1. Misamis University
Ozamiz City
Graduate School
A Case Study on Diabetes Mellitus-II
with Chronic Kidney Disease-IV
In partial fulfillment of the requirements in CHN 315
Submitted to:
Prof. Maricar M. Mutia, RN, MN-MAN
Faculty, Graduate School
Submitted by:
Reynel Dan L. Galicinao, RN
Student, Master in Nursing
June 4, 2011

2. GENERAL CONSIDERATIONS
INSULIN SECRETION AND FUNCTION
 Insulin is a hormone secreted by the beta cells of the islet of Langerhans in the pancreas.
 Small amounts of insulin are released into the bloodstream in response to changes in
blood glucose levels throughout the day.
 Increased secretion or a bolus of insulin, released after a meal, helps maintain euglycemia.
 Through an internal feedback mechanism that involves the pancreas and the liver,
circulating blood glucose levels are maintained at a normal range of 60 to 110 mg/dL.
 Insulin is essential for the utilization of glucose for cellular metabolism as well as for the
proper metabolism of protein and fat.
o Carbohydrate metabolism - insulin affects the conversion of glucose into glycogen
for storage in the liver and skeletal muscles, and allows for the immediate release
and utilization of glucose by the cells.
o Protein metabolism - amino acid conversion occurs in the presence of insulin to
replace muscle tissue or to provide needed glucose (gluconeogenesis).
o Fat metabolism - storage of fat in adipose tissue and conversion of fatty acids from
excess glucose occurs only in the presence of insulin.
 Glucose can be used in the endothelial and nerve cells without the aid of insulin.
 Without insulin, plasma glucose concentration rises and glycosuria results.
o Absolute deficits in insulin result from decreased production of endogenous insulin
by the beta cell of the pancreas.
o Relative deficits in insulin are caused by inadequate utilization of insulin by the cell.
CLASSIFICATION OF DIABETES
Type 1 Diabetes Mellitus
Type 1 diabetes mellitus was formerly known as insulin dependent diabetes mellitus and juvenile
diabetes mellitus.
 Little or no endogenous insulin, requiring injections of insulin to control diabetes and
prevent ketoacidosis.
 Five to 10% of all diabetic patients have type 1.
 Etiology: autoimmunity, viral, and certain histocompatibility antigens as well as a genetic
component.
 Usual presentation is rapid with classic symptoms of polydipsia, polyphagia, polyuria, and
weight loss.
 Most commonly seen in patients under age 30 but can be seen in older adults.
Type 2 Diabetes Mellitus
Type 2 diabetes mellitus was formerly known as noninsulin dependent diabetes mellitus or adult
onset diabetes mellitus.
 Caused by a combination of insulin resistance and relative insulin deficiency - some
individuals have predominantly insulin resistance, whereas others have predominantly
deficient insulin secretion, with little insulin resistance.
 Approximately 90% of diabetic patients have type 2.
 Etiology: strong hereditary component, commonly associated with obesity.
 Usual presentation is slow and typically insidious with symptoms of fatigue, weight gain,
poor wound healing, and recurrent infection.
 Found primarily in adults over age 30; however, may be seen in younger adults and
adolescents who are overweight.
 Patients with this type of diabetes, but who eventually may be treated with insulin, are still
referred to as having type 2 diabetes.
Prediabetes
Prediabetes is an abnormality in glucose values intermediate between normal and overt diabetes.
Impaired Fasting Glucose
 A new category adopted by the American Diabetes Association in 1997 and redefined in
2004.
 Occurs when fasting blood glucose is greater than or equal to 100 but less than 126
mg/dL.
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3. Impaired Glucose Tolerance
 Defined as blood glucose measurement on a glucose tolerance test greater than or equal
to 140 mg/dl but less than 200 in the 2-hour sample.
 Asymptomatic; it can progress to type 2 diabetes or remain unchanged.
 May be a risk factor for the development of hypertension, coronary heart disease, and
hyperlipidemias.
Gestational Diabetes Mellitus
 Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance occurring
during pregnancy.
 Occurs in approximately 4% of pregnancies and usually disappears after delivery.
 Women with GDM are at higher risk for diabetes at a later date.
 GDM is associated with increased risk of fetal morbidity.
 Screening for GDM for all pregnant women other than those at lowest risk (under age 25,
of normal body weight, have no family history of diabetes, are not a member of an ethnic
group with high prevalence of diabetes) should occur between the 24th and 28th weeks of
gestation.
Diabetes Associated with Other Conditions
 Certain drugs can decrease insulin activity resulting in hyperglycemia - corticosteroids,
thiazide diuretics, estrogen, phenytoin.
 Disease states affecting the pancreas or insulin receptors - pancreatitis, cancer of the
pancreas, Cushing's disease or syndrome, acromegaly, pheochromocytoma, muscular
dystrophy, Huntington's chorea.
DIAGNOSTIC TESTS
LABORATORY TESTS
Laboratory tests include those tests used to make the diagnosis as well as measures to monitor
short- and long-term glucose control.
Blood Glucose
Fasting blood sugar (FBS), drawn after at least an 8-hour fast, to evaluate circulating amounts of
glucose; postprandial test, drawn usually 2 hours after a well-balanced meal, to evaluate glucose
metabolism; and random glucose, drawn at any time, nonfasting.
Nursing and Patient Care Considerations
 For fasting glucose, make sure that patient has maintained 8-hour fast overnight; sips of
water are allowed.
 Advise patient to refrain from smoking before the glucose sampling because this affects
the test results.
 For postprandial test, advise patient that no food should be eaten during the 2-hour
interval.
 For random blood glucose, note the time and content of the last meal.
 Interpret blood values as diagnostic for diabetes mellitus as follows:
o FBS greater than or equal to 126 mg/dL on two occasions
o Random blood sugar greater than or equal to 200 mg/dL and presence of classic
symptoms of diabetes (polyuria, polydipsia, polyphagia, and weight loss)
 Fasting blood glucose result of greater than or equal to 100 mg/dL demands close follow-
up and repeat monitoring.
NURSING ALERT
 Capillary blood glucose values obtained by finger stick samples tend to be higher than
values in venous samples.
Oral Glucose Tolerance Test
The oral glucose tolerance test (OGTT) evaluates insulin response to glucose loading. FBS is
obtained before the ingestion of a 50- to 200-g glucose load (usual amount is 75 g), and blood
samples are drawn at ½, 1, 2, and 3 hours (may be 4- or 5-hour sampling).
Nursing and Patient Care Considerations
 Advise patient that for accuracy in results, certain instructions must be followed:
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4. o Usual diet and exercise pattern must be followed for 3 days before OGTT.
o During OGTT, the patient must refrain from smoking and remain seated.
o Oral contraceptives, salicylates, diuretics, phenytoin, and nicotinic acid can impair
results and may be withheld before testing based on the advice of the health care
provider.
 Diagnostic for diabetes mellitus if 2-hour value is 200 mg/dL or greater.
Glycated Hemoglobin (Glycohemoglobin, HbA1c)
Measures glycemic control over a 60- to 120-day period by measuring the irreversible reaction of
glucose to hemoglobin through freely permeable erythrocytes during their 120-day lifecycle.
Nursing and Patient Care Considerations
 No prior preparation, such as fasting or withholding insulin, is necessary.
 Test results can be affected by red blood cell disorders (eg, thalassemia, sickle cell
anemia), room temperature, ionic charges, and ambient blood glucose values.
 Many methods exist for performing the test, making it necessary to consult the laboratory
for normal values.
C-Peptide Assay (Connecting Peptide Assay)
Cleaved from the proinsulin molecule during its conversion to insulin, C-peptide acts as a marker
for endogenous insulin production.
