NURSING PROCESS FORMAT

Introduction to diabetes

Diabetes is the inability of the body to control the blood sugar level. High blood sugar levels are known as hyperglycemia this is controlled by the hormone insulin. So having diabetes means there is interference with the creation and secretion of insulin. There three types of diabetes

Type 1 diabetes

This first type of diabetes is known as Type 1 diabetes, what it means is that the person with it is insulin dependent mellitus or has juvenile diabetes. It can be called juvenile because of the age it is often acquired. It is not common to get Type 1 diabetes when you have past your mid 20's.

This type of diabetes is also known as autoimmune disorder. That means the body destroys cells that produce the insulin the reason for this is that it thinks that it is harmful to the body. The cells are called the beta cells that are found in the islet cells and are found in the pancreas. When the insulin producing cells get destroyed blood sugar levels are not able to be regulated by the body so insulin has to be injected into the body to perform this function.

Type 2 diabetes

The second type of diabetes or Type 2 diabetes, which is sometimes also known as adult onset diabetes, this is because it was commonly found to occur in later life. It is caused by insulin resistance. Beta cells in the pancreas continue to produce insulin but the body needs more insulin than secreted to process the glucose or the insulin is less effective in converting glucose into glycogen and thus reducing the blood sugar level.

It is not completely verified why Type 2 diabetes happens, being overweight seems to be a common condition of most people that have Type 2 diabetes. There is a theory that a

lifestyle of eating unhealthy foods with out taking regular or adequate exercise could contribute to causing this disease. it is also believed that type 2 diabetes can be hereditary, although the most documented advice on avoiding type 2 diabetes is to lose weight, eat healthily and do more exercise.

Symptoms for diabetes Type 2

It is important to be aware that you could have diabetes and diabetes related problems without symptoms.

Type 3 diabetes

Third type of diabetes is Gestational diabetes this is acquired during pregnancy and is the product of hormonal changes in the body during the pregnancy stage and also hereditary genes. this type 3 diabetes usually stops after childbirth.

CONCLUSION

The most common type of diabetes is type 2 diabetes it is estimated that 90% of diabetics suffer the type 2 diabetes ailment. There is also more information on how to avoid and prevent type 2 diabetes than any of the others. Exercising more regularly and eating a healthy, balanced diet can help considerably reduce the chances of getting diabetes. And if you have diabetes, exercise and healthy eating can make it less intrusive to your lifestyle.

I. Biographic Data

Name: E.R.Address: Tatalon, Quezon City Gender: Male Religious Affiliation: Roman CatholicMarital Status: MarriedRoom and Bed #: 216A Occupation: noneChief Complaint: Wound in the right footProvisional Diagnosis: Gangrene of the big toe and distal plantar area ®Attending Physician: Dr. Nelson Dy / Emil dela Rosa

II. Nursing History

A. Past Health History1. Childhood Illness – None2. Immunizations - None3. Allergies - None4. Accidents - None5. Hospitalizations 6. Medications used or currently taken

Motillium tablet TID 8-1-6FeSO4 capsule TID 8-1-6Cefuroxime 500 g / tab BID 8-6Aminobrane 1 capsule BID 8-6

7. Foreign Travel ( when, length of stay) – NoneB. History of Present Illness

Patient is a diagnosed case of DM Type II (2003), with irregular follow-up. Two weeks PTA, patient noted a wound on the ® big toe. It was associated with on-and-off fever. No consultation done. One week PTA, the signs and symptoms persisted. Few hours PTA, patient was brought to the attending physician who advised admission.

C. Family History

D. 1987

fatherheartattack

D. 1983

motheroldage

D. 1997

eldestbrother

kidney failure

1937

ETDiabetes

71

1940

sisterHTN/alive

67

1944

sisterHTN/alive

63

1947

brotherTB/alive

60

1939

wifeHTN/alive

68

eldestson

well/alive

daugtherasthma/

alive

sonwell/alive

V. Physical Assessment

General Appearance Norms Actual Findings Interpretation and Analysis1. Posture/Gait

2. Skin Color

3. Personal Hygiene/Grooming

Relaxed, erect posture; coordinated movement

Healthy appearance

Clean, neat

Slouched, and in bent posture.

Pallor and weak in appearance

Unkempt

Poor posture distorts the body’s proper vertical alignment and the back’s natural curves. If you have poor posture, your bones are not properly aligned, and your muscles, joints, and ligaments take more strain than nature intended. Faulty posture may cause you fatigue, muscular strain, and, in later stages, pain. Many individuals with chronic back pain can trace their problems to years of faulty postural habits. In addition, poor posture can affect the position and function of your vital organs, particularly those in the abdominal region.Due to patient’s present health condition he is experiencing weakness and this is one of the signs and symptoms of diabetes mellitus II.

