A Case Study on Diabetes Mellitus _____________________________________________________________________

In Partial Fulfillment of the Course Requirement In Medical Nursing

_____________________________________________________________________

Presented to the Faculty of San Lorenzo Ruiz College College of Nursing Ormoc City

_____________________________________________________________________

Submitted by:

Amor, Rolex C. Delta Class 2011

March 2011

TABLE OF CONTENTS Title I. Introduction--------------------------------------------------------------------------------------------II. Objectives----------------------------------------------------------------------------------------------III. Nursing Assessment 1. Clients personal history-----------------------------------------------------------------------------4 1.1 Patients Profile-------------------------------------------------------------------------------------4 1.2 Family and Individual Information, social and Health History-----------------------------1.3 Levels of Growth and Development------------------------------------------------------------1.3.1 Normal Development at particular stage--------------------------------------------------1.3.2 Ill Person at Particular Stage of the Patient-----------------------------------------------2. Diagnostic Result-------------------------------------------------------------------------------------3. Present Profile of Functional Health Pattern------------------------------------------------------ 12 4. Pathophysiology and Rationale 4.1 Normal Anatomy and Physiology of Organ Affected--------------------------------------- 14 4.2 Schematic Drawing of Physiology of Disease----------------------------------------------- 18 4.3 Discuss the Disease Process and its Effects on Different Organ/System-----------------4.4 Comparative Chart -------------------------------------------------------------------------------22 IV. Nursing Intervention 1. Care Guide of Patient with Disease Condition----------------------------------------------------25 2. Actual Patient Care 2.1 Nursing Assessment---------------------------------------------------------------------------2.2 Nursing Care Plan-----------------------------------------------------------------------------2.3 Drug Therapeutic Record---------------------------------------------------------------------2.4 SOAPIE-----------------------------------------------------------------------------------------2.5 Health Teaching Plan--------------------------------------------------------------------------V. Evaluation and Recommendation-------------------------------------------------------------------VI. Evaluation and Implication of this Case Study to Nursing Practice-----------------------------------------------------------------------------------Nursing Education--------------------------------------------------------------------------------Nursing Research----------------------------------------------------------------------------------52 VII. Bibliography----------------------------------------------------------------------------------------53 52 52 27 32 39 43 46 51 20 4 5 6 7 8 Page 1 2

I. INTRODUCTION After having been exposed in Ormoc Sugar Planter's Association Farmer's Medical Center Hospital, a study or specific condition is being made to as to improve the knowledge and skills at the student-nurse in providing care to the patient during their stay in the hospital. This case study is made for the reason that the student-nurse aspires to learn more about Diabetes Mellitus. This case study is made under the supervision of the clinical teacher in order to make thorough understanding and application of knowledge from the classroom to actual setting. After this case study, it is expected that the student-nurse will be able to have a comprehensive understanding about the care for the patient before, during and after hospitalization. As well as disease process of Diabetes Mellitus. Lastly, it is expected that the student-nurse will have a better understanding at the nurse's role in the incidence of such disease that may develop him a better studentnurse by gaining knowledge and skills in rendering holistic nursing care. Diabetes Mellitus is a group of metabolic disorders characterized by elevated blood glucose (hyperglycemia) resulting from decreased of insulin production and secretion, decreased cellular response to insulin or both. Insulin, a hormone produced by the pancreas, controls the blood glucose level by regulating the production and storage of glucose. In Diabetes Mellitus, there may be decrease in body's ability to respond to insulin and or a decrease or absence of insulin produce by the pancreas. This leads to abnormalities in the metabolism of carbohydrates, proteins and fats. In type 2 diabetes mellitus, formerly known as Non-Insulin Dependent Diabetes Mellitus (NIDDM) and adult onset diabetes, the body's delicate balance between insulin production and the ability of cell to use insulin goes away. Symptoms characterized of type 2 diabetes include those found in type 1 diabetes. As well as repeated infection or skin sore that heals slowly or not all, generalized tiredness, and tingling or numbness in the hands or feet. If left untreated, diabetes mellitus may cause life threatening complications.

II. OBJECTIVES Student-nurse centered General Objectives: At the end of 1 week rendering holistic nursing care, the student nurse, the patient and significant others will be able to acquire knowledge, develop appropriate skills and show positive attitude in the care with Diabetes Mellitus. Specific Objectives: After 8 hours of student-nurse-patient and significant others interaction, the student nurse will be able to: 1. introduce self and establish rapport with the patient and significant others 2. make a thorough assessment about the patient's history, family background and lifestyle 3. review the anatomy and physiology of Endocrine System 4. discuss the pathophysiology of Diabetes Mellitus 5. enumerate some manifestation of Diabetes Mellitus 6. formulate a comprehensive nursing care plan for patient with Diabetes Mellitus 7. implement health teachings for the improvement of patients well being 8. evaluate feedback from the patient and significant others on the care rendered

Patient- centered General Objectives: At the end of 4 week of holistic nursing care, the patient and the family will be able to obtain an optimum level of wellness and will also gain knowledge, skills and attitude about the management of Diabetes Mellitus. Specific Objectives: After 3 days of student-nurse-patient and significant others interaction, the patient and significant others will be able to: 1. develop rapport to the student-nurse 2. verbalized feelings, thoughts about the present condition 3. gain information about Diabetes Mellitus by its definition, manifestation, complication and pathophysiology 4. perform appropriate attitude and skills in the management of Diabetes Mellitus 5. apply the learned nursing measures in his activity of daily living 6. show positive responses to medication 7. show positive feedback towards the nursing care rendered 8. develop self-care to the fullest possible level

III. NURSING ASSESSMENT 1. Personal History Name of patient: Age: Sex: Civil Status: Religion: Ward/bed: Complaints: Diagnosis: Physician: Case: Mr. Uswaldo, Jaca 58 years old male Married Roman Catholic 125A fever Diabetic Ulcer left foot Dr. V. Rodriguez 13965

Date of Admission: April 5, 2010

1.2 Family and individual information, Social and Health History A case of Mr. Uswaldo, Jaca, 58 years old, married, a Roman Catholic and a Filipino citizen. Currently residing at Barangay Panalian, Ipil Ormoc City. Living together with his wife Mrs. Linda Jaca and their 6 children. The other 2 children are already married and have their own family as well. Both the couple's occupation is fish vendor. Mr. Uswaldo, Jaca was admitted at OSPA-FMC Hospital last April 5,2010 at exactly 3:00pm via wheelchair due to fever for 3 days already related to Diabetes Mellitus and he was schedule for debridement because at a gangrenous wound and his left lower foot. On April 6, 2010, he knew that he has Diabetes Mellitus because it is in their family history. The patient has no allergies to food and drinks. The patient started that this is his first time to be admitted in the hospital and first time to undergone an operation.