Nursing and Patient Care Considerations
 Test can be performed after an overnight fast or after stimulation with Sustacal, I.V.
glucose, or 1 mg of glucagon subcutaneously.
 Absence of C-peptide indicates no beta cell function, reflecting possible type 1 diabetes.
Fructosamine Assay
Glycated protein with a much shorter half-life than glycated hemoglobin, reflecting control over a
shorter period, approximately 14 to 21 days. May be advantageous in patients with hemoglobin
variants that interfere with the accuracy of glycated hemoglobin tests.
Nursing and Patient Care Considerations
 Note if patient has hypoalbuminemia or elevated globulins because test may not be
reliable.
 Should not be used as a diagnostic test for diabetes mellitus.
 No special preparation or fasting is necessary.
GENERAL PROCEDURES AND TREATMENT MODALITIES
BLOOD GLUCOSE MONITORING
Accurate determination of capillary blood glucose assists patients in the control and daily
management of diabetes mellitus. Blood glucose monitoring helps evaluate effectiveness of
medication; reflects glucose excursion after meals; assesses glucose response to exercise
regimen; and assists in the evaluation of episodes of hypoglycemia and hyperglycemia to
determine appropriate treatment.
Procedure
 Guidelines for glucose monitoring are included in Procedure Guidelines 25-1.
 The most appropriate schedule for glucose monitoring is determined by the patient and
health care provider.
o Medication regimens and meal timing are considered to set the most effective
monitoring schedule.
o Scheduling of glucose tests should reflect cost effectiveness for the patient.
Glucose meter test strips may cost up to $1 each.
o Glucose monitoring is intensified during times of stress or illness or when changes
in therapy are prescribed.
 Patients with type 2 diabetes controlled with oral hypoglycemic agents or a single injection
of intermediate-acting insulin may test glucose levels before breakfast and before supper
or at bedtime (twice-per-day monitoring).
 Patients with type 1 diabetes using a multiple-dose insulin regimen may test before meals
and at bedtime, occasionally adding a 2 to 3 a.m. test (four to six times daily monitoring).
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5.  Alternate site testing has been recommended by some clinicians for patients who
complain of painful fingers and for individuals such as musicians, who use their fingertips
for occupational activities. However, testing in such sites as the forearm, palm, thigh, and
calf have not proved as accurate as fingertip testing in most studies.
o If alternate site is used, the area should be rubbed until it is warm before testing.
o Do not use an alternate site when accuracy is critical; for example, if hypoglycemia
is suspected, before or after exercise, or before driving.
o Check with the glucometer manufacturer to see if it is approved for alternate site
testing.
INSULIN THERAPY
Insulin therapy involves the subcutaneous injection of immediate-, short-, intermediate-, or long-
acting insulin at various times to achieve the desired effect. Short-acting regular insulin can also
be given I.V. About 20 types of insulin are available in the United States; most of these are
human insulin manufactured synthetically. Only about 6% of diabetics are still using beef or pork
insulin due to problems with immunogenicity.
Self-Injection of Insulin
 Teaching of self-injection of insulin should begin as soon as the need for insulin has been
established.
 Teach the patient and another family member or significant other.
 Use written and verbal instructions and demonstration techniques.
 Teach injection first because this is the patient's primary concern; then teach loading the
syringe.
 See Procedure Guidelines 25-2, pages 914 and 915, for technique.
 For patients who have difficulty with the injection procedure, newer insulin pens are
available that use a prefilled cartridge that automatically delivers the set dose of insulin by
jet stream without a needle.
Community and Home Care Considerations
 Assist the patient in deciding whether to reuse insulin syringe at home. The patient may
decide to do so due to cost; however, reuse has become controversial because the newer,
finer needles may become dull or bent after one or two injections, causing tearing of
tissue, which can lead to lipodystrophy.
o Needles should not be reused if painful injection or irritated site results.
o Needle should be recapped by patient and stored in a clean place if it is going to
be reused.
 Assist the patient in obtaining the appropriate syringe size and needle length for injections.
o Determine if there are visual or dexterity issues that make a syringe with
gradations farther apart more desirable.
o Determine if the patient is obese and should continue to use standard ½-inch
needles or if 5/16-inch needles will be desirable. Shorter needles are more
comfortable for some and prevent inadvertent I.M. injection.
 Advise the patient that it is not necessary to use alcohol to wipe off the top of the vial or
prepare the skin before injection. It has not proved to result in lower rate of infection and
adds cost and time to the procedure. The patient should maintain good hygiene.
 Make sure that the patient stores insulin in a clean, secure place away from sunlight and
heat. Check manufacturer recommendations for when to discard insulin vials and pens;
recommendations may vary from 10 to 30 days after opening.
 Check manufacturer's recommendations before teaching the patient how to mix insulin;
for example, the patient should know that Lantus insulin must never be mixed with any
other insulin.
 Avoid prefilling syringes if at all possible because manufacturers have no data on the
stability of insulin stored in syringes for long periods. If prefilling is the only option, store in
refrigerator or suggest an insulin pen injection device.
 Help the patient develop a plan for the disposal of needles. There are no federal
regulations for discarding needles used at home; however, needles and lancets can be a
risk for injury.
o Sharps can be placed in a hard plastic or metal container with a tightly secured lid
after use.
o When one-half to two-thirds full, the container should be secured with duct or
masking tape, marked "do not recycle" and placed in the trash.
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6. Insulin Regimens
NPH Only
 Used alone only in type 2 diabetes when patients are capable of producing some
exogenous insulin as a supplement for better glucose control.
 Traditionally given as a morning dosage to assist with normalization of glucose during the
afternoon and evening.
 Evening or bedtime dosage can be helpful in controlling early-morning hyperglycemia.
 NPH can also be given twice daily (morning and bedtime) to eliminate afternoon
hypoglycemia yet provide nighttime coverage. Typically, 2/3 to ¾ of the daily dosage is
given before breakfast and 1/3 to ¼ is given at bedtime.
NPH/Regular or NPH/Lispro
 Short-acting regular insulin or immediate-acting lispro (Humalog) or aspart (Novolog)
insulin is added to NPH to promote postprandial glucose control.
 Short- or immediate-acting insulin added to morning NPH controls glucose elevations after
breakfast.
 Increased blood glucose levels after supper can be controlled by the addition of short- or
immediate-acting insulin before supper.
 NPH and regular, lispro, or aspart insulin given before breakfast and before supper is
termed a "split-mix" regimen, providing 24-hour insulin coverage for type 1 diabetes.
Intensive Insulin Therapy
 Designed to mimic the body's normal insulin responses to glucose.
 Uses multiple daily injections of insulin.
 NPH or ultralente or glargine (Lantus) insulin is used for basal insulin control.
 Regular insulin acts as a premeal bolus given 30 minutes before each meal. Lispro or
aspart insulin may be used instead of regular and is taken just before eating.
 24-hour insulin coverage designed in this way can be flexible to accommodate mealtimes
and physical activity.
Sliding Scale Versus Algorithm Therapy
 Sliding scale therapy uses regular insulin to retrospectively correct hyperglycemia.
 Algorithm therapy prospectively determines regular insulin dosages, taking into account
meal content and physical activity.
 Individualization of regular insulin dosages is the most important aspect of sliding scale
and algorithm therapy.
o The patient is encouraged to test blood glucoses to analyze insulin dose response.
o A pattern of increased blood glucose associated with certain foods (eg, pasta,
pizza) can help determine the appropriate regimen of insulin dosage.
o Physical activity, which enhances insulin activity and decreases serum glucose,
may indicate the need to reduce the dosage of premeal regular insulin.