Personal grooming includes activities such as showering, dressing, toileting and attention to personal presentation, such as brushing hair, applying makeup etc. due to his present condition the patient is unable to undertake personal grooming because of underlying causes of diabetes, like muscle weakness, easy

4. Nutritional Status

5. Age Appropriateness

6. Verbal Behavior

7. Non-verbal Behavior

Proportionate, varies with lifestyle

Understandable, moderate pace; exhibits thought associations

Cooperative, no distress noted

Excessively thin

Adult age 71 years old

Understandable, exhibits thought associations

Cooperative, no distress noted

fatigability.

Due to his diabetes the patient experiences polyphagia, polydipsia, and polyuria, because of this there is variation to his nutritional status.

Genetic makeup influences biologic characteristics, innate temperament, activity level, and intellectual potential. It has been related to susceptibility to specific disease, such as diabetes. The distribution of disease. Certain acquired and genetic diseases are common in middle-aged males.

No abnormalities found

No abnormalities noted

Measurements 1. Temperature2. Pulse Rate3. Respiratory Rate4. Blood Pressure5. Weight6. Height

36.5 – 37.560 – 120 bpm14 – 24 bpm120/70 mmHg

37.1 C73 bpm23 bpm110/70 mmHg45 kg153 cm

Normal NormalNormalNormal

Body Part Norms Actual Findings Interpretation and AnalysisHair White, fine,

FaceOval in shape, symmetrical, facial expression is dependent on the mood or true feelings, uneven with wrinkles, no involuntary muscle movements

Eyes Parallel and evenly placed, symmetrical, non-protruding, with scant amount of secretions, both eyes black but patient does not have clear vision, slowed blink reflex

Eyebrows Black symmetrical, parallel to each other

Eyelashes Black evenly distributed and turned outward

Eyelids

Upper eyelids cover a small portion of the iris and the cornea and the sclera when the eyes are open. When the eyes are closed, the lids meet completely. Symmetrical in color is the same as the surrounding skin. Looseness of the eyelids.No palpable mass

Lid MarginsClear without scalings, lacrimal duct are evident at the nasal ends of the upper and lower lids

Sclera White but not that clearIris Proportional to the size of the

eyes, round, black and symmetrical

Eye Movement Not able to move eyes in full range of motion and not able to move in all directions

EarsParallel, symmetrical, proportional to the size of the head, bean-shaped, is in line with the outer canthus of the eye, skin is same in color as the surrounding area

Firm cartilageEar Canal Pinkish, with scant amount of

cerumen and few ciliaHearing Acuity Not able to hear spoken words,

you need to louder you voice and repeat it again

Nose Midline, symmetrical, Mouth (lips) Pinkish, symmetrical, lip margin

well defined, uneven and dryGums Pinkish, smooth, moist no

swelling, no dischargeTeeth Has denture and 1 tooth

Tongue Medium, pink, slight rough on top, smooth along lateral margins, moist but not freely movable

Neck Proportional to the size of the head, symmetricalPresence of internal jugular vascular access(temporarily used for hemodialysis), presence of blister

Neck (ROM) Not freely movableThorax and Lungs No lumps, masses, areas of

tendernessHas difficulty in breathing

Heart The heart sounds are audible at apical area, cardiac rate is 72

Abdomen

Blemished skin, flat, symmetrical movements caused by respiration, umbilicus is flat and positioned midway between the xiphoid process and the symphisis pubis, color is the same as the surrounding skinBorborygmi sounds, “stomach growling” heardNo tenderness, no lumps or masses

Upper Extremities Dark skin, symmetrical, fine hair

Arms evenly distributed, presence of visible veins, presence of vascular access for hemodialysis on the left arm.Warm, dry, non-elastic, no areas of tenderness, poor muscle tone

Palms and Dorsal Surfaces Non-elastic, dry and saggyNails Five fingers in each hand, brittle

Shoulders Has slight difficulty raising arms to vertical position

Arms Has slight difficulty to abduct, adduct, and rotate arms(internal and external)

Elbows Bend and straighten elbows with slight difficulty

Hands and Wrists Extend and spread fingersLower Extremities

LegsFine hair evenly distributed, presence of varicose veins, presence of edemaPoor muscle tone

