Tonsils and Pink and smooth

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 oropharynx Pink and smooth Normal

Present Present

f. Gag reflex INSPECTION

NECK
a. Lymph nodes INSPECTION Muscles equal in size Muscles equal in size Normal

PALPATION Coordinated, smooth movements with no Coordinated, smooth movements with no

discomfort discomfort

Equal strength Equal strength

b. Trachea Not palpable The lymph nodes are not palpable.

INSPECTION Normal

PALPATION

c. Thyroid gland Central placement in the midline Central placement in the midline
INSPECTION Normal
Spaces are equal in both sides Spaces are equal in both sides
PALPATION
Not visible on inspection Not visible on inspection

Glands ascend during swallowing but not Glands ascend during swallowing but not
visible visible

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 Lobes may not be palpable Lobes are not be palpable

POSTERIOR THORAX
a. Posterior thorax INSPECTION Anteroposterior to transverse diameter in Anteroposterior to transverse diameter in Normal
ratio of 1:2 ratio of 1:2
PALPATION
Spine vertically aligned Spine vertically aligned

Uniform temperature skin intact Uniform temperature skin intact

No tenderness No tenderness

No masses No masses

Symmetrical chest expansion Symmetrical chest expansion

Normal
b. Respiratory 3-5cm thumb separation at inspiration 3-5cmThumb separate at inspiration.
excursion INSPECTION
Bilateral symmetry of vocal fremitus Bilateral symmetry of vocal fremitus
PALPATION Normal
c. Vocal tactile Fremitus is heard most clearly at the apex of Fremitus is heard most clearly at the apex
fremitus. INSPECTION Deviation from Normal due
the heart of the heart
to mucus secrétions.
PALPATION
Normal
Resonance except over the scapula Resonance except over the scapula
d. Percussion
PERCUSSION
Dullness over the ribs Dullness over the ribs

e. Auscultation Vesicular and bronchovesicular breath Vesicular and bronchovesicular breath

sounds sounds

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 AUSCULTATION

ANTERIOR THORAX
a. Anterior Thorax INSPECTION Quiet, rhythmic, and effortless respirations Quiet, rhythmic, and effortless Normal
respirations
PALPATION Uniform temperature
Uniform temperature
No tenderness Normal
No tenderness
No masses or any lesions
No masses or any lesions

INSPECTION Symmetrical chest expansion Normal

b. Respiratory Symmetrical chest expansion
excursion PALPATION 3-5cm thumb separation at inspiration
3-5cm thumb separation at inspiration

PERCUSSION Resonance down at the 6th rib at diaphragm

c. Percussion level Resonance down at the 6th rib at
diaphragm level
Flat over heavy muscles and bone
Flat over heavy muscles and bone
Dull over heart and liver
Normal
Dull over heart and liver
Tympanic over underlying stomach
Tympanic over underlying stomach

Trachea; Brochial breath sounds

d. Auscultation AUSCULTATION
Trachea; Brochial breath sounds
Anterior chest; Bronchovesicular and
vesicular breath sounds

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 Anterior chest; Bronchovesicular and
vesicular breath sounds

CARDIOVASCULAR
a. Heart AUSCULTATION No pulsations at the aortic, pulmonic, No pulsations at the aortic, pulmonic, Normal
tricuspid and mitral area. tricuspid and mitral area.
PALPATION
Aortic pulsations at the epigastric area Aortic pulsations at the epigastric area
INSPECTION

S1 – all sites S1 is heard at all sites especially at the

Normal
apical site and S2 is heard at all sites
S2 – all sites
especially at the base of the heart.
S3- in children/young adults

S4 – older adults

Symmetric pulse volumes

AUSCULTATION Symmetric pulse volumes Normal
b. Carotid artery Elastic arterial wall
Elastic arterial wall
No sound heard on auscultation
No sound heard on auscultation

Veins are not visible

c. Jugular veins INSPECTION Veins are not visible Normal

BREAST INSPECTION Rounded shape Rounded shape Normal

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 PALPATION Slightly unequal in size Slightly assymetric

Generally symmetric Skin uniform in color, skin intact and

smooth
Skin uniform in color, skin intact and smooth

No tenderness, masses or nodules. Normal

No tenderness, masses or nodules.