Continuous Subcutaneous Insulin Infusion and Insulin Pump Therapy
 Continuous subcutaneous insulin infusion (CSII) and insulin pump therapy provide
continuous infusion of regular, lispro, or aspart insulin via subcutaneous catheter inserted
in the abdomen. Regular insulin is used during pregnancy.
 The catheter should be replaced every 72 hours or sooner if the site becomes painful or
inflamed.
o Frequently, the insulin pump is removed for bathing, and tubing and catheter are
changed at that time.
o To reduce tubing and catheter blockage, diluted insulin is used.
 Intensive insulin management by pump therapy requires patient motivation.
o Blood glucose monitoring must be done at least four to six times each day.
o Frequent contact with health care team is necessary to adjust insulin dosage.
o Careful recordings of diet, insulin, and activity are required to evaluate adjustments.
o Increased cost of insulin pump and infusion set compared to usual syringe method.
o Heightened risk of hypoglycemia with tighter glucose control.
o Danger of hyperglycemia exists should insulin pump fail to deliver correct insulin
dosage.
o Increased visibility of diabetes by use of an external device.
 Advantages of CSII in improving blood glucose control:
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7. o Insulin pump can deliver basal insulin at individualized programmed rates
throughout a 24-hour period.
o Bolus injections of regular insulin given 30 minutes before eating and lispro or
aspart immediately before a meal allow for flexibility in meal content and timing.
o Correction supplements of regular, lispro, or aspart insulin are easily given to
rapidly correct elevated glucose levels.
Combination Oral Agent and Insulin Therapy
 Appropriate only in type 2 diabetes.
 Intermediate-acting insulin (NPH) is given in the evening and an oral sulfonylurea agent in
the morning - called BIDS therapy (Bedtime Insulin, Daytime Sulfonylurea).
o No oral antidiabetic agent is given at bedtime.
o Controlling hepatic glucose production overnight with evening insulin helps to start
the day with a lower FBS.
o Daytime antidiabetic agent (usually sulfonylurea), along with diet and exercise,
controls daytime blood glucose levels.
o Some patients may require regular/NPH insulin injected before supper to assist
with elevated postprandial evening glucoses.
 Combination therapy may also include the use of a thiazolidinedione (pioglitazone [Actos],
rosiglitazone [Avandia]), metformin (Glucophage), or other agents.
DIABETES AND RELATED DISORDERS
DIABETES MELLITUS
Diabetes mellitus is a metabolic disorder characterized by hyperglycemia and results from
defective insulin production, secretion, or utilization.
Pathophysiology and Etiology
 There is an absolute or relative lack of insulin produced by the beta cell, resulting in
hyperglycemia.
 Defects at the cell level, impaired secretory response of insulin to rises in glucose, and
increased nocturnal hepatic glucose production (gluconeogenesis) are seen in type 2
diabetes.
 Etiology of type 1 diabetes is not well understood; viral, autoimmune, and environmental
theories are under review.
 Etiology of type 2 diabetes involves heredity, genetics, and obesity.
Clinical Manifestations
Onset is abrupt with type 1 and insidious with type 2.
Hyperglycemia
 Weight loss, fatigue
 Polyuria, polydipsia, polyphagia
 Blurred vision
Altered Tissue Response
 Poor wound healing
 Recurrent infections, particularly of the skin
Diagnostic Evaluation
 Diabetes can be diagnosed in any of the following ways (and should be confirmed on a
different day by any of these tests):
o FBS of greater than or equal to 126 mg/dL
o Random blood glucose of greater than or equal to 200 mg/dL with classic
symptoms (polyuria, polydipsia, polyphagia, weight loss)
o OGTT greater than or equal to 200 mg/dL on the 2-hour sample
 Tests for glucose control over time are glycated hemoglobin and fructosamine assay (see
pages 911 to 912). These tests are not used for diagnosis.
Management
Diet
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8.  Dietary control with caloric restriction of carbohydrates and saturated fats to maintain ideal
body weight.
 The goal of meal planning is to control blood glucose and lipid levels (see Table 25-1).
 Weight reduction is a primary treatment for type 2 diabetes.
Exercise
Regularly scheduled, moderate exercise performed for at least 30 minutes most days of the week
promotes the utilization of carbohydrates, assists with weight control, enhances the action of
insulin, and improves cardiovascular fitness.
Medication
 Oral antidiabetic agents for patients with type 2 diabetes who do not achieve glucose
control with diet and exercise only (see Table 25-2).
o Act by a variety of mechanisms, including stimulation of insulin secretion from
functioning beta cells, reduction of hepatic glucose production, enhancement of
peripheral sensitivity to insulin, and reduced absorption of carbohydrates from the
intestine.
o Sulfonylureas and meglitinide analogues may cause hypoglycemic reactions.
o Biguanides, alpha-glucosidase inhibitors, and meglitinide analogues may cause
significant flatus and GI adverse effects.
 Insulin therapy for patients with type 1 diabetes who require replacement (see Table 25-3,
page 920).
o May also be used for type 2 diabetes when unresponsive to diet, exercise, and
oral antidiabetic therapy.
o Hypoglycemia may result as well as rebound hyperglycemia (Somogyi effect).
o Commonly results in increased appetite and weight gain.
General Health
Rigid prevention and management guidelines have been established for glycemic control, blood
pressure (BP), lipid values, and kidney function to prevent complications. The American Diabetes
Association (2003) recommends the following goals of treatment.
 Glycemic control
o HbA1c < 7%
o Preprandial glucose 90 to 130 mg/dL
o Peak postprandial glucose < 180 mg/dL
 BP < 130/80 mm Hg
 Lipid control
o Low-density lipoprotein < 100 mg/dL
o High-density lipoprotein > 40 mg/dL
o Triglycerides < 150 mg/dL
 Microalbumin (spot urine) < 30 mcg/mg creatinine
NURSING ALERT
 Regular insulin is the only insulin that may be administered I.V.; all other insulin
formulations are suspensions. Lispro insulin and aspart are for subcutaneous injection
only and are not approved for use in pregnancy.
Complications
Acute
 Hypoglycemia occurs as a result of an imbalance in food, activity, and insulin/oral
antidiabetic agent.
 Diabetic ketoacidosis (DKA) occurs primarily in type 1 diabetes during times of severe
insulin deficiency or illness, producing severe hyperglycemia, ketonuria, dehydration, and
acidosis.
 Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) affects patients with type 2
diabetes, causing severe dehydration, hyperglycemia, hyperosmolarity, and stupor.
Chronic
Chronic Complications of Diabetes Mellitus
ASSESSMENT INTERVENTION PREVENTION/TEACHING
Macroangiopathy
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9. Cerebrovascular Disease
 Incidence: Twice as frequent in diabetes
 Hypertension, increased lipids, smoking, and uncontrolled blood glucose increase risk of
stroke and transient ischemic attack.
 Increased blood pressure  Check blood glucose level  Maintain target goals of blood
(BP) to differentiate signs and glucose avoiding severe
 Change in mental status symptoms of stroke versus hypoglycemia and hyperglycemia,
 Hemiparesis hypoglycemia. If stroke is which predispose the patient to
 Aphasia suspected, do not give fast- stroke. In hypoglycemia, increased
 Clinical presentation acting carbohydrate as levels of adrenalin and
mimics that of nondiabetic increased levels contribute to catecholamines can produce cardiac
patient. recurrence and high mortality arrhythmias.
of strokes in patients with  Hyperglycemia can lead to
diabetes. Monitor for bleeding dehydration, which affects platelet
if aspirin or other platelet- aggregation.
active medicine is used.