1.3.1 Normal Growth and Development Middle-Aged Adult (45-65 years old) The middle years from 40-65 have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or moving away from home. Thus, partners generally have more time for and with each other and time to pursue interests they may have deserved for years. PHYSICAL DEVELOPMENT A number of changes take place during middle years. At 40. Most adults can function as effectively as they did in their 2o's. However, during ages 40-65 many physical changes take place. Both men and women experienced decreasing hormonal production during the middle years. Sexual arousal both men and women takes longer after midlife than in younger adulthood. In men, there is no change comparable to the menopause in women. Although the term climacteric ( andropause) has been used to denote the change in sexual response in men. Androgen levels decreases version, however man can father children even in late life. Developmental task by Havighurst -achieving adult and social responsibilities -establishing and maintaining an economic standard of living -assisting teenage children to become responsible and happy adults -accepting and adjusting to the physiologic changes of middle age -relating oneself to one spouse as a person -adjusting to aging parents COGNITIVE DEVELOPMENT The middle-aged adult's cognitive and intellectual abilities change very little. Cognitive processes include reaction time, memory perception, learning, problem-solving are maintained through middle adulthood. Learning continues and can be enhance by increased motivation at this time in life. The experiences of the profession, social and personal life of middle-aged persons will be reflected in their cognitive performances. These approaches to problem solving and task completion will vary considerably in a middle-aged group. The Middle-aged adult can reflect on the past and concept experience and can imagine, anticipate, plan and hope. 5

MORAL DEVELOPMENT According to Kohlberg, the adult can move beyond the conventional level of the postconventional level. Kohlberg believe that extensive experience of personal moral choice and responsibility is required before people can reach the post-conventional level. Kohlberg found that few of his subjects achieved the highest level of moral reasoning. To move from stage 4, a law and order orientation, to stage 5, social contract orientation requires that individual move to a stage in which right of others takes prudence. Recent research demonstrate that moral development continues through adulthood and that few individuals attain stage 5 before age 40

SPIRITUAL DEVELOPMENT The middle-aged, people tend to be less dogmatic about religious beliefs and religion often more comfortable to the middle ages person that it did previously. People in this age group often rely on spiritual beliefs to help them with illness, death and tragedy.

1.3.2 The ill person at this particular stage Many middle-aged adults remain healthy: however, the risk of developing a health problem is greater than that of the young adult. Leading causes of death in this stage group include motor vehicle and occupational accidents, chronic disease such as cancer and cardiovascular disease. Mr. Uswaldo, Jaca is experiencing fatigue and weakness and apparently loss of muscle balance and gait problem due to gangrenous wound on his left lower foot. Lifestyle patterns in combination with aging. Family history and developmental stressor and situational stressor are often related to health problems that do avoid. The ill behavior of the patient at this stage can be manifested the following: polyuria, general weakness, delayed wound healing, fatigue, pale conjunctiva, lowered resistance to infection and loss of sensation of the affected area.

Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice Eighth Edition

2. Diagnostic Result (pre-op) Name of patient: Mr. Uswaldo, Jaca Impression/ Diagnosis: Diabetic Ulcer left foot Physician: Dr. V. Rodriguez Age: 58years old Room No. 125A

Diagnostic Test Hematology Hemoglobin

Normal Values

Patient's Result

Significance

14.0-17.5

7.6

Decreased Anemia (iron deficiency, aplastic) Sources: Laboratory and Diagnostic Test with Nursing Implications; 7th edition by Joyce LeFever page 220

Hematocrit

41.5-50.4

23.9

Decreased: Acute blood loss; anemia; malignancy of organ; cirrhosis of liver; protein malnutrition; vitamin deficiency

Peptic ulcer disease; rheumatoid arthritis Sources: Laboratory and Diagnostic Test with Nursing Implications; 7th edition by Joyce LeFever page 218 Decreased : Red blood cells (RBC) 4.50-5.90 2.76 hemmhorage (blood loss); anemia; chronic infections; leukemias; multiple myeloma; excessive intravenous fluid; chronic renal failure; overhydration Sources: Laboratory and Diagnostic Test with Nursing Implications; 7th edition by Joyce LeFever page 380

Bone marrow depression White blood cells (WBC) 4000-11000 16.2 Source: MedicalSurgical Nursing Volume 2; by Black

Page 2097 Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin (MCH) Mean Corpuscular Hemoglobin Concentration (MCH) Platelet 80.0-96.0 84 Normal

27.0-31.0

27.7

Normal

32.0-36.0

33.0

Normal

150000-450000

469

Increased: acute infections; hodgskins disease, acute cholecystitis, acute pancreatitis, acute appendicitis Sources: Laboratory and Diagnostic Test with Nursing Implications; 7th edition by Joyce LeFever page 488 Normal

Neutrophils Monocyte

50.0-70.0% 0.0-0.7%

69.1 Normal 6.7

April 5, 2010 CBS 62.79-117.0 mg% 279.0 mg%

Increased:indicates hyperglycemia. Sources:laboratory test and Diagnostic, 6th ed. By Jane Vincent Corbert.

10

Basophils

0-1%

0.2

Normal

Eosinophils

1-5%

1.1

Normal

Lymphocytes

20-40%

4.3

Decreased; Cancer; leukemia; aggranulocytosis; renal failure; aplastic anemia; nephrotic syndrome Source: Laboratory and Diagnostic Test

11 3. Present Profile of Functional Health Patterns

1.1 Health Perception/Health Management Pattern Prior to admission, the patient experienced high body temperature 38.2 C. The patient was taking medication (paracetamol) for fever. The drug that was taken did not take effect and his fever still fever remains. Initial intervention was done by the family such as tepid sponge bath. The patient knew that he has diabetes mellitus for almost 20 years. He has an open wound on his left lower foot and have taking medication (amoxicillin) for gangrenous wound but the drug that was taken did not take the effect. Upon admission fever is still present 37.8 C and was proposed to undergo debridement because of a gangrenous wound. The patient verbalizes that he is afraid on the operation.