ROM Difficulty in performing ROM

VI. Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation and Analysis

04/15/087:30am

Capillary Blood Glucose

80.00 – 110.00 mg/dl 128.00 mg/dl High

04/14/08 Capillary Blood Glucose

80.00 – 110.00 mg/dl 150.00 mg/dl High

04/13/08 Capillary Blood Glucose

80.00 – 110.00 mg/dl 442.00 mg/dl High

04/14/08 AST/RBS/CBG 80.00-110.00 mg/dl 423.00 mg/dl High 04/13/08 AST/RBS/CBG 80.00-110.00 mg/dl 335.00 mg/dl High 04/12/08 AST/RBS/CBG 80.00-110.00 mg/dl 196.00 mg/dl High 04/03/08 RBS/CBG 80-120.00 mg/dl 162 mg/dl High04/02/08 RBS/CBG 80-120.00 mg/dl 123 mg/dl High

Generic/ trade name

Dosage/Frequency

Classification Indication Contarindication Side Effects Nursing Responsibility

Humulin-NIsophane insulin suspension

10 units 6am, AC5 units 6pm PC

Hormonal drug Control hyperglycemia in patients with type II diabetes

contraindicated during episodes of hypoglycemia

GI: dry mouth Metabolic: hyperglycemia

Don’t use insulin that changes color or becomes clumped or granular in appearance

Make sure that the pt knows that the drug relieves symptoms but doesn’t cure disease

Instruct pt about the dse. and importance of following therapeutic regimen, adhering to specific diet, losing weight, getting exercise, following personal hygiene program, and avoiding infection.

Teach pt that

glucose level and urine ketone test provide essential guides to dosage and success of the therapy. It’s impt to pt to recognize symptoms of high and low glucose levels.

Advise pt not to smoke within 30 minutes after insulin injection bec. Smoking decreases amount of insulin absorbed by subcutaneous route.

Ferrous SO4 1 cap 3x a day for 1 month

Hematinics For iron deficiency Use cautiously on long-term basis

No side effects noted

Between meals are preferable

Tell patient to take capsules with juice (preferably orange juice) or water, but not with milk or antacids.

Advise patient to report constipation and change in stool color or consitency

Cefuroxime axetil

500 mg tab, 1 tab 2x/day

Cephaiosporins For skin structure infection.

> Contraindicated to pts with hypersensitivity to

No side effects noted

Tell pt to take drug even after he feels better.

drug or other cephalosporins.

Instruct patient to take oral form with food

Instruct pt to notify prescriber about rash or evidence of superinfection

Clinadamycin

600 mg IV TID 8-2-8

Anti-infectives Infections caused by sensitive staphylococci, streptococci, pneumococci and other sensitive aerobic and anaerobic organisms.

Contraindicated to pts with hypersensitivity to drug.

EENT: decreased visual acuity

Instruct patient to notify prescriber if adverse reactions occur, especially nausea, vomiting, diarrhea, fever, confusion, sore throat, or mouth sore.

Instruct patient to report signs and symptoms of superinfection.

VIII. Anatomy and Physiology

Pancreas

The islets of Langerhans are destroyed in type I diabetes mellitus. This occurs probably as a consequence of a genetic susceptibility, followed by the onset of autoimmune destruction triggered by some environmental factor such as a viral infection. Heavy lymphocytic infiltrates appear in and around islets. The number and size of islets are eventually reduced, leading to decreased insulin production and glucose intolerance.

The islets of Langerhans are normal in number or somewhat reduced with type II diabetes mellitus. Fibrosis and deposition of amylin polypeptide within islets are most characteristic of the chronic states of type II diabetes.

XI. Prioritized List Nursing Problem

Date Nursing Problems Identified Cues JustificationApril 16, 2008 Altered Nutrition less than body

requirements related to insufficient intake to meet

verbalized dietary concern

weight under normal

The state in which an individual experiences an intake of nutrients insufficient to meet

metabolic demands as manifested by verbalized dietary concern

loss of weight with adequate food intake

poor muscle tone

metabolic needs. As a physiologic need an adequate intake of balance nutrients: water, carbohydrates, proteins, fats, vitamins, and minerals. Nutrients have 3 major functions: providing energy for body processes and movement, providing structural material for body tissues, and regulating body processes.

April 16, 2008 High risk for infection related to poor wound healing as manifested by gangrenous foot

Poor wound healing Clients with diabetes are susceptible to infections of many types. Once infection occur, it is difficult to treat. Because diabetes mellitus is chronic, nursing intervention focuses on teaching the client and family how to manage the disorder on a day-to-day basis and how to assess complications.

April 17, 2008 Knowledge deficit regarding disease process related to development of preventable complications

Lack of exposure Unfamiliarity of

information resources Cognitive limitation

This is a state where an individual lacks specific information necessary to make choices regarding condition/therapies/treatment.

XII. Nursing Care Plan

Nursing Problem Cues

Analysis Goal/Objectives Nursing Interventions

Rationale Evaluation