Coronary Artery Disease (CAD)
 Incidence: Increased vessel disease with more vessels affected in diabetes. Higher incidence
of "silent" myocardial infarctions (MIs).
 Hyperglycemia contributes to atherosclerosis and vessel deterioration.
 Severe CAD is commonly  Usual medical treatment  Emphasis must be placed on
asymptomatic, seen only in for angina prevails - reducing cardiac risk factors, eg,
electrocardiogram (ECG) sublingual nitroglycerin, oral cigarette smoking, hypertension,
changes. ECG changes may nitrates. Beta-adrenergic hyperlipidemia. Avoid wide
indicate silent MI. blockers and calcium channel fluctuations in blood glucose. Patients
 Symptoms can also blockers can also be used. with autonomic neuropathy, which
present as pain in the jaw, can cause orthostatic hypotension,
neck, or epigastric area. should be carefully monitored when
cardiac drug therapies are
introduced. Beta-adrenergic blockers
can blunt or eliminate the clinical
signs and symptoms of
hypoglycemia.
Peripheral Vascular Disease
 Incidence: 50% of nontraumatic amputations are related to diabetes.
 Intermittent claudication, absent pedal pulses, and ischemic gangrene are increased in
diabetes.
 Physical examination of  Any lesion, decrease in  Foot care guidelines and smoking
the lower extremities may peripheral pulses, or change cessation must be stressed. Safe
reveal changes in skin in skin color, temperature or exercise guidelines and weight
integrity associated with sensation should be reduction as appropriate will further
diminished circulation. evaluated within 24-48 hours. reduce risk of foot injury.
 Decreased lower leg hair, To ensure proper healing and
absent or decreased anterior prevent infection, treatment
tibial or dorsal pedis pulses, should begin as soon as
poor capillary refill of possible and be carefully
toenails may occur. The monitored. Mild
extremity may appear antiseptics/antibiotic
pale/cool. Further preparations are used to
examination for neurologic avoid further damage to the
changes is indicated. surrounding skin. Avoid the
use of surgical tape to skin.
Rest affected leg to promote
circulation and wound
healing.
Microangiopathy
Retinopathy
 Incidence: Type 1 - 10 years postdiagnosis 60% have some degree of retinopathy. Type 2 -
approximately 20% present with retinopathy at diagnosis, which increases to 60% -85% after 15
years.
 Appearance of hard exudates, blot hemorrhages, and microaneurysms on the retina in
background retinopathy. Progresses to neurovascularization in proliferative diabetic retinopathy.
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10.  Usually asymptomatic in  Laser therapy  Stress importance of annual eye
the early stages. Symptoms (photocoagulation) can be examination with an ophthalmologist
occurring with acute visual helpful in macular edema (preferably retina specialist). Optimal
problems (floaters), flashing (focal laser) and proliferative glucose control can prevent or slow
lights, blurred vision may retinopathy (panretinal laser). the progression of retinopathy.
indicate hemorrhage or Reduction of active Maintaining normal BP also reduces
retinal detachment. neovascularization by laser the risk of retinopathy.
Funduscopic examination therapy reduces the risk of
should be done by an vitreous hemorrhage.
ophthalmologist for full Vitrectomy may be needed to
retinal visualization. treat retinal detachment or
remove vitreous hemorrhage.
 During the acute phase,
before laser therapy, patients
must avoid activities that
increase the chances of
vitreous hemorrhage (eg,
weight lifting, high-impact
aerobics).
Nephropathy
 Incidence: Type 1 - with > 20 years history of diabetes, approximately 40% will have renal
disease. Type 2 - 5-10 years after diagnosis 5% -10% of patients develop nephropathy, with
higher incidence in Native Americans, Hispanics, and Blacks.
 Thickening of the glomerular basement membrane, mesangial expansion, and renal vessel
sclerosis are caused by diabetes.
 Subsequently, diffuse and nodular intercapillary glomerulosclerosis diminishes renal function.
 Evidence of increased  Hypertension control,  Frequent hypertension screening,
glomerular filtration rate. blood glucose control, and noting any deviation from patient's
 Microalbuminuria is the reduction of protein and normal reading. Early initiation of BP
first clinical sign of renal sodium are essential. control to prevent kidney damage.
disease. Angiotensin-converting Excellent glucose control with
 Elevation in blood urea enzyme inhibitors are the insulin/oral agent adjustment to
nitrogen and creatinine drugs of choice to control BP. compensate for reduced kidney
indicate advanced renal Calcium channel blockers function, which predisposes the
disease. may also be used. In end- patient to hypoglycemia. Avoidance
 Gross proteinuria is stage renal disease dialysis of nephrotoxic drugs, dyes, or renal
further indication of renal or transplantation may be procedures that may cause infection.
deterioration. necessary. Immediate treatment for any urinary
tract infections.
Peripheral Neuropathy
 In general, neuropathy affects 60% of persons with diabetes, with nearly 100% showing signs
and symptoms of slowing nerve conduction velocity.
 It can affect almost every organ system with varying specific symptoms.
 Distal symmetrical polyneuropathy involving the lower extremities is most commonly seen.
 In conjunction with peripheral vascular disease, neuropathy to the feet increases susceptibility
to trauma and infection.
 Three clinical syndromes of distal symmetrical polyneuropathy are seen: acute painful, small
fiber, and large fiber neuropathy.
 Decreased light touch,  All foot wounds or injuries  In general, blood glucose control is
vibratory, temperature are immediately evaluated. recommended, avoiding wide
sensation. Loss of foot Culture and sensitivity tests fluctuations. In patients who are
proprioception, followed by ordered for any drainage poorly controlled, care must be taken
ataxia, gait disturbances. present. Affected foot is to correct glucoses slowly to avoid
 Diminished ankle jerk elevated - avoid weight- increasing symptoms of neuropathy.
response. bearing. Wet to dry dressings  Foot care guidelines.
 Formation of “hammer applied as ordered. Avoid use  Smoking cessation.
toes”, Charcot joint disease, of caustic chemicals,  Frequent evaluation by podiatrist
which predispose patient to dressing tapes. for modified foot wear, eg, orthotics,
new pressure point areas.  Use of systemic antibiotics extra-depth shoes.
 Hypersensitivity or other as needed.  Safe exercise guidelines.
dysesthetic symptoms are  Medication for painful  Weight reduction as necessary.
experienced, followed by neuropathy may include use
hypnoanesthesia or of the tricyclic antidepressant
10 | P a g e

11. anesthesia, which is not drugs (eg, amitriptyline
reversible. [Elavil], a serotonin and
epinephrine reuptake inhibitor
(duloxetine [Cymbalta]), or
topical application of
capsaicin (Zostrix) ointment.
Autonomic Neuropathy
Gastroparesis
 Incidence: Occurs in 25% of people with diabetes
 Characteristics: Delayed gastric emptying, prolonged pylorospasms and loss of the powerful
contractions of the distal stomach to grind and mix foods.
 Typical symptoms may  Excellent glucose control  Maintenance of excellent glucose
include nausea/vomiting, to avoid hyperglycemia, control. Regular exercise
early satiety, abdominal which interferes with gut improves/maintains GI motility. Avoid
bloating, epigastric pain, contractility. Avoidance of use of laxatives. Small, frequent
change in appetite. Wide severe postmeal meals may help.
fluctuations in blood hypoglycemia by small,
glucoses and postmeal frequent meals, low fat and
hypoglycemia caused by low fiber. This diet is also
poor glucose absorption. helpful in bloating/early
Visualization of the gut by satiety. Medication to improve
upper GI barium series may gut motility is metoclopramide
show retained food after an (Reglan).
