University of Perpetual Help System ² Dalta Calamba, Campus Brgy.

Paciano Rizal Calamba, Laguna

A Case Study Presented to the Faculty of College of Nursing In Partial fulfillment of the requirements In Related Learning Experience 102 for the degree of Bachelor of Science in Nursing

Submitted by: Camille Angeli M. Opis BSN- 3A3 Group 4

Introduction
y Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications. y Diabetes mellitus is a chronic disease that causes serious health complications including renal failure, heart disease, stroke, and blindness.

Every cell in the human body needs energy in order to function. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. The body's primary energy source is glucose which from the digested food that circulates in the blood as a ready energy source for any cells that need it. This form is also called non-insulindependent diabetes. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. The pancreas may produce enough insulin. . cells have become resistant to the insulin produced and it may not work as effectively. Type II is considered a milder form of diabetes because of its slow onset because it usually can be controlled with diet and oral medication. however. When there is not enough insulin produced. insulin injections are sometimes necessary if treatment with diet and oral medication is not working. now the glucose stays in the blood rather entering the cells. However. a term that is somewhat misleading. Insulin is a hormone or chemical produced by cells in the pancreas.

Trias Cavite High school Undergraduate Housekeeper Security guard(husband) Type 2 Diabetes Mellitus.I. DEMOGRAPHIC DATA Name: Gender: Age: Birth date: Birth place: Marital status: Nationality: Address: Educational Background: Occupation: Usual source of income: Admission Diagnosis: Patient X Female 34y/o October 7. Hypertension II . 1975 Eastern Samar Married Filipino Gen.

Cavite.II. and dated December 10&12. Emilio Aguinaldo Memorial Hospital in Trece Martires . taking her usual medications. IV. SOURCES AND RELIABILITY OF THE INFORMATION The data presented in the case was collected from Gen. HISTORY OF PRESENT ILLNESS 3 days PTA the patient started to experience dizziness and dyspnea. 2009. III. she suffered from dizziness and difficulty of breathing from December 1-3 of 2009 even though she s taking her usual medications so her cousin decided to take her to the hospital. The data collected are from medical records of the patient and most of the information was given by her. Losartan and Neobloc 50mg BID of signs and symptoms prompt to consult health care. no consult done. . REASON FOR SEEKING HEALTH CARE Based in my interview with the patient.

According to Patient X her menarche was when she is on her grade five.V. cough and colds during her childhood years. After giving birth to her last child she had undergone tubal ligaton. she was diagnosed with Diabetis Mellitus Type 2 five years ago. . All of her five children have been given birth through normal spontaneous vaginal delivery. PAST MEDICAL HISTORY Patient X was hospitalized a year ago due to weakness and increased BP. She received complete tetanus toxoid immunization when she was pregnant. She has no known allergies to food and drugs. She had already experienced common childhood illnesses like chickenpox. diarrhea.

pept ic ulcer. DM(61y/o) Patient Husband 38y/o (CAD) (CAD) Brother 40y/o Brother 37y/o Patient 34y/o (DM typeII) Deceased Daughter 10y/o Daughter 9y/o Son 7y/o Son 6y/o Son 4 1/2 y/o . alcoholic(63y/o) Hypertension.VII. Family History LEGEND Grandfather(nat ural death) Grandmother(s toke) Male Female Hypertension stroke (60y/o) Hypertension.

B. Self-esteem. . Self Concept and Self Perception Pattern The patient is kind and approachable. She walks for 30 minutes once a week and considers this as her form of exercise. Activity and Exercise Pattern The client reports that she has a sedentary lifestyle. C. Health Perception and Health Maintenance Patient is aware of her condition. She exercise once a week only because she often gets tired easily. she knows that she needs to control her diet. When someone has a chronic illness in their family she seeks the help of the doctor. FUNCTIONAL ASSESSMENT A. She drinks alcohol occasionally. She only consults to the health provider when she already tolerates the symptoms she s experiencing. She can described herself as a nice and kind person and she feels good about herself. Patient X is a non-smoker.VIII. She said that she have a good relationship with her family and friendly to other people. She also added that she sees equality to other people.

There are days that she has feels burning sensation when urinating. Sexuality/Reproductive The patient has harmonious relationship with her family and her relatives.D. She doesn t practice monthly BSE. During days when she s exhausted she has difficulty sleeping and difficulty staying asleep. She frequently naps after meals. Now she s already ligated. Sleep/Rest Pattern Patient X sleeps for at least seven hours in the evening from 10:30pm-5:30am. Even though she knows she needs to avoid foods high in sugar and fats sometimes she cannot help herself in indulging to this kinds of foods. Her favorite food is siomai. She frequently urinates and she defecates every other day. F. She had her menarche when she was in grade five. She has five children (G5P5). . She also loves to drink lots of water because she always feels thirsty. Nutrition and Elimination The patient eats any kind of food. E. She is not sexually active because her husband is away always because of his work.

I. it is clean and quiet environment. People there have a harmonious relationship with each other. patient tends to be quiet. Isolation stage where in she is afraid of rejections such as being turned down by her partner. Environment Hazards The patient stated that their house is a apartment type located in sunny brook subdivision. and chatting with her friends. She also stated that she is fond of watching T. J.G. Personal Habits According to the client.V. H. far from noise and air pollution. Coping and Stress Management Tolerance Pattern When problems are present. Interpersonal Relationship According to Erik Erickson s stages of psychosocial development patient X is in the Intimacy vs. if her closest cousin is with her she seeks help to her cousin. . She is capable of forming intimate reciprocal relationships and willing to make sacrifices and compromises that such relationships require. she is fond of eating lots of foods not knowingly if it s healthy or not and drinking alcohol occasionally.