1.2 Cognitive/Perceptual Pattern The patient was coherent, communicative and speaks clearly. He answers questions appropriately. The patient has no sensory deficit and responds verbally. He is afraid because it is his first time to be admitted very worry of his present condition if it will be treated or not. 1.3 Self-Perception /Self-Concept Prior to admission, patient was able to do things he likes to do (watching tv, sitting, reading). Patient knows his limitations in performing daily activities. He loves to do those things as what he is doing before until the onset of the disease. During admission, patient thinks for his family and shows concern in the family he left home. Patient verbalizes that his health condition brought burden to the family. 1.4 Roles and Relationship Mr. Uswaldo, Jaca lived together with his wife together with their 6 children. Their other 2 children were already married and have their own family as well. Patient and his wife have a good communication as evidenced by sharing of ideas and opening with problems to avoid arguments. His present health condition makes him strong. They always discuss things concerning their health and able to express things freely.

12 1.5 Values and Beliefs

The family and the patient are Roman Catholic. They do not attend mass regularly. The patient and his family sometimes believed in superstitious belief but do not believed in faith healer. The family use herbal medicines as an alternative if they cannot avail drugs. 1.6 Nutritional and Metabolic Pattern The patient verbalizes that prior to admission, he eat 3 times a day about 1 cup of rice every meal and sometimes with snacks in between meals. Mr. Jaca consumes 8-9 glasses of fluids a day including water, teas and juices. During admission, he cannot eat what he wants to eat because of the restriction or limited food intake. 1.7 Elimination Pattern Before admission, the patient usually voids 8-9 times a day with an amount of 200-300ml per voiding and defecated only once with an amount of approximately 1 to 1 1/2 cup with a color of brown. During admission, he also voids 8-9 times a day and defecates once. Color of urine usually yellow. 1.8 Sexuality and Reproduction The patient is 58 years old, which belongs to the middle-aged adult. According to Freud, middle-aged adult has many changes in their sexuality and reproductive pattern. The patient experienced andropause, androgen level decreases, fatigue and less energy, depression and mood swing. 1.9 Activity/Exercise Pattern Before admission, the patient spent most of his leisure time watching television and listening to the radio. The patient usually baths once a day. During hospitalization, since there is no tv and radio in the hospital, he chooses to stay in bed and take some rest. The patient cannot bathe him self due to the open wound. 1.10 Rest/Sleep Pattern Prior to admission, the patient sleeps 6-7 hours a day. He had a good sleep. Sometimes he has a naptime with approximately 2-3 hours especially when he feels tired. When he was admitted, the patient cannot sleep well due to noisy and unfamiliarity to the environment. Usually he sleeps 4-6 hours everyday. 13 4. Pathophysiology and Rationale

4.1 Explain the Normal Anatomy and Physiology of Endocrine System

14 a. Pituitary Gland

The pituitary gland is located in the sella turcica of the sphenoid bone. The infundibular stem attaches the gland below to the hypothalamus above. The hypophysis consists of 2 lobes. The larger anterior lobe, the adenohypophysis which is derived embryologically from primitive pharyngeal epithelium and the posterior lobe, the neurohypophysis, which is derived from neural ectoderm. An intermediate lobe is found between these two main lobes and is prominent in animals but not in humans. The hypophysis is highly vascular and receives its blood from the superior and inferior hypophyseal arteries. These are branches of the internal carotid artery and the posterior communicating artery. b. Thyroid Gland The thyroid gland consists of two lobes, situated at the side of the trachea and thyroid cartilage. The lobes are connected by strands of thyroid tissue called the isthmus, ventral to the trachea. The external layer of the thyroid is connective tissue that extend inwards as trabeculae and divides the gland secreted by the columnar epithelial cells that line in follicle. The substance is called thyroglobulins. c. Parathyroid Glands The parathyroid, usually four in number and arrange in pairs, are independent of the thyroid both in origin and function but are usually located on its dorsal surface. These small reddish glands are about 6-7mm long 2-3mm thick. The parathyroid secretes a hormone parathyroid hormone, protein which plays on important role in the maintenance of the normal calcium level of the blood. It also regulates phosphorus metabolism and increase the rate of calcium absorption in the senal tubule.

15 d. Adrenal Gland

The adrenal glands are two small bodies that lie at the posterior pole of each kidney. The right adrenal gland is somewhat triangular in shape and the left one or more semilunar. They vary in size and average weight of each is about 8 to 9 cm. each gland is surrounded by a thin capsule and consists of two parts known as the cortex or internal tissue and the medulla or chomophil tissue. These parts different in origin and function. The adrenal cortex secretes a group of hormone called corticosteroid. These include the mineralocorticosteroids and the glucocorticoids. The adrenal medulla consists of large granular cells arranged in networks. It secretes two hormones, amine in nature called epinephrine and norepinephrine.

e. Ovary The ovary produces two hormones whose actions are understood. First is follicular hormone or estrogen is present in the blood of females from puberty to the menopause, reaching in highest concentration just before ovulation. Second is corpus luteum hormone or progesterone promoting further development of the uterine mucosa in preparation of the implantation of the developing ovum. f. Testis The testis produces the male sex hormone, testosterone. The hormone promotes the development of male secondary sex characteristics, leading to increase in growth of tissue and muscularity, in addition to development of sex organs. The term androgen is used to refer to any hormone that like testosterone, promotes the development of male sex characteristics. g. Pancreas Deep within the pancreas are special group of cell, the islets of langerhans which secrete two hormones, insulin and glycogen. Two main types of cell are identifiable in the islet and are called alpha and beta: the alpha cell produce glucagon and the beta cell produce insulin. Insulin promotes the diffusion of glucose across the cell membrane of moss cells, with the exception of the brain, its effect is dramatic and result in prompt fall of blood sugar level. The glucose concentration in the blood is the stimulus for insulin. 16 When the glucose level is high, insulin is promptly secreted until the glucose resumes a normal level, when the glucose level is low, insulin secretion stop. Glucose uptake by the cell facilitates

glycogen synthesis in liver and skeletal muscle. Glucagon has the opposite affects on blood glucose level by stimulating liver glucomogenesis and glycogenolysis. Glucagon is secreted in response to low blood sugar level.