Round, everted, pointing in the same Normal

direction.

The nipples and areola are rounded,

equal in size and similar in color.
Dark brown color of areola
a. Nipples and Areola
No discharge, tenderness, or masses
Normal

No discharge, tenderness, or masses,

presence of breast milk

ABDOMEN INSPECTION Uniform in color, unblemished skin Uniform in color Normal

Flat, rounded (convex), or scaphoid Rounded (convex)

(concave)
Symmetric contour

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 Symmetric contour Symmetric movements caused by
respirations
Symmetric movements caused by
respirations

Bowel sounds are audible.

Bowel sounds are audible. Absence of friction rub and arterial bruits.
AUSCULTATION Normal
Absence of friction rub and arterial bruits.

Tympany over the stomach and gas-filled Tympany over the stomach and gas-filled
PERCUSSION Normal
bowels bowels

Dullness over the liver and spleen. Dullness over the liver and spleen.

The liver size is determined when

PALPATION percussed, 6 – 12cm MCL. Normal
Liver size:

MCL: 6 – 12cm

MSL: 4 – 8cm
No tenderness, relaxed abdomen with
smooth consistent tension.
Normal
No tenderness, relaxed abdomen with
smooth consistent tension.

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 Liver: no enlargement may not be palpable Normal

The liver is not enlarged.

Gall bladder: Normal

No distention There is no distention in the gall bladder

when palpated.

UPPER EXTREMITIES
a. Shoulders, arms, Symmetrical Symmetrical Normal
elbows, wrists
hands and fingers No redness, swelling, deformities, masses No redness, swelling, deformities, masses
and tenderness and tenderness

b. Shoulders and arms: Extent of forward flexion should be 180 The client can flex, extend, adduct, Normal
movement and degrees; hyperextension, 50 degrees; abduct and hyperextend without pain
force adduction, 50 degrees and abduction 180 and with equal force.
degrees

c. Elbows: movement Normal ranges of motion are 160 degrees of The client can flex, extend, and Normal
and force flexion; 180 degrees of extension, 90 hyperextend without pain and with equal
degrees of pronation, 90 degrees of force.
supination.

d. Wrists: movement Normal ranges of motion are 90 degrees, The client can flex, extend, and Normal
and force flexion 70 degrees, hyperextension; 55

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 degrees, ulnar deviation; and 20 degrees,
radial deviation
Should have full ROM against resistance
e. Hands and fingers: Normal ranges are 20 degrees of abduction,
movement and full adduction of fingers, 90 degrees of
force flexion and 30 degrees of hyperextension
The thumb should easily move away from
other fingers and 50 degrees of thumb
flexion is normal
Should have full ROM against resistance
LOWER EXTREMITIES
a. Hips, knees, ankles Symmetrical, No redness, swelling,
and feet: deformity
Muscles are fully developed
b. Hips: movement Normal ROM: 90 degrees of hip flexion with
and force knee straight and 120 degrees of hip flexion
with the knee bent and the other leg
remaining straight
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hyperextend without pain
There is full range of motion against
resistance
The client can flex, extend, adduct, Normal
abduct and hyperextend without pain.
There is full range of motion against
resistance
Symmetrical, No redness, swelling, Normal
deformity
Muscles are fully developed
The client can flex, knees bent and the Normal
other leg remaining straight.
There is full range of motion against
resistance.
 Full ROM against resistance

c. Knees: movement Normal ranges: 120 degrees to 130 degrees The client can flex, extend and Normal
and force of flexion; 0 degrees of extension to 15 hyperextend.
degrees of hyperextension
There is full range of motion against
Full ROM against resistance resistance.

d. Ankles and Feet: Normal ranges: The client can perform dorsiflexion, Normal
movement and plantar flexion, eversion,
force 20 degrees dorsiflexion of ankle and foot; 45
inversion,abduction, adduction, flexion
degrees plantar flexion of ankle and foot
and extension without pain.
20 degrees of eversion 30 degrees of
There is full range of motion against
inversion
resistance.
10 degrees of abduction; 20 degrees of
adduction

40 degrees of flexion; 40 degrees of

extension

Full ROM against resistance.