8-12-hour fast.
Diarrhea
 Incidence: Approximately 5% of diabetic patients
 Characteristics: Frequent, watery movements
 Mild steatorrhea
 Can be intermittent, persistent, or alternate with constipation.
 Diarrhea occurs without  Dietary changes may  Routine bowel elimination habits.
warning, frequently at night include increased fiber,  Maintenance of adequate
or after meals. Fecal elimination of milk products. hydration.
incontinence may be caused Sphincter-strengthening  Excellent blood glucose control
by loss of internal sphincter exercises may help. reduces dehydration.
control and anorectal Medications: For diarrhea  Inclusion of dietary fiber in the daily
sensation. Other causes, hydrophilic fiber supplement diet.
such as celiac sprue, (Metamucil), cholestyramine  Daily exercise program that
pancreatic insufficiency, and (Questran), or synthetic includes walking or swimming has
lactose intolerance, must be opiates are used. been effective in encouraging bowel
investigated. Bacterial  Tetracycline, ampicillin are regularity.
overgrowth in the bowel is used for bacterial overgrowth.
also suspected.
Impotence/Sexual Dysfunction
 Incidence is not well documented due to inhibitions about reporting this problem to health care
providers.
 Sexual dysfunction can involve changes in erectile ability, ejaculation, or libido.
 Men: History of poor  Men: Referral to urologist  Reduce consumption of alcohol,
erectile function despite for full examination is which may hasten or contribute to
stimulation. Absence of early indicated. Treatment options neuropathy.
morning erection in may include injection of  Maintain target ranges of blood
response to increased alprostadil (a prostaglandin), glucose control to reduce likelihood of
hormonal levels. inflatable penile prosthesis, or vaginal infections.
 Women: May experience oral sildenafil (Viagra).  Discuss alternative ways of
decreased vaginal  Women: Increase maintaining intimacy.
lubrication and dyspareunia. lubrication with use of water-
 Screening for use of based lubricant (K-Y jelly) or
ethanol or other medications estrogen creams, which may
associated with impotence also help thicken the vaginal
(eg, antidepressants, mucosa, affecting
antihypertensives). dyspareunia.
Orthostatic Hypotension
 One of three syndromes associated with cardiovascular autonomic neuropathy, orthostatic
11 | P a g e

12. hypotension occurs when the "postural reflex", which increases heart rate and peripheral
vascular resistance is dysfunctional.
 Patients may report  Improvement in blood  Encourage increased fluid intake to
episodes of syncope, glucose control to prevent maintain hydration.
weakness, or visual fluid loss from glycosuria.  Caution should be used in
impairment particularly with Moderate amounts of sodium changing position from lying to
positional changes. Evaluate may be used in the diet to standing. Dangling is recommended
BP and pulse in lying and encourage fluid retention until BP stabilizes.
standing position at each during hot weather or  Avoid standing in one position,
visit. BP changes that strenuous exercise. which may increase venous pooling.
indicate neuropathic Mechanical devices such as
involvement: fall in systolic support stockings (full hose to
pressure of > 30 mm Hg or waist) may decrease venous
fall in diastolic pressure of > pooling. Drugs to enhance
10 mm Hg with change from volume expansion may be
lying to standing position. used (eg, fludrocortisone
[Florinef]).
 In type 1 diabetes, chronic complications usually appear about 10 years after the initial
diagnosis.
 The prevalence of microvascular complications (retinopathy, nephropathy) and
neuropathy is higher in type 1 diabetes.
 Because of its insidious onset, chronic complications can appear at any point in type 2
diabetes.
 Macrovascular complications - in particular cardiovascular disease, occurring in type 1
and type 2 diabetes - are the leading cause of morbidity and mortality among persons with
diabetes.
Nursing Assessment
 Obtain a history of current problems, family history, and general health history.
o Has the patient experienced polyuria, polydipsia, polyphagia, and any other
symptoms?
o Number of years since diagnosis of diabetes
o Family members diagnosed with diabetes, their subsequent treatment, and
complications
 Perform a review of systems and physical examination to assess for signs and symptoms
of diabetes, general health of patient, and presence of complications.
o General: recent weight loss or gain, increased fatigue, tiredness, anxiety
o Skin: skin lesions, infections, dehydration, evidence of poor wound healing
o Eyes: changes in vision - floaters, halos, blurred vision, dry or burning eyes,
cataracts, glaucoma
o Mouth: gingivitis, periodontal disease
o Cardiovascular: orthostatic hypotension, cold extremities, weak pedal pulses, leg
claudication
o GI: diarrhea, constipation, early satiety, bloating, increased flatulence, hunger or
thirst
o Genitourinary (GU): increased urination, nocturia, impotence, vaginal discharge
o Neurologic: numbness and tingling of the extremities, decreased pain and
temperature perception, changes in gait and balance
Nursing Diagnoses
 Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity
expenditures
 Fear related to insulin injection
 Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat
 Activity Intolerance related to poor glucose control
 Deficient Knowledge related to use of oral hypoglycemic agents
 Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower
extremities
 Ineffective Coping related to chronic disease and complex self-care regimen
Other Nursing Diagnoses
 Deficient fluid volume
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13.  Disabled family coping
 Disturbed sensory perception: Visual, tactile
 Imbalanced nutrition: Less than body requirements
 Impaired skin integrity
 Impaired urinary elimination
 Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
 Risk for infection
 Sexual dysfunction
Nursing Interventions
STANDARDS OF CARE GUIDELINES
Caring for Patients with Diabetes Mellitus
When caring for patients with diabetes mellitus:
 Assess level of knowledge of disease and ability to care for self
 Assess adherence to diet therapy, monitoring procedures, medication treatment, and
exercise regimen
 Assess for signs of hyperglycemia: polyuria, polydipsia, polyphagia, weight loss, fatigue,
blurred vision
 Assess for signs of hypoglycemia: sweating, tremor, nervousness, tachycardia, light-
headedness, confusion
 Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral
vascular disease and any injury to the feet or lower extremities
 Assess for trends in blood glucose and other laboratory results
 Make sure that appropriate insulin dosage is given at the right time and in relation to
meals and exercise
 Make sure patient has adequate knowledge of diet, exercise, and medication treatment
 Immediately report to health care provider any signs of skin or soft tissue infection
(redness, swelling, warmth, tenderness, drainage)
 Get help immediately for signs of hypoglycemia that do not respond to usual glucose
replacement
 Get help immediately for patient presenting with signs of either ketoacidosis (nausea and
vomiting, Kussmaul respirations, fruity breath odor, hypotension, and altered level of
consciousness) or hyperosmolar hyperglycemic nonketotic syndrome (nausea and
vomiting, hypothermia, muscle weakness, seizures, stupor, coma).
Improving Nutrition
 Assess current timing and content of meals.
 Advise patient on the importance of an individualized meal plan in meeting weight-loss
goals. Reducing intake of carbohydrates may benefit some patients; however, fad diets or
diet plans that stress one food group and eliminate another are generally not
recommended.
 Discuss the goals of dietary therapy for the patient. Setting a goal of a 10% (of patient's
actual body weight) weight loss over several months is usually achievable and effective in
reducing blood sugar and other metabolic parameters.
 Assist patient to identify problems that may have an impact on dietary adherence and
possible solutions to these problems. Emphasize that lifestyle changes should be
maintainable for life.
 Explain the importance of exercise in maintaining/reducing body weight.
o Caloric expenditure for energy in exercise
o Carryover of enhanced metabolic rate and efficient food utilization
 Assist patient to establish goals for weekly weight loss and incentives to assist in
achieving them.