(Elaine Marieb; Essential of Human Anatomy and Physiology 7th edition page 282-299)

17 4.2. Pathophysiology of Diabetes Mellitus

PREDISPOSING FACTOR -Genetic/hereditary -Sex and obesity -Age older than 30 years

PRECIPITATING FACTOR -Lifestyle -Habits (eating sweet foods) -History of familial disease

Islets of Langerhans

Alpha cell produce the somastatin hormone glucagon insulin) ( stimulates the breakdown of glucagon in the liver, the formation of carbohydrates in the liver and the breakdown of lipids in both the liver and adipose tissue)

Beta cells secretes the hormone insulin (facilitates the movement of glucose across cell membranes into cells, decreasing blood glucose level)

Delta cells produce (production of glucagon and

beta cells cannot produce insulin decreased secretion of insulin increased glucose concentration increases conversion of glucagon to

18 glucose to liver

signs and symptoms

weight loss

fatigue

hyperglycemia

polyuria

polydipsia

nursing management -obtain patient's history -monitor vital signs -check intake and output -encourage adequate sleep -encourage regular exercise -limit consumption of fats -provide safety for the patient -avoid any sharp objects causing injury -increased fluid intake

medical management -intravenous fluid administration -close monitoring for those other minor symptoms -administer insulin -ranitidine (anti-ulcer drug)

surgical management -amputation -debridement

19 4.3 Discuss the Disease Process and its Effect on Different Organ/System

1. Alteration in Cardiovascular Coronary Artery Disease Coronary artery disease is a major risk factor in the development of myocardial infarction in people with diabetes especially in the middle to older adult with type 2 diabetes mellitus. Peripheral Vascular Disease Occlusion and thrombosis of large vessel and smaller arteries and arterioles as well as alteration in neurologic function and infections, resulting gangrene.

2. Alteration in Sensory System Diabetic Retinopathy is the name for the changes in retina that occur in the person with diabetes. The retinal capillary structure undergoes alteration in blood flow, leading to retinal ischemia and a breakdown in the blood-retinal barrier.

3. Alteration in Urinary System Diabetic Nephropathies It is the thickening of the basement membrane of the glomeruli eventually impairs renal function. It is suggested than increased intercellular concentration of glucose supports the formation of abnormal glycoprotein in the basement membrane. The accumulation of these stage large proteins stimulates glomerulosclerosis. Glomerulo-sclerosis severely impairs the filtering function of the glomerulus and protein is lost in the urine.

4. Alteration in Peripheral and Autonomic Nervous System The peripheral neuropathies also called somatic neuropathies one common type of polyneuropathies. The manifestation appears first in the toes and feet progress upward. The person with polyneuropathies commonly has a distal paresthesias (a subjective feeling of changes in sensation such as a numbness or tingling) 20 5. Increased Susceptibility to Infection

Person with diabetes has an increased risk of developing infection. The exact relationship between infection and diabetes in not clear, but many dysfunction that result from diabetic complication, predispose the person to develop an infection. The person with diabetes may have sensory deficit resulting in inattention to trauma and vascular deficit that decreased circulation to the injured area, as a result. The normal inflammatory response is admonished and healing is showed.

Source: Pathophysiology, Concept of Altered Health State 6th edition

21

4.4 Comparative Chart showing the Classical and Clinical Signs and Symptoms of the Disease

Classical symptoms

Clinical symptoms

Rationale

Polyuria

Manifested (sige man ko ihi) 9-12 times a day and volume of 600-800 a day

-hyperglycemia acts as an osmotic diuretics the amount of glucose filtered by the glomeruli of the kidney exceeds that which can be reabsorbed by the renal tubules, glycosuria results, accompanied by large amount of water lost in the urine Source: Understanding Pathophysiology 3rd edition by Sue Huether

General Weakness

Manifested -numbness felt after ROM exercise

-decreased plasma volume leads to postural hypotension, potassium loss. A protein catabolism contribute to weakness Source: Medical-Surgical Nursing 3rd edition by Priscilla Lemone page 473

Delayed wound healing

Manifested -5 months prior to admission, patient claimed to have an open wound on his left lower foot and becomes infected

-Infected because oxygen,

areas the

heal

slowly vascular cells,

damage blood

system cannot carry sufficient white nutrients and antibiotics to the injured sites. Source: Medical-Surgical Nursing 3rd edition by Priscilla Lemone page 473

22

Fatigue

Manifested Weakness Tiredness Always lying on bed

-increased plasma volume produce weakness and fatigue Source: Medical-Surgical Nursing 3rd edition by Priscilla Lemone page 473

Pale conjunctiva

Not manifested

-result from occusion of the outflow channels by new blood cells Source: Medical-Surgical Nursing 3rd edition by Priscilla Lemone page 473

23 Lowered resistance for Manifested -clients with diabetes mellitus are

infection

-swollen, gangrenous wound on the left lower foot

susceptible for infection to many types. Once infection occur, they are difficult to treat. Source: Medical-Surgical Nursing 3rd edition by Priscilla Lemone page 473

Loss of sensation of affected part

Not manifested

-people with sensory neuropathies have impaired pain sensation and often are unaware of the constant trauma Source: Medical-Surgical Nursing 3rd edition by Priscilla Lemone page 473

24

1V. NURSING INTERVENTIONS:

Care Guide of Patient with Diabetes Mellitus Type II Promote Proper Nutrition Dietary Management is an essential component of diabetes care and management. The general goal of dietary management is to help client with diabetes improve metabolic control by making changes in nutrition habits. Promote Regular Physical Activity A program planned exercise is a crucial part of the treatment plan for a client with diabetes. Exercise lowers blood glucose by increasing carbohydrate metabolism, fasters weight reduction and maintenance, increase insulin insensitivity increase high density, lipoprotein level; decreased triglyceride level lowers blood pressure and reduces stress and tension. Eating habits based on the food guide pyramid The food pyramid is another tool used to develop meal plans. It is commonly used for patients with Type II Diabetes who have difficulty time following a calorie controlled diet. In general, eating foods that are raw and whole results in a lower glycemic response than eating chopped, pureed or cooked food. This can help patient improve blood glucose control through individualized manipulation of the diet. Administer Medication Oral antidiabetes agent, pharmacologic interventions should be considered when the client cannot achieve normal or near normal blood glucose level with nutrition and exercise therapy. Oral; hypoglycemic agents are effective in people with Diabetes Mellitus Type Ii after nutrition and exercise therapy have failed. Use of Sweeteners Sweeteners are acceptable for patient with diabetes, especially if it assists in overall dietary adherence. Moderation in the amount of sweeteners used is encouraged, to avoid potential adverse effect.

25 Elimination Pressure Eliminating pressure on an infected area is essential to wound healing. Teach client with foot ulcers to not wear shoes on the foot while the ulcer is healing. Clients with poor

sensation keep walking on an ulcer because it does not hurt. This results in pressure necrosis that delays healing and increases ulcer size. Pressure is reduced by specialized orthotic devices, custom-molded shoes inserts or shoe adjustments that redistribute weight. Maintaining a Healthy Weight Is one of the most important things you can do to prevent Type II Diabetes because being overweight is a major risk factors. When you eat too much, the extra calories that are not immediately used are stored as fat. When you regularly eat too much, the stored fat that isnt used keeps accumulating. Loosing Weight Sensibly The best way to lose successfully is to adopt healthy eating and exercise habits you can maintain for the rest of your life. Making an Eating Plan It is much sensible to follow a reasonable diet plan that you can stick to for the rest of your life. A diabetes- fighting diet is heart. Calorie conscious, high in fiber and other important nutrients, and low in harmful fats and sweets.