SUMMARY OF SIGNIFICANT FINDINGS:

 Weak in appearance due to aging
 Dry skin and poor skin turgor due to hydration status of the cliet.
 Presence of skin pigmentation over the body due to melatonin deficiency.
 Obvious sign of illness or disease because of his resent condition.

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  Paleness of lip/ buccal mucosa caused by decreased oxygen in the tissue cells.
 Presence of dentures
 Visual acquity with the grade of 250 in both eyes.
 Nails are pale in color due to decreased oxygen supply in the tissue cells and dead toe nail.

VIII. DRUGS/MEDICATIONS

DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS NURSING

ACTIONS RESPONSIBILITIES

Generic Name: Decreases blood glucose Management of type 2 Hypoglycemia and Lipodystrophy; insulin Obtain patience history,
HUMULIN 70/30 by transport of glucose Non-dependent hypersensivity reactions resistance; allergic including drug history

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Classification: into cells; conversion of diabetes mellitus reactions; and any known allergies.
Antihyperglycemic / glucose to glycogen . hypoglycemia Monitor fasting blood
Antidiabetic glucose, 2hrs after
Route/Dosage: meals.
Subcutaneous; 10ml Monitor urine ketones
during illness.
Monitor body weight
Monitor for
hypoglycemic /hyper
glycemic reactions.

Generic Name: Inhibits HMG-CoA Treatment of Pregnancy and Abdominal pain; Prior:
Simvastatin reductase enzyme, Hyprlipidemias Hypersensitivity to any constipation; headache; Assess BP and apical
Classification: which reduces components of dizziness pulse before the initial
Antihyperlipidemic cholesterol synthesis preparation. dose
agent/HMG-CoA Monitor baseline for
reductase inhibitor renal, liver functions
Route/Dosage: tests before therapy
40mg/tab OD begins.
During:
Assess for symptoms of
CHF ,edema,dyspnea
wet rales. BP weight
gain, report significant
changes.
After:
Note for allergic
rteactions monitor
blood pressure.

Generic Name: Blocks the Treatment for Pregnancy and lactation. Diarrhea; headache; Prior:

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Telmisartan (micardis) vasoconstrictive and Hypertension Biliary obstructive fatigue; Assess BP and apical
Classification: aldosterone-secreting disorder. hypersensivity Urinary tract infection pulse before the initial
Angiotensin II effects of angiotensin II dose
antagonist/ by selectively blocking Monitor baseline for
Antihypertensive the binding of renal, liver functions
Route/Dosage: angiotensin II to the AT1 tests before therapy
80mg/tab OD receptor in many tissues begins.
During:
Assess for symptoms of
CHF ,edema,dyspnea
wet rales. BP weight
gain, report significant
changes.
After:
Note for allergic
rteactions monitor
blood pressure.

Generic Name: Decreases pheripheral Treatment for Palpitations; headache; Prior:

Amlodipine vascular resistance of hypertension dizziness; fatigue; Assess BP and apical
Classification: smooth muscle pulse before the initial
Antihypertensive agent (decrease blood dose
Route/Dosage: pressure) Monitor baseline for
10mg/tab OD sublingual renal, liver functions
tests before therapy
begins.
During:
Assess for symptoms of
CHF ,edema,dyspnea
wet rales. BP weight
gain, report significant

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 changes.
After:
Note for allergic
rteactions monitor
blood pressure.