 Strategize with patient to address the potential social pitfalls of weight reduction.
Teaching About Insulin
 Assist patient to reduce fear of injection by encouraging verbalization of fears regarding
insulin injection, conveying a sense of empathy, and identifying supportive coping
techniques.
 Demonstrate and explain thoroughly the procedure for insulin self-injection (see page 914).
 Help patient to master technique by taking a step-by-step approach.
o Allow patient time to handle insulin and syringe to become familiar with the
equipment.
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14. o Teach self-injection first to alleviate fear of pain from injection.
o Instruct patient in filling syringe when he or she expresses confidence in self-
injection procedure.
 Review dosage and time of injections in relation to meals, activity, and bedtime based on
patient's individualized insulin regimen.
GERONTOLOGIC ALERT
 Assess elderly patients for sensory deficits, such as impaired vision, hearing, fine touch,
and tremors that may have an impact on learning and ability to self-administer insulin.
Suggest use of an insulin pen or magnifying glass to assist with drawing up insulin. Pen
must be inverted 10 times to ensure mixing.
Preventing Injury Secondary to Hypoglycemia
 Closely monitor blood glucose levels to detect hypoglycemia.
 Instruct patient in the importance of accuracy in insulin preparation and meal timing to
avoid hypoglycemia.
 Assess patient for the signs and symptoms of hypoglycemia.
o Adrenergic (early symptoms) - sweating, tremor, pallor, tachycardia, palpitations,
nervousness from the release of adrenalin when blood glucose falls rapidly
o Neurologic (later symptoms) - light-headedness, headache, confusion, irritability,
slurred speech, lack of coordination, staggering gait from depression of central
nervous system as glucose level progressively falls
 Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates.
o Half cup (4 oz) juice, 1 cup skim milk, three glucose tablets, four sugar cubes, five
to six pieces of hard candy may be taken orally.
o Nutrition bar specially designed for diabetics - supplies glucose from sucrose,
starch, and protein sources with some fat to delay gastric emptying and prolong
effect; may prevent relapse. Used after hypoglycemia treated with fact-acting
carbohydrate.
o Glucagon 1 mg (subcutaneously or I.M.) is given if the patient cannot ingest a
sugar treatment. Family member or staff must administer injection.
o I.V. bolus of 50 mL of 50% dextrose solution can be given if the patient fails to
respond to glucagon within 15 minutes.
 Encourage patient to carry a portable treatment for hypoglycemia at all times.
 Assess patient for cognitive or physical impairments that may interfere with ability to
accurately administer insulin.
 Between-meal snacks as well as extra food taken before exercise should be encouraged
to prevent hypoglycemia.
 Encourage patients to wear an identification bracelet or card that may assist in prompt
treatment in a hypoglycemic emergency.
DRUG ALERT
 If the patient is taking an alpha-glucosidase inhibitor, he must use a monosaccharide
(glucose tablets) to treat hypoglycemia because sucrose will not be broken down to an
absorbable sugar.
Improving Activity Tolerance
 Advise patient to assess blood glucose level before and after strenuous exercise.
 Instruct patient to plan exercises on a regular basis each day.
 Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia.
 Advise patient that prolonged strenuous exercise may require increased food at bedtime
to avoid nocturnal hypoglycemia.
 Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and
urine ketones are present. Patient should contact health care provider if levels remain
elevated.
 Counsel patient to inject insulin into the abdominal site on days when arms or legs are
exercised.
Providing Information About Oral Antidiabetic Agents
 Identify barriers to learning, such as visual or hearing impairments, low literacy, distractive
environment.
 Encourage active participation of the patient and family in the educational process.
 Teach the action, use, and adverse effects of oral antidiabetic agents.
14 | P a g e

15. o Sulfonylurea compounds promote the increased secretion of insulin by the
pancreas and partially normalize both receptor and postreceptor defects. Many
drug interactions exist, so patient should alert all health care providers of use.
Potential adverse reactions include hypoglycemia, photosensitivity, GI upset,
allergic reaction, reaction to alcohol, cholestatic jaundice, and blood dyscrasias.
o Metformin (Glucophage), a biguanide compound, appears to diminish insulin
resistance. It decreases hepatic glucose production and intestinal reabsorption of
glucose and increases insulin reception and glucose transport in cells. Many drug
interactions exist, so patient should alert all health care providers of its use.
Metformin must be used cautiously in renal insufficiency, conditions that may
cause dehydration, and hepatic impairment. Potential adverse reactions include GI
disturbances, metallic taste, and lactic acidosis (rare).
o Alpha-glucosidase inhibitors (acarbose [Precose] and miglitol [Glyset]) delay the
digestion and absorption of complex carbohydrates (including sucrose or table
sugar) into simple sugars, such as glucose and fructose, thereby lowering
postprandial and fasting glucose levels.
o Thiazolidinedione derivatives (rosiglitazone [Avandia] and pioglitazone [Actos])
primarily decrease resistance to insulin in skeletal muscle and adipose tissue
without increasing insulin secretion. Secondarily, they reduce hepatic glucose
production. They should be used cautiously in liver disease and heart failure. Liver
function tests should be monitored periodically. Ovulation may occur in
anovulatory premenopausal women. Adverse reactions include edema, weight
gain, anemia, and elevation in serum transaminases.
o Meglitinide analogues (repaglinide [Prandin]) and amino acid derivatives
(nateglinide [Starlix]) stimulate pancreatic release of insulin in response to a meal.
They have a more rapid onset and shorter duration than sulfonylureas. They
should not be taken when a meal is skipped or missed. They should be used
cautiously in patients with renal and hepatic dysfunction, and may cause
hypoglycemia.
DRUG ALERT
 Lactic acidosis is a rare but potentially fatal complication of metformin. The drug should be
discontinued for conditions that predispose to lactic acidosis, including dehydration,
alteration in renal function, vomiting and diarrheal illnesses, fasting for surgery and other
procedures, imaging studies requiring I.V. iodinated contrast media, septicemia, heavy
alcohol use, and hemodynamic instability.
 Alpha-glucosidase inhibitors are contraindicated in inflammatory bowel disease and other
conditions of the intestinal tract. They are used cautiously in renal insufficiency and with
several other drugs. Flatulence, abdominal pain, and diarrhea are common.
 Thiazolidinediones themselves do not cause hypoglycemia; when administered with
insulin or oral medications that increase the secretion of insulin, however, they increase
the risk of hypoglycemia. Be aware that insulin requirements will drop with therapy, so
glucose monitoring and insulin adjustments should be done regularly.
Maintaining Skin Integrity
 Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses,
dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon
reflexes.
o Use a monofilament to test sensation of the feet and detect early signs of
peripheral neuropathy (see Figure 25-2).
o Test vibratory sense over interphalangeal joints of the feet using a low-frequency
tuning fork. Vibratory sense is typically lost before tactile sensation.
 Maintain skin integrity by protecting feet from breakdown.
o Use heel protectors, special mattresses, foot cradles for patients on bed rest.
o Avoid applying drying agents to skin (eg, alcohol).
o Apply skin moisturizers to maintain suppleness and prevent cracking and fissures.
 Instruct patient in foot care guidelines (see Procedure Guidelines 25-2).
 Advise the patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral blood flow. Help patient to establish behavior
modification techniques to eliminate smoking in the hospital and to continue them at home
for smoking-cessation program.
Improving Coping Strategies
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16.  Discuss with the patient the perceived effect of diabetes on lifestyle, finances, family life,
occupation.
 Explore previous coping strategies and skills that have had positive effects.