Source: Medical-Surgical Nursing, 10th ed. Volume 1, Suzanne C. Smeltzer pages 855-856. 26

Physical Assessment (IPPA)

Body parts Head Inspection Head is round, Palpation Non tender, Percussion Auscultation

symmetrical and body

without masses

proportionate to its and depression

Hair

Hair is black in color with a white strands and it is short in cut

No presence of nodules and masses temporal pulse is present and no lesions

Forehead

Color is similar to face

Face

Pale in color as well as his skin

No pain felt upon palpation

Brows

Moves proportionate when the facial expression changes

Lashes

Are evenly distributed along the lid margin

No mass or lesion

Lids

Skin is intact, no discharges, no redness

27

Body parts Sclera

Inspection White in color with superficial vessels

Palpation

Percussion

Auscultation

Conjunctiva

Pinkish in color, transparent and slightly moist

Iris

Equal in size and round

Pupil

equal in size and reactive to light accommodation

Visual acuity

patient can read with eye glasses lies on the midline of the face

Nose Frontal sinuses Maxillary sinuses Mouth Lips Gums Teeth

lies on the midline of the face bright red in color bright red in color pinkish in color pinkish in color moist 30 teeth is present, yellowish in color, no presence of carries Pinkish in color, moves freely
28

Tongue

Body parts Frenulum

Inspection Attached to the tongue Prominent vein was observed

Palpation

Percussion

Auscultation

Sublingual area

Hard palate Soft palate Uvula

Pink in color Pink in color Pink and found at the midline No inflammation Symmetrical, no discharges Skin is brown in color Not visible Rise and fall when swallowing No pain felt

Tonsils Ears

Neck

Carotid pulse is present No pain felt No pain felt during swallowing No presence of lesions, equal chest expansion Symmetrical expansion

Lymph nodes Thyroid gland

Chest anterior

Fair in color and presence of scars

Resonance sound is heard

21 breaths per minute

Lungs

Resonance sound is heard

Clear breath sound heard 75 beats per minute

heart

chest posterior

Fair in color, spine vertically aligned

lungs
29

clear breath sound

Body parts Abdomen

Inspection Abdomen is flat, symmetrical bilaterally, yellowish discoloration was

Palpation

Percussion

Auscultation

still observed, poor skin turgor, abdomen rises when inspiration and falls when expiration Liver Not palpable, no pain felt Not palpable, no pain felt Not palpable, no pain felt

Spleen

Kidney

Extremities Upper

Fair in color with IVF D5LR 1l @ 30 gtts/ minute in the left hand, arms are symmetrical Pain felt weak, he always stays in bed

No pain felt upon palpation, T; 37.7 C, PR: 86, warm skin and elastic

BP: 110/70mmhg

Muscle tone

No pain felt

Muscle strength

Cannot resist energy to the student nurse Skin is pale, evenly distributed, presence of open wound in the left lower foot,

lower

30

Body parts

Inspection wound is reddish in color with foul odor, approximately 6 inches in length

Palpation

Percussion

Auscultation

and 4 inches in wide Muscle strength cannot strongly resist upon student nurse strength unable to walk due to his gangrenous wound on the left lower foot

Gait, balance and coordination

31

Nursing Care Plan

Nursing problem I. Physiologic deficit: Nursing diagnosis Impaired skin integrity: Scientific basis Disruption of normal skin integrity can Objectives of Interventions care After 8 hours Measures to of holistic improve skin Rationale

Impaired skin integrity Objective cues: -disruption of skin surface -poor skin integrity -swelling -redness -presence of pus -foul smell -gangrenous foot with approximately 6 inches in length and 4 inches wide -destruction of skin layer Subjective cues: "nakoy samad nga nagtika dako dri sa ako tiil" as verbalized by the patient

gangrenous wound of the left foot related to disease process secondary to diabetes mellitus

manifest lesion or open wound. Any break in the skin's epidermal layers signifies that skin integrity is altered. Usually the disruption to the epidermis is evident Source: Fundamentals of Nursing by Ruth Craven p.991

nursing care, the patient will be able to maintain optimal well being as evidenced by understanding on importance of wound care

integrity 1. monitor/note changes in color, texture and turgor

-to monitor progress of wound healing Source: Nurses Pocket Guide 11th ed. by Doenges p.619 -to assist body's natural process of repair Source: Nurses Pocket Guide 11th ed. by Doenges p.619

2. keep area of wound clean and dry

-to protect the 3. use wound appropriate Source: Nurses wound dressing Pocket Guide 11th ed. by Doenges p.619 4. avoid use of plastic materials -moisture penetrates skin breakdown Source: Nurses Pocket Guide 11th ed. by Doenges p.619

32

5. use - aid in healing appropriate and to maintain wound dressing good health Source: Nurses Pocket Guide 11th ed. by Doenges p 619

6. assist the patient and significant others in following preventive measures 7. encourage early ambulation

-enhances commitment to plan of care Source: Nurses Pocket Guide 11th ed. by Doenges p 619 -promotes circulation and reduces risk associated with immobility Source: Nurses Pocket Guide 11th ed. by Doenges p 619 -to promote faster healing of the wound Source: Nurses Pocket Guide 11th ed. by Doenges p 619

8. administer medication as ordered

33

Nursing problem II. Physiologic deficit Poor appetite Objective data: -restricted food

Nursing diagnosis Imbalanced nutrition: Less than body requirements: Poor appetite related to

Scientific basis Status can be affected by disease or injury, physical, social,

Objectives of care After 8 hours of student nurse patient interaction, the patient will be able

Interventions Regain normal appetite for food

Rationale

1. suggest ways - elevated the to assist the head of the bed

such as sweets, low in saturated fats -body malaise -poor muscle tone -weakness of muscle Subjective data: " gamay ra au ako kaon tungod sa paglikay sa pagkaon na dili angay nako

restricted consumption of food such as sweets

psychological factors during time of illness. Adequate nutrition plays an important role in healing and recovery Nursing Care Plan by Gulanick page 134-135 6th edition

to:

regain normal appetite for food as evidenced by a consuming a whole serving of diet for age

patient meals as needed. Ensure a pleasant environment. Facilitate proper positioning and provide oral hygiene 2. provide companionship during meal time

to 30 degrees, aids in swallowing and reduces risk for aspiration Source: Nursing Care Plan 6th edition page 136 by Gulanick/Myers - attention to social aspects of eating is important in both hospital and home setting Source: Nursing Care Plan by Gulanick/Myers page 136