Generic Name: Blocks the Treatment for Hypersensivity to the Headache; dizziness; Prior:
Valsartan vasoconstrictive and Hypertension components fatigue
Classification: aldosterone-secreting Assess BP and apical
Angiotensin II receptor effects of angiotensin II pulse before the initial
blocker / by selectively blocking dose
Antihypertensive agent the binding of Monitor baseline for
Route/Dosage: angiotensin II to the AT1 renal, liver functions
80mg OD receptor in many tests before therapy
tissues. begins.
During:
Assess for symptoms of
CHF ,edema,dyspnea
wet rales. BP weight
gain, report significant
changes.
After:
Note for allergic
rteactions monitor
blood pressure.
Generic Name:
Clonidine Stimulates central Management of all Hypersensitivity to Drowsiness, dry mouth, Prior:
Classification: alpha-adrenergic grades of hypertension clonidine headache, urinary Assess BP and apical
AntiHypertensive agent receptors to inhibit retention pulse before the initial
Route/Dosage: symphatetic hypotension dose
750mcg/Tab BID cardioaccelerator and Monitor baseline for

34 | P a g e
 vasoconstrictor centers renal, liver functions
tests before therapy
begins.
During:
Assess for symptoms of
CHF ,edema,dyspnea
wet rales. BP weight
gain, report significant
changes.
After:
Note for allergic
rteactions monitor
blood pressure.

IX. LABORATORY/DIAGNOSTIC PROCEDURE

Laboratory Date Indication/ purposes Analytes Result Normal Interpretation Nursing responsibilities
procedure ordered/
date
result

35 | P a g e
Hematology December  I t provides White Blood 14.7 4.1-11.1 The result is above Prior to examination:
19, 2012 valuable Cell normal it indicates:  Check the doctors order.
information  there is a  Explain the procedure to the
about the blood presence of client.
 Assess for the presence of
and some leukocytosis
hematophobia.
extent the bone infection  Check the medications of
marrow, which Lymphocytes% 14.1 16.0-46.0 The result is below the patient that may affect
is the blood normal it indicates : the result.
forming tissue.  Presence of During:
It is used for autoimmune  Provide comfort to lessen
the following disease. patients anxiety while
purposes: waiting for the result.
 To ensure both After:
adequate  Secure laboratory result to
oxygen the chart of the patient.
( refer result to the physician)
carrying
capacity and Monocytes % 2.9 2.3-8.5 Within normal result
hemostasis. Granulocytes 83.0 48.7-81.2 The result is above
 To identify % normal level it
persons who indicates:
may have an  The patient
infection. may develop
 To identify an anemia
acute and Red Blood 4.53 3.90-5.20 The result is within
chronic illness, Cells normal
bleeding Hemoglobin 127 120-151 The result is within
tendencies.and normal.
number of Hematocrit 0.377 0.364-0.460 The result is within
circulating normal.
white blood MCHC(Mean 377 318-342 The result is above

36 | P a g e
 cells. corpuscular normal it indicates:
hemoglobin  The patient
concentration) may suffer
from anemia.

RDW(red 14.7 11.9-14.4 The result is above

blood cell normal it indicates:
distribution  That the
width) patient
develop
cardiovascular
disease.
Platelet 402 169-418 The result is within
normal.
MPV(mean 6.7 7.0-10.5 The result is below
platelet normal it indicates
volume) that :
 The patient
may develop
leukemia.

Laboratory Date ordered/ Indication/ Analytes Result Normal Interpretation Nursing

procedure date result purpose consideration
Urinalysis December  It is an Color Light yellow  Pale Normal Prior:
19,2012 essential yellow
procedure to 1. Review
for
amber physicians
patients order.
undergoin Transparency Slightly  clear to Normal
turbid slightly 2. Gather all

37 | P a g e
 g hospital hazy the
admission CHEMICAL necessary
or EXAMINATION: materials
physical Positive result of needed.
examinati +1 Negative
Glucose glucose in the urine 3. Explain the
on.
may indicate: procedure
 It is a  high blood to the
useful glucose level patient.
indicator  undiagnosed or 4. 4 .Instruct
of a uncontrolled the patient
healthy or
diabetes to void
diseased
mellitus directly into
state and
has Specific gravity 1.030 1.010-1.025 The result is above a clean, dry

remained normal level it container.