2009 Conscious and coherent Height: 5 4 Weight= 58kgs.pale lips Pink gums Skin y y y y y y y H: y y y y E: y y E: y y y N: y y y T: y y y y y y y y y H: y y y y HEENT y E: y y E: y y y N: y y y T: y y . REVIEW OF SYSTEMS System General December .2 C) Brown skin complexion Good skin turgor Smooth and warm to touch Normocephalic scalp has no dandruff black hair round face without edema and disproportionate structures PERRLA Pale conjunctiva Symmetrical Sound is heard on both ears Same color with facial skin Midline and straight Pink mucosa No discharge Smooth. Afrebrile (T=36. pink lips Pink gums December . Afrebrile (T=36 C) Brown skin complexion Good skin turgor Sweaty and warm to touch Normocephalic scalp has no dandruff black hair round face without edema and disproportionate structures dizziness(HGT=62mg/dl) PERRLA Pale conjunctiva Symmetrical Sound is heard on both ears Same color with facial skin Midline and straight Pink mucosa No discharge Smooth .IX.2009 Conscious and coherent Height: 5 4 Weight = 58kgs.

person and place Appears quiet Cardiovascular Gastrointestinal y y y y y Genitourinary Peripheral vascular Musculoskeletal Neurologic y y y y y y y Urine color: yellow Voided 2x the shift No cyanosis 2 seconds capillary refill Moves in full range of without tenderness Oriented to time.Respiratory y y y y y y y y y y y Symmetrical chest wall Clear breath sounds No cough eupnea Pulse rate= 76bpm BP=110/80mmHg Grade 2 peripheral and apical pulses Veins not visible Regular rhythm Absent palpitations Cold extremities Good appetite Distended abdomen Absence of masses and tenderness in the abdomen Hypoactive bowel sounds Did not defecate during the shift y y y y y y y y y y y y y y y y y y y y y y y y y Symmetrical chest wall Clear breath sounds No cough eupnea Pulse rate= 77bpm BP=100/70mmHg Grade 2 peripheral and apical pulses Veins not visible Regular rhythm Absent palpitations Cold extremities Good appetite Distended abdomen Absence of masses and tenderness in the abdomen hypoactive bowel sounds Defecated once within the shift Stool color: yellow Consistency: soft Urine color: yellow Voided 3x the shift No cyanosis 2 seconds capillary refill Moves in full range of without tenderness Oriented to time. person and place Appears relax .

X. ANATOMY AND PHYSIOLOGY .

XI. PATHOPHYSIOLOGY Precipitating factors: Predisposing factors: Age  genetics Etiology unknown Sedentary lifestyle Diet Obesity(wt=58kgs) Altered beta-cell function Receptor defect Receptor defect Destruction of Beta cells Decrease # of insulin specific receptors Delayed / insufficient insulin production Decrease binding of insulin to insulin specific receptors .

glycogenolysis CBG= 203 mg/dl Vascular hyperglycemia polyphagia PROTEIN S/sx: good appetite FATS polyuria Hypersmolar diuresis Glucosuria[+3] Atherosclerosis ¡   Blood glucose reaches renal thresholds   ecreased GFR Free fatty acids eposition to vessel alls .Increase insulin demand Insulin resistance Beta cells exhaustion and dysfunction Cells starvation Cellular hypoglycemia S/sx:(CBG=62mg/dl Gluconeogenesis.

Cl in the blood(106 .Increase LDL Water loss Increase BP(160/100 during admission) Excretion of Na+. K. Cl- S/sx: excessive thirst Na in the blood(133.5mmol/L) polydipsia .8mmol/L) .

par asitic infestation. eosinophilic leukemia .XII. LABORATORY RESULTS Hematology Date: December 4. 2009 Procedure Results Normal Values Significance Nursing Implications MCHC 37.4 1-4% increase Allergic disorder.2 33-37 g/dL increase Spherocytosi s(hereditary) Eosinophils 8.

8-6.ex cessive fluid loss Dehydration Chloride 106.5 96-106 mmol/L increase .3 2.8 decrease Hyponatremia. 2009 Procedure Results Normal Values Significance Nursing Implication Hyperglycemia Poorly controlled diabetis mellitus Poorly controlled diabetis mellitus.40-1.86 mmol/L increase increase HDL 11.06mmol/L . lipoproteinemia Hyperlipidemia.Blood Chemistry Date: December 5.4 <130mg/dL(desir able) 140159(borderline high-risk) 160 mg/dl(highrisk) 135-145 mmol/L increase Sodium 133.7 3. hypercholesterol emia FBS Triglycerides 15.9 30-75mg/dL decrease LDL 131.

2009 Results Normal Values Significance Nursing Implications Transparency Slightly cloudy Clear-slightly hazy abnormal This can be due to the presence of glucose.Urinalysis Date: December 5.pus cells and RBC in the urine Glucose +3 (-) increased Diabetis mellitus infection Indicates bleeding Pus cells RBC 5-7/hpf 1-3/hpf <5hpf <5hpf increased increased .

Capillary Blood Glucose Date 12-8-09 5am 11pm 12-9-09 5am 11pm 12-10-09 5am 11pm 12-12-09 5am Result Significance Nursing Implications Somogyi effect hyperglycemia hyperglycemia hyperglycemia 196 mg/dl 203mg/dl 161 mg/dl 159mg/dl 68mg/dl 70mg/dl 62mg/dl abnormal abnormal abnormal abnormal normal normal abnormal hypoglycemia .

XIII. DRUG STUDY .

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2009 Date resolved On going December 12. 2009 December 10. 1 Problem Risk for deficient fluid volume Date Identified December 10. 2009 Problem No.XIV. 1 2 Problem Dizziness The patient is requesting for information Date Identified December 12. 2009 Date Resolved . PROBLEM LIST Problem No.

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