-seasoning may 3. for patient enhance the with changes in flavor of food to sense of taste enhance eating encourage Source: Nursing seasoning use Care Plan by Gulanick p 136

34

Nursing problem

Nursing diagnosis

Scientific basis

Objectives of care

Interventions 4. for hospitalization patient, encourage to bring food from home as appropriate

Rationale -patient with specific ethnic or religious preferences or restrictions may not eat hospital foods Source: Nursing

Care Plan by Gulanick p 136 -such supplement can be food source without interfering with voluntary food intake Source: Nursing Care Plan by Gulanick p 136 - this may decrease appetite and lead to early satiety Source: Nursing Care Plan by Gulanick/Myers page 136

5. suggest liquid drinks for supplemental nutrition

6. discourage beverages that are caffeinated or carbonated

35

7. promote pleasant relaxing environment including socialization when possible

-to enhance intake Source: Nursing Care Plan by Gulanick/Myers page 136

8. administer replacement fluids and

- to support circulating volume and tissue perfusion

electrolyte as ordered

Source: Nursing Care Plan by Gulanick/Myers page 136

36

Nursing Nursing problem diagnosis III. Physiologic Impaired deficit physical mobility: un Physical able to walk Immobility related to gangrenous Objective cues: wound on the -unable to walk left lower because of the foot gangrenous wound in the left lower foot -restlessness -limited range of

Scientific basis Presence of wound in a physiologic body part can change a client's ability to perform activities of daily living. Some skin conditions restrict clients to home because of

Objectives of care After 8 hours of holistic nursing care, the patient will be able to increase strength and function of affected body part

Interventions Measures to increase strength and function of affected body part 1. instruct family to use side rails and roller pads

Rationale

-for position changes and transfer Source: Nurses Pocket Guide 11th ed. by Doenges pg.

motion -unable to perform activities of daily living -decreased muscle strength Subjective cues: " dili ko kaayo makalihok ug makalakaw tungod sa akong samad sa tiil" as verbalized by the patient"

treatment demands. Discomfort or limitations on their ability to return to walk with open wounds

457-460 2. support affected body part using pillows -to maintain position to function and reduce risk of pressure ulcer Source: Nurses Pocket Guide 11th ed. by Doenges pg. 457-460 -to reduce fatigue Source: Nurses Pocket Guide 11th ed. by Doenges pg. 457-460 -limit fatigue maximizing participation Source: Nurses Pocket Guide 11th ed. by Doenges pg. 457-460

3. schedule activities with adequate rest periods during the day

4. identify energy conserving technique for ADL's

37

Nursing problem

Nursing diagnosis

Scientific basis

Objectives of care

Interventions 5. consult with physical therapist as indicated

Rationale -to develop individual exercise or mobility program and identify appropriate adjunctive devices Source: Nurses Pocket Guide 11th ed. by Doenges pg 457-460

6. encourage adequate intake of fluids, nutritious foods

7. provide for safety measures as indicated

-promote wellbeing and maximizes energy production Source: Nurses Pocket Guide 11th ed. by Doenges pg 457-460 -to prevent falls Source: Nurses Pocket Guide 11th ed. by Doenges pg 457-460

38

DRUG THERAPEUTIC RECORD Drug, dose, route, freq. Classifications, mechanism of action Ranitidine Classification: IVTT 50mg anti-ulcer q 8 hour Mechanism of Timing action: 8am Competitively 4pm inhibits actions 12mid of histamine on the h2 receptor site in parietal cells which Indications, contraindications, side effects Side effects: Headache, malaise, dizziness, tachycardia, constipation, diarrhea, nausea, vomiting, abdominal pain Indications: -duodenal ulcer Principle of care 1. teach patient that impotence may occur but reversible 2. teach patient to avoid other hazardous activities Treatment Evaluation

-monitor vital signs -monitor intake and output -monitor for allergic reaction

Effectiveness of therapy can be demonstrated by resolution of the signs and symptoms of the infection

inhibits gastric acid secretion

-gastric ulcer -GERD Contraindications: -allergy to histamine

-diet therapy 3. teach patient to avoid pepper, caffeine, alcohol 4. assess patient to abdominal pain 5. tell the patient to report if he experience sore throat, fever and severe head ache

39

Drug, dose, route, freq. Insulin SQ 150-200 . 5"U" 201-250 10"U" 251-300 15"U" 301-350 20"U" 351-400 25"U"

Classifications, mechanism of action Antidiabetic hormone Mechanism of action: Insulin is a hormone secreted by beta cells of pancreas that by receptor mediated effects, promote storage of the body's fuels, facilitating the transport of

Indications, contraindications, side effects Side effects -rashes to injection site -redness -swelling -itchiness Indications: -treatment for type 1 DM Contraindications: -allergy to pork products -history of

Principle of care 1. tell patient to use the some type and brand of syringe 2. tell patient and family do not change the order of mixing insulin 3. tell patient and family to

Treatment

Evaluation

-monitor vital signs -monitor intake and output -monitor for allergic reaction -IVF therapy

Effectiveness of therapy can be demonstrated by resolution of the signs and symptoms of the infection

metabolites and ions (potassium) through cell membrane and stimulating the synthesis of glycogen from glucose or fats from lipids and protein from amino acids

smoking or lung disease

store drug in the refrigerator or in a cool place 4. tell patient to monitor his urine or blood level 5. tell patient to avoid drinking alcohol beverages 1. instruct patient to take oral drug in an empty stomach -monitor vital signs -monitor intake and output Effectiveness of therapy can be demonstrated by resolution of the signs and symptoms of the infection

Antibiotic Floruquinolone Ofloxacin 400mg 1 tab OD Timing 8 am Mechanism of action: Bactericidal; interferes with DNA replication

40

Drug, dose, route, freq.