 Encourage patient and family participation in diabetes self-care regimen to foster
confidence.
 Identify available support groups to assist in lifestyle adaptation.
 Assist family in providing emotional support.
Community and Home Care Considerations
 A home care or visiting nurse referral can be initiated to follow up on patient education
initiated in the hospital or clinic and ensure that the patient has the resources to care for
self at home.
 Patient should be checking fingerstick glucose at home, and glucometer should be
checked by home care or clinic nurse periodically to make sure it is properly calibrated
and correlates with meter used at clinic or hospital.
 As long as the home is clean and the patient uses reasonable hygiene, procedures for
glucose self-monitoring and insulin injection do not need to be sterile. No alcohol
preparation of the skin or insulin vial is needed.
 Insulin syringes may be reused, so long as the needle is kept clean and no pain or signs
of skin irritation develop after multiple use.
 Although urine glucose testing is no longer recommended to monitor diabetic condition,
the patient may benefit from urine ketone testing, especially when ill. Teach the patient
how to test urine with ketone test strip and to notify health care provider if ketosis persists.
 Make sure that all patients have a handy source of glucose for hypoglycemic episodes. A
small tube of glossy decorating gel for cakes, easily carried in a pocket or purse, contains
about 15 g glucose and can be squirted in the mouth for fast absorption during a
hypoglycemic attack.
 Draw blood work on a fasting basis (no food or fluids other than water for 8 hours) or
ensure that patients attend laboratory appointments for drug monitoring.
o For patients taking thiazolidinediones, serum transaminases (aspartate
aminotransferase, alanine aminotransferase) should be monitored every 2 months
for a year and then periodically. If levels rise, more frequent monitoring and
possibly drug discontinuation will be necessary.
o Renal function tests (blood urea nitrogen [BUN] and serum creatinine) and urine
for microalbumin or microalbumin/creatinine ratio will be monitored periodically.
o Fasting plasma glucose and glycated hemoglobin are followed regularly.
o Fasting lipid panel (12 to 14 hours fasting) is done periodically.
 Address safety issues if patient has hypoglycemic attacks - driving, operating machinery,
and exertional activity.
Patient Education and Health Maintenance
 Ongoing education of patient to include advanced skills and rationales for treatment,
prevention, and management of complications.
 Educational focus - lifestyle management issues, to include sick-day management (see
Patient Education Guidelines), exercise adjustments, travel preparations, foot care
guidelines, intensive insulin management, and dietary considerations for dining out.
 For additional information and support, refer to drug manufacturers' Web sites for special
programs for diabetics and to agencies, such as American Diabetes Association, Inc.,
http://www.diabetes.org; and American Dietetic Association, http://www.eatright.org.
Evaluation: Expected Outcomes
 Maintains ideal body weight with body mass index less than 25
 Demonstrates self-injection of insulin with minimal fear
 Hypoglycemia identified and treated appropriately
 Exercises daily
 Verbalizes appropriate use and action of oral hypoglycemic agents
 No skin breakdown
 Verbalizes initial strategies for coping with diabetes
NURSING HEALTH ASSESSMENT
DEMOGRAPHIC DATA
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17. Name: Poong Kulz
Address: Poblacion, Iligan City, Lanao del Norte
Age: 49 yrs old
Sex: Male
Status: Married
Religion: Roman Catholic
Occupation: Government employee
HEALTH HISTORY
A. Chief Complaint/s: Difficulty of breathing
B. Admitting Diagnosis: T/C CKD, DM II, T/C CHF, S/P AKA (2005)
C. History of Present Illness:
1 month prior to admission, patient started to have 2-3 pillows orthopnea and difficulty of
breathing even at rest. He was admitted in Dr. Uy Hospital 13 days prior to admission due to
difficulty of breathing and oliguria for 3 days. He was discharged apparently well, but not until 1
day PTA until DOB reassured associated with dry productive cough with yellowish phlegm, not
associated with fever. These prompted admission.
D. History of Past Illness/es:
Patient had cataract surgery on left eye 5 yrs ago. Hospitalized 4 yrs ago due to diabetic
foot and eventual AKA amputation of the left leg. Diagnosed with Diabetes mellitus type 2 for 9
yrs maintaining meds. Diagnosed with kidney disease 4 years ago. Left eye is totally blind due to
glaucoma. Right eye is diagnosed with cataract. Patient claimed to be completely immunized. No
asthma, TB, or allergy to any food or drug. Prefers non-salty and non-fatty foods. Quit smoking
and drinking alcohol 10 years ago.
E. Health Habits
Frequency Amount Period
Tobacco Every day 10 sticks/day 21 years
Alcohol 2-4x/ week 1000 ml 21 years
OTC drugs/non-prescription drugs
N/A N/A N/A
Specify: none
F. Family History with Genogram
History of Heredo-familial diseases:
Cancer x
DM √
Asthma x
Hypertension √
Cardiac Disease x
Mental Disorder x
G. Patient’s Perception of Present Illness:
Patient feels hopeless and verbalized: “unsaon ta man in-ani man jud. Dili man ta
kabayad mag sige ug pa dialysis. Naa man gyud ning sakita sa linya sa among dugo”
H. Summary of Interaction
Patient and SO are very cooperative. Answered the questions well and without hesitation.
Interview and assessment went on smoothly.
GORDON’S ASSESSMENT
Normal Pattern Before Hospitalization Clinical Appraisal
1. Activities – Rest
a. Activities a. Pt. was able to perform ADLs a. Pt. was able to perform ADLs
b. Sleeping pattern with wife’s assistance and he with wife’s assistance and most
c. Rest was able to work inside the of the time stays on the bed.
office. Pt. had intermittent
17 | P a g e

18. nausea and vomiting.
b. Patient usually sleeps about 6- b. Pt. often had frequent
7 hours; sleeping time: 10:30- awakening between 12 AM to 6
11:30 PM and waking time: 4:30- AM
5:30 AM
c. Pt. was able to rest in the c. Pt. preferred to rest on bed
afternoon for 30 minutes to 1 most of the day.
hour.
2. Nutrition – Metabolic
a. Typical intake a. After diagnosis of DM, pt was a. The intake of pt. was ½ cup of
(food or fluid) advised to eat a diabetic diet but rice, fish, 1 banana, and 6-8
b. Diet was noncompliant. Pt. often eats glasses of water.
c. Diet restriction a 1 ½- 2 cups of rice, high-fat
d. Weight pork and often drinks soft drinks.
e. Medication/Suppl Pt. consumes 5-6 glasses of
ement food water per day. Pt. was an
alcoholic drinker. The pt. also
smokes.
b. High fat, high sugar diet.
b. The diet followed is diabetic
diet, low salt, low fat diet.
c. Pt. was advised to avoid fatty c. The pt. avoided fatty and salty
and sweet foods but was not
foods.
compliant.
d. The pt. stated that he weighs
70 kg
d. Weight was not taken
e. After diagnosis of DM, pt. was
able to take oral diabetic agents e. Allopurinol 100 mg 1 tab BID
but has stopped taking medicine Vessel due 1 cap BID
with no consultation and had not Iberet & Folic acid 1 cap OD
recalled medicines taken due to NaHCO3 1 tab BID
the long period of time.
3. Elimination
a. Urine (frequency, a. Usually, pt. urinates 5 times a a. Pt was catheterized, with
color, day, with a yellowish, cloudy yellowish, cloudy characteristic
transparency) characteristic at 800 mL/ day. at 1300 mL.
b. Bowel (frequency, b. Patient defecates 1-2 times a b. Pt. defecates every other day,
color) day, with a dark, formed with semi-formed, brown stool.
characteristic.