an indicates that: Sterile,
integral Urine is concentrated disposable
part of the MICROSCOPIC containers
patient EXAMINATION: are
examinati The result is abnormal recommend
on. Amorphous urate Rare it indicate that: ed. Women
Faint aromatic  the patient eats should
 The always have
process of
food cause
musty odor. a clean-
urinalysis
 Infected urine catch
determine
specimen if
s the  Urine that have
a
abnormal glucose.
constituen Bacteria microscopic
Rare Negative Abnormal result
ts examination
indicates:
revealed  Infection is ordered.
by Feces,
process.
microsco discharges,

38 | P a g e
 pic vaginal
examinati secretions
on of the and
urine menstrual
sediment.
blood will
contaminate
the urine
specimen.

After:

1. Cover all
specimens
tightly, label
properly and
send
immediately
to the
laboratory.
2. If a urine
sample is
obtained
from an
indwelling
catheter, it
may be
necessary
to clamp the
catheter for
about 15-30
minutes

39 | P a g e
 before
obtaining
the sample.
Clean the
specimen
port with
antiseptic
before
aspirating
the urine
sample with
a needle
and a
syringe.

3. Observe
standard
precautions
when
handling
urine
specimens.

4. If the
specimen
cannot be
delivered to
the
laboratory
or tested
within an

40 | P a g e
 hour, it
should be
refrigerated
or have an
appropriate
preservative
added.

X. NURSING PRIORITIZATION
NURSING PROBLEM JUSTIFICATION

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 1. Altered Tissue Perfusion We consider this problem as our first priority because diabetes mellitus has a
primary feature of constricted blood vessels which caused by an inadequate
oxygenated blood circulate in the body which is the reason of having a fatigue in
relation to the decrease muscle strength

2. Fatigue We choose the fatigue as our 2nd priority because it is more important than the
deficient knowledge and considered to be a physiologic needs of an individual.

3. Deficient Knowledge We consider the deficient knowledge as the 3rd priority because it is very
important to know the care, course and the treatment of her condition, for her to
be aware in her body.

4. Risk for Activity Intolerance Intolerance of activity is our 4th priority because if we resolved the problems in the
circulation or the fluid volume, fatigue and the possible unstable blood glucose
level, our client will have a capacity to tolerate activities just like before because
our client has a sufficient energy to perform desired activities.

XI. NURSING CARE PLAN

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 NURSING INTERVENTION/S

ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION

OBJECTIVE CUES: Ineffective tissue After 8 hours of Teach the patient to the mobilization improves blood
perfusion related to nursing intervention, mobilize. circulation
weakening due to the patient will be able
- Verbalization of vasoconstriction of to achieve a normal
the problem blood vessels circulation in the Teach about the factors which
- Statement of peripheral. can increase blood flow :
misconception

Vital Signs: Elevate feet slightly

lower than the heart
BP: 130/70 mmHg
(the position of To increase blood flow through so that
RR: 29cpm elevation at rest), avoid does not happen edema.
crossing legs, avoiding
tight bandage, avoid the
use of pillows,
hamstrings and so forth.

Teach about the

modification of risk
factors such as:

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 Avoid a diet high High cholesterol can accelerate the
in cholesterol, relaxation occurrence of atherosclerosis; smoking
techniques, smoking can cause vasoconstriction of blood
cessation, and drug use vessels, relaxation to reduce the effects
vasoconstriction. of stress.

Giving vasodilators will increase the

dilation of blood vessels so that
Collaborate with other health tissue perfusion can be improved, while
team in giving vasodilators and checking blood sugar regularly to know
checking blood sugar regularly the progress and state of the patient.