Classifications, mechanism of action Insusceptible gram negative bacteria preventing cell production

Indications, contraindications, side effects Side effects: -headache -dizziness -insomnia -fatigue -nausea, vomiting -diarrhea -abdominal pain Indications: -lower respiratory tract infection -uncomplicated skin soft tissue infection Contraindications:

Principle of care 2. tell patient to drink plenty of water 3. instruct patient to avoid long exposure to sunlight 4. report lack of response, review list of side effects 5. tell patient

Treatment

Evaluation

-IVF therapy -monitor for allergic reaction

-allergy to fluroquinolones

to report if he experience rash, visual changes, severe GI problems, weakness, tremors 1. instruct patient to take drug with food or meal if GI upset occur 2. tell the patient to take only the prescribed drug -monitor vital signs -monitor intake and output -IVF therapy -provide rest and safety Effectiveness of therapy can be demonstrated by resolution of the signs and symptoms of the infection

Celecoxib 200mg 1 cap OD Timing 8 am

Analgesic, NSAIDS Mechanism of action: Analgesics and antiinflammatory activities related to inhibition of the coxz enzyme which is activated in

Side effects: -headache -dizziness -insomnia -fatigue -nausea, vomiting -diarrhea -abdominal pain Indications: -acute and long term treatment of signs and
41

Drug, dose, route, freq.

Classifications, mechanism of action inflammation to cause the signs and symptoms associated with inflammation

Indications, contraindications, side effects symptoms of rheumatoid arthritis, management of acute pain contraindications: -allergic to NSAIDS or aspirin -use cautiously with impaired hearing, hepatic and CV condition

Principle of care 3. tell the patient of the side effects of medication 4. tell the patient to take drug with water 5. tell the patient to report if he experience sore throat, fever, rash, itching 1. tell patient

Treatment

Evaluation

-monitor for allergic reaction

Effectiveness of therapy can be demonstrated by resolution of the signs and symptoms of the infection

Chlorpheni

Antihistamine

Side effects:

-monitor vital

Effectiveness

ramine maleate IM before BT

(alkaline type) Mechanism of action: Competitively blocks the effects of histamine at H1 receptor site

-drowsiness -sedation -headache -blurred vision -anorexia -urinary frequency Indications: -symptomatic relief of symptom associated with perinial and seasonal allergic rhinitis Contraindications: -allergic to histamine - peptic ulcer -bladder neck obstruction
42

take as prescribed do not overdose 2. tell the patient to take it with food if GI upset occur

signs -monitor intake and output -IVF therapy -provide rest and safety

of therapy can be demonstrated by resolution of the signs and symptoms of the infection

3. avoid OTC drug -monitor for allergic 4. avoid reaction drinking alcohol 5. report any difficulty in breathing, hallucination

Name of patient: Mr. Uswaldo Jaca Diagnosis: Diabetic Ulcer Left Foot Physician: Dr. V. Rodriguez SOAPIE # 1

Age: 58 years old Room no: 125A

S- "nagsugod man siya sa gamy nga samad dong niya hantod nag tika dako" as verbalized by the patient O- seen patient lying on bed, conscious with oxygen regulated at 3L/minute via nasal cannula with ongoing Intravenous fluid no. 6 PLRil at 30 gtts/minute infusing well at the right arm. Presence of gangrenous wound noted on the left foot, reddish in color with foul smell approximately 6 inches in length and 4 inches wide With a following vital signs of T: 36.9 C, pulse rate of 72 beats per minute, respiratory rate of 21 breaths per minute and a blood pressure of 110/70mmhg A- Impaired skin integrity: gangrenous wound on the left foot related to disease process secondary to diabetes mellitus P-to promote skin integrity

I- placed side-rails up; keep the left foot clean and dry; apply sterile dressing on the left foot; maintained proper moisture on the left foot; encouraged ambulation/mobilization; wound dressing as needed; health teaching on proper wound dressing; monitored vital signs; IVF checked and regulated; I and O monitored and recorded; due medications given E-the patient was able to demonstrate behaviors to prevent complication as evidenced by proper wound care and dry wound

Rolex C. Amor Student-nurse

Mrs. Hearty Cindy Penaranda, R.N, MAN Clinical Instructor

43

Name of patient: Mr. Uswaldo Jaca Diagnosis: Diabetic Ulcer Left Foot Physician: Dr. V. Rodriguez SOAPIE # 2

Age: 58 years old Room no: 125A

S- "kapoy jud kaayo akong lawas dong, nag sige lang kog higda" as verbalized by the patient O- seen patient lying on bed, conscious, sleepy eyes, weak, coherent and communicative with oxygen regulated at 2L/minute via nasal cannula with ongoing Intravenous fluid no. 1 PLRil at 30 gtts/minute infusing well at the right arm. With a following vital signs of T: 37.2 C, pulse rate of 80 beats per minute, respiratory rate of 20 breaths per minute and a blood pressure of 130/80mmhg A- Activity Intolerance: unable to perform activities of daily living related to increase blood glucose secondary to Diabetes Mellitus P-to be able to perform activity within level of capability

I- provided comfort; provided good ventilation; encouraged patient to perform activity within level of capability; instructed patient less movement; provided safety to the patient; give time for rest; taught deep breathing exercised; monitored vital signs; IVF checked and regulated; I and O monitored and recorded; due medications given E-the patient was able to perform activity within level of capability as evidenced by the patient can sit alone in his bed and walks 5-10 steps away from his bed with assistance

Rolex C. Amor Student-nurse

Mrs. Hearty Cindy Penaranda, R.N, MAN Clinical Instructor

44

Name of patient: Mr. Uswaldo Jaca Diagnosis: Diabetic Ulcer Left Foot Physician: Dr. V. Rodriguez SOAPIE # 3

Age: 58 years old Room no: 125A

S- "dili kaayo ko makalihok ug makalakaw tongod sa samad sa akong tiil dong" as verbalized by the patient O- seen patient sitting on bed, conscious, weak, restless, body malaise presence of gangrenous wound on the left foot noted with ongoing Intravenous Fluid no. 4 PLRil at 30 gtts/minute infusing well at the right arm. With a following vital signs of T: 36.9 C, pulse rate of 78 beats per minute, respiratory rate of 22 breaths per minute and a blood pressure of 110/70mmhg A- Impaired Physical Mobility: unable to walk related to gangrenous wound on the left foot P-to be able to increase strength of affected body part

I- placed side-rails; instructed family to support affected body parts by using pillows; provided safety to the patient; encouraged self-care to the patient; monitored vital signs; IVF checked and regulated; I and O monitored and recorded; due medications given E-the patient was able to gain some strength on his affected body as evidenced by moving forward and backward, left to right at 5 times of his affected part