4. Ego Integrity
a. Perception of Self a. Pt. verbalized, “makatrabaho a. Pt. verbalized, “naglisod ani
b. Coping ra bisag naay sakit.” akong sakit…”
Mechanism b. The coping mechanism used b. Pt. often talks with his wife.
c. Support often by the client were crying or
Mechanism talking with his wife.
d. Mood/Affect c. He sees his wife, son, c. Pt’s wife was there to take care
brothers, and sisters as his of him.
support mechanism.
d. Pt. was often calm. d. Pt. was calm.
5. Neuro-Sensory
a. Mental State a. Pt. was conscious, coherent, a. Pt. was conscious, coherent,
b. Condition of 5 oriented to time, date, place, oriented to time, date, place,
senses (sight, person, and day. person, and day.
hearing, smell, b. Sight: OS- totally blind with b. Sight: OS- totally blind with
taste, touch) glaucoma, OD-PERRLA, blurred glaucoma, OD-PERRLA, blurred
vision vision
Hearing: slight hearing difficulty Hearing: slight hearing difficulty
on both ears on both ears
Smell: able to smell food, or other Smell: able to smell food, or other
things with odor things with odor
Taste: able to taste food Taste: able to taste food
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19. Touch: able to feel decreased Touch: able to feel decreased
sensation to pain, pressure, sensation to pain, pressure,
warmth, and cold. warmth, and cold.
6. Oxygenation and
Vital Signs a. Unable to assess a. RR: 25 cpm
a. Respiratory rate b. Unable to assess b. PR: 86 bpm
b. Pulse rate c. Unable to assess c. HR: 86 bpm
c. Heart Rate d. Unable to assess d. BP: 140/80 mmHg
d. Blood pressure e. Unable to assess e. Upon auscultation, fine
e. Lung sounds crackles all over lung fields were
f. History of heard.
respiratory f. Pt. had pneumonia 1 year ago, f. Pt. had pneumonia 1 year ago,
problems no asthma. no asthma.
7. Pain – Comfort
a. Pain (location, a. Relapsing phantom limb pain a. Relapsing phantom limb pain
onset, intensity, on left lower extremity lasting for on left lower extremity lasting for
duration, a few seconds at a scale of 5/10. a few seconds at a scale of 5/10.
associated b. Comfort measures used by the b. Comfort measures used by the
symptoms, client were massaging and client were massaging and
aggravation) cutaneous stimulation on application of eucalyptus oil on
b. Comfort amputated area. area.
measures/allevi c. Pt. took no medications for his c. Pt. took no medications for his
ation phantom pain. phantom pain.
c. Medication/s
8. Hygiene and activities The pt. usually takes a bath and Pt. was given sponge bath by his
of daily living change clothes once or twice a wife every day during
day. hospitalization and assisted in
changing his clothes every day;
pt. brushes his teeth only once a
day.
9. Sexuality
a. Male Pt. is a male, circumcised, Pt. is a male, circumcised,
(circumcision, married, and has 1 son. married, and has 1 son.
civil status,
number of
children)
PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS
General
Pt. is a 49 yrs. old Filipino, male with amputated left leg due to gangrene of diabetic foot.
Patient is conscious, coherent, not in respiratory distress. He has symmetrical facial features,
bilaterally equal body parts except left lower extremities amputated on mid-thigh. Left eye non-
reactive to light and accommodation. +2 edema noted on right leg. Patient has large body frame.
Pt. uses crutches for ambulating. Weight loss was not monitored.
HEENT
Head: graying hair equally distributed symmetrical facial features; no headache and
dizziness. Eyes: OS totally blind, nonreactive to light and accommodation, with glaucoma. OD-
PERRLA, blurred vision with cataract. Cataract surgery on OS 5 yrs ago. Ears: no discharges,
symmetric in size and shape, with auricles mobile, and firm. Earwax noted on both ears.
Responsive to sound. Nose: symmetric and straight, no discharges or flaring of all nares, septum
is intact and in midline. Throat: no tonsillo-pharyngeal erythema and congestion, lips are dry. No
cervical lymphadenopathy.
Integumentary System
Patient has brown skin, warm to touch with a temperature of 37.8 °C, has a poor skin
turgor, dry, itchy and scaly skin with even pigmentation. Body hair evenly distributed on bilateral
19 | P a g e

20. parts of the body. Noted +2 pedal pitting edema on right leg. Pale nail beds with a capillary refill
time of 2-3 seconds. No wounds noted. Scar noted on stump on left lower extremities.
Respiratory System
Tachypneic at 25 cpm, equal chest expansion noted. Fine crackles auscultated over all
lung fields. No intercostal retractions noted. No wheezing noted. Equal diaphragmatic excursion.
Not in respiratory distress. No hemoptysis. No history of PTB or asthma. Chest X-ray result
shows possible pneumonia.
Cardiovascular System
PR=86 bpm, strong pulse. HR=86 bpm, regular. PMI noted @ 5th ICS left MCL. No jugular
vein distention, no precordial bulge, heaves, thrills, or murmurs noted. Hypertensive @ 140/80
mmHg. Pale nail beds. Good peripheral pulses. Noted +2 pedal edema on right side. Chest x-ray
result shows enlarged heart shadow with impression of cardiomegaly. Blood studies shows
decreased hemoglobin 100 g/L, and decreased hematocrit 0.30.
Digestive System
Abdomen has unblemished skin and uniform in color, soft. Symmetric abdominal
movement upon respiration. Normoreactive bowel sounds ranges from 1-2 BS / 15 sec., negative
fluid volume test, no tenderness upon palpation. No organomegaly or masses noted. Nausea and
vomiting was noted before hospitalization. No abdominal pain. Weight loss was not monitored.
Patient experienced a decrease in appetite. Patient is on diabetic diet with low salt and low fat but.
Semi formed brown stool. No parasites on stool exam.
Excretory System
Patient has patent anal opening and urethral meatus. Foley catheter inserted. Yellowish
cloudy urine. Urinates 1,300 ml/day. Urinalysis results specific gravity of 1.015 with pus 18-56 /
hpf and RBC 2-4 / hpf. With increase serum creatinine to 12.3 mg/dL. Urinalysis shows
proteinuria and ketones-rare.
Musculoskeletal System
Pt has approximately equal bilateral size of muscles on peripheries. Undergone AKA on
left side 4 yrs. ago. Relapsing phantom pain on left lower extremity with pain scale of 5/10, for few
seconds relieved by massage and application of eucalyptus oil. +2 pedal pitting edema noted on
right side. Large body frame. Able to ambulate with crutches. Patient has complaints of weakness.
Functional level 3- requires help from another person and equipment device. Muscle strength +4
on all extremities. Grip is equal on both arms, but weak.
Nervous System
Patient is conscious, coherent, and oriented to place, person, and time. OS nonreactive to
light and accommodation. OD- pupil equally round, equally reactive to light and accommodation.
GCS of 14/15 (eye response is 3, motor response is 6, verbal response is 5). Intact cranial nerves.
Positive gag reflex. Decreased sensation on lower extremities, paresthesia reported.
Endocrine System
Patient has equal hair distribution on bilateral parts of the body. Patient is diagnosed with
DM type 2 (adult onset diabetes). No recent weight loss or gain. No heat or cold intolerance. No
thyroid enlargement noted. Decreased appetite. Increased thirst. HGT shows hyperglycemia 162
mg/dl.
Reproductive System
Patient is male, circumcised, married with one son. Grossly male. Testes descended.
Patient has decreased libido. No masses, unusual discharges on genital area. Pt reported erectile
dysfunction.
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