SUBJECTIVE:
Fatigue related LONG TERM GOAL:

44 | P a g e
OBJECTIVE: to decrease After 3 days of nursing
muscle strength interventions, the patient will be
- generalized free from signs of fatigue
weakness
- increased SHORT TERM GOAL:
respiratory rate
of 25cpm After 2-3 hours of nursing - Response to an activity
- body weakness interventions, the patient will be - Assess response can be evaluated to
- weight loss able to identify measures to to activity achieve desired level of
- fatigue conserve and increase body - Asses muscle tolerance.
- -limited ROM energy. strength of - To determine the level of
- inability to patient and activity
perform ADL functional level
- altered VS of activity. - Education may provide
- altered - Discuss with motivation to increase
sensorium patient the activity level even though
need for activity patient may feel too weak
initially

- Prevents excessive
- Alternate fatigue.
activity with
periods of rest/
uninterrupted
sleep.
- Indicates physiological
- Monitor pulse, levels of tolerance.
respiration rate
and blood
pressure

45 | P a g e
 before/after
activity
- Perform activity - Interventions should be
slowly with directed at delaying the
frequent rest onset of fatigue and
periods optimizing muscle
efficiency.
- Promote energy - Symptoms of fatigue are
conservation alleviated with rest. Also,
techniques by patient will be able to
discussing ways accomplish more with a
of conserving decreased expenditure of
energy while energy.
bathing,
transferring and
so on.

- Provide - For proper oxygenation

adequate
ventilation
- Provide comfort - To be free from injury
and safety
- Instruct patient - Promotes relaxation For
to perform muscle strength and
deep breathing tissue repair
exercises
- Instruct client to - To prevent weakness and
increase paleness
Vitamins A, C

46 | P a g e
 and D and
protein in her
diet. - To provide proper
- Instruct also ventilation
patient to
increase iron in
diet
- Administer
oxygen as
ordered.

NURSING
INTERVENTION/S
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION

OBJECTIVE CUES: Deficient knowledge After 8 hours of nursing Encourage client to do For the client to do self
related to the disease intervention, the patient self monitoring of her monitoring of her
process due to lack of will be able to verbalize glucose level. condition.

47 | P a g e
 - Verbalization of information or accurate information,
the problem information report understanding of
- Statement of misinterpretation condition and discuss Provide explanations of Information can
misconception reasons for the decrease the anxiety of
process and treatment.
procedure and the the patient.
preparation needed.
Vital Signs:
Identify individual
BP: 130/70 mmHg Any things that can
restrictions such as too
sugar in the food. aggravate her condition.
RR: 29cpm

Review the patient to

maintain an optimal Promotes well being of
nutritional status. the patient and her
recovery

XII. CONCLUSION
At the end of our case study, our group learned things about Type II Diabetes Mellitus and Urinary Tract Infection that are needed for us to know. We
therefore conclude that we, as nursing students must give time in knowing disease or illness like our case. These things would help us further in giving or
disseminating information to people who are concerned or involved in this condition.

On the other hand, this case study is not only for nursing student but this can be also helpful to other professionals and ordinary people. We studied
about the risk factors, its sign and symptoms, treatment, medication for Type II Diabetes Mellitus and Urinary Tract Infection. Hence, we learned that any
individual is prone to this condition if their lifestyle puts them to a higher risk. That’s why we must all be well-informed to prevent its occurrence.

48 | P a g e
 Lastly, at the end of our case study we, student nurses apprehend all essential things about Type II Diabetes Mellitus and Urinary Tract Infection. Avoid
exposure, proper lifestyle, proper hygiene and proper nutrition is the best way to prevent the acquiring of Type II Diabetes Mellitus and Urinary Tract Infection
and any other diseases.

XII. BIBLIOGRAPHY

- Kozier B. et al: Fundamentals of Nursing 10th edition Pearson education Inc. New jersey Copyright 2004 p.434
- Moorhouse , Doenges, M.: Nurses’ Pocket Guide: Nursing Diagnoses with Interventions
- Brunner and Suddart: textbook of Medical and Surgical Nursing 12 th edition, hippincott, Williams & Wilkins
- -http://www.justmommies.com/articles/anemia-during-pregnancy.shtml#ixzz1lN1GVpZL
- http://en.wikipedia.org/wiki/Pain#Management

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 - http://www.livestrong.com/article/202712-a-nursing-diagnosis-of-limited-mobility/
- http://nurseslabs.com/d5w-iv-fluid-study/\

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