Rolex C. Amor Student-nurse

Mrs. Hearty Cindy Penaranda, R.N, MAN Clinical Instructor

45 HEALTH TEACHING PLAN Objective General objectives: At the end of 8 hours of nursepatient interaction, the patient and significant others will be able to gain knowledge, develop skills and acquired positive attitude in caring for patient with diabetes mellitus specific objectives: after 45 minutes of nurse-patientsignificant others interaction, the patient and Content Methodology Time alloted Resources Evaluation

significant others will be able to: 1. define diabetes mellitus Definition: Informal -a group of discussion metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, action or both Classification: -type 1 DM A metabolic disorder characterized by an absence of 5 minutes Brunner & Suddarth's textbook of MedicalSurgical Nursing 11th ed. pg 13751438 The patient was able to define diabetes mellitus in his level of understanding

2. identify classification of diabetes mellitus

Informal discussion

5 minutes

Brunner & Suddarth's textbook of MedicalSurgical Nursing 11th ed. 1375

Identified classification of diabetes mellitus

46 Objective Content insulin production and secretion from autoimmune destruction of beta cells of islets of langerhans in the pancreas formerly called insulin dependent juvenile or type 1 diabetes mellitus -type 2 DM A metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin Methodology Time alloted Resources Evaluation

resistance formerly called non-insulin dependent adult onset or type 2 diabetes mellitus -gestational diabetes Any degree of glucose intolerance with its onset during pregnancy

47

Objective 3. enumerated method to control diabetes mellitus

Content

Methodology

Methods: Informal -diet discussion Low calorie diet should be maintained. It is planned by first calculating a person's energy need and caloric requirements based on age, gender, height and weight -exercise It is extremely important in diabetes management because of its effects on

Time alloted 5 minutes

Resources Brunner & Suddarth's textbook of MedicalSurgical Nursing 11th ed. pg 13751438

Evaluation Enumerated methods to control diabetes mellitus

lowering blood glucose and reducing cardiovascular risk factor -oral anti-diabetic agent May be effective for patients who have type 2 diabetes that cannot be treated effectively with medical nutrition therapy and exercise alone -insulin In type 1 diabetes mellitus, exogenous insulin must be administered for 48 Objective Content life because the body lose ability to produce insulin 4. state some complication of diabetes mellitus Complications: Diabetic ketoacidosis- a metabolic derangement in type 1 diabetes that results from a deficiency of insulin. Highly acidic ketone bodies are formed resulting in acidosis Nephropathy- a long term Informal discussion 10 minutes Brunner & Suddarth's textbook of MedicalSurgical Nursing 11th ed. pg 13751438 Methodology Time alloted Resources Evaluation

complication of diabetes in which the kidneys cells are damaged. Characterized by microalbuminuria in early stages NeuropathyA long term complication of diabetes resulting from damage to the nerve cell Retinopathy- a long term complication of diabetes in which the microvascular system of the eye is damaged 49 Objective Content Methodology Time alloted Resources Evaluation

5. demonstrate beginning skills in wound care

Basic Procedure of Wound Care 1. Cleanse in a direction from the least contaminated area such as from the wound incision to the surrounding skin or from an isolated drain site to the surrounding skin -use gentle in applying solution locally to the skin -allow the solution to flow from the least to the most contaminated -after cleaning, cover again with a clean gauze as prescribed

Demonstration and return demonstration

15 minutes

Barbara Kozier: Fundamentals of Nursing

Performed beginning skills in wound care

6. show interest and willingness by asking question related to health teaching given by the student nurse as evidenced by understanding the patient about his condition

discussion

5 minutes

Showed interest and willingness by asking question related to health teaching given by thestudent nurse as evidenced by understanding patient about his condition

50 V. EVALUATION AND RECOMMENDATION

Based on nursing assessment and patient's response to nursing interventions, the prognosis of patient is good. The patient has already adapted in terms of his diet restrictions. He was able to stabilize his vital signs. Even though he still feels weak, he was able to show improvements before he was discharged. As he go home, the patient was reminded of several discharged teaching such as diet modification (diabetic diet), lifestyle modification and regular check-up to the physician. Recommendation: Mr. Uswaldo Jaca's health goal was focused on following his treatment and to evade the occurrence of his disease condition. These goals are essential to the patient to fulfill for his early revitalization and on promotion of his optimum level of functioning. The patient together with his family should establish well managed lifestyle. These include a regular exercise regimen with an adequate rest and sleep periods and a well controlled diet. Patient should also build up his behaviors on ways on managing stressful situations. The patient should fulfill with his medications being prescribed to him. He should submit himself to a regular consultation for continual monitoring. Though these actions and health teachings, the patient and his family's knowledge and his condition will be enhanced and will have an assurance to have a good health.

51 VI. Evaluation and implication of this case study to:

Nursing Practice This case study implies the importance of nursing skill in caring of patients with diabetes mellitus in all type. It is important to know the clients capability in order to meet the nursing action done for the treatment. The plays a role in the provision of care to promote his own well-being and nurses remain committed to enhance the client's health condition. Nursing Education As a profession, nursing requires that its member possess a significant amount of education. Nurse's knowledge is vital in taking good care of patient. This case study will help and give additional information about patient with diabetes mellitus and its management. The care of patient is in the hands of health care provider so he must be knowledgeable enough to manage the patient's health status. Nursing Research The significance of this case study to nursing research is helpful in a way that we learn more about the disease. We are aware that diabetes mellitus is one of the most common causes of death in the country. By relating this case study to nursing research, we learn preventive measures and management of patient having the disease. It is important in the nursing field how to manage and have a comprehensive nursing care plan to the client.

52 VII. BIBLIOGRAPHY

Books: -Black, Joyce and Esther Mattasarin, Medical-Surgical Nursing Clinical Management for Positive Outcomes (7th edition) Elsevier (Singapore) PTD LTD Copyright @ 2005 -Doenges, Marilyn, et, al Nurse's Pocket Guide Diagnosis, Prioritized Interventions and Rationales (7th edition) Philadelphia F.A. Davis Company, Copyright 2004 -Ignatavicius, Donna Workman Medical-Surgical Nursing Critical Thinking for Collaboration Care (5th edition), Reprinted in the Philippines. Singapore Elsevier PTE LTD Copyright @ 2006 -Kozier, Barbara, et al Fundamentals of Nursing: Concept, Process and Practice (7th edition) Pearson Education Incorporated Copyright @ 2004 -Marieb, Elaine M. Essentials of Human Anatomy and Physiology (7th edition) Published by Pearson Education South Asia PTE LTD Copyright @ 2004 -Smeltzer, Suzanne and Brenda Bare Medical-Surgical Nursing Brunner and Suddarth's Textbook (11th edition) Reprint authorized by Lippincott Williams and Wilkins Copyright @ 2008

Internet: -www.yahoo.com. www.google.com ww.wikepidia.com www.medicine.com

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