A Case Presentation

of

DIABETES
MELLITUS
I. Vital Information :

Name : Mr. E.A.

Age : 60 y.o.
Address : Villa Hermosa Subd.
LaPaz I.C.
Date/Time Admitted : April 07, 2010; 3:45 pm
Ward/Bed # : MMSW Bed #12
Impression/Diagnosis : BKA Right foot
secondary to Diabetes Mellitus II
Surgical Operation Performed : Below the Knee
Amputation Right foot
Days Post-Op : 24 days
 NURSING HISTORY

HISTORY OF PRESENT ILLNESS

Four months prior to admission, patient’s both feet was accidentally burned
by charcoal while ironing his clothes. According to him he applied burn ointment
on is wound without consultation from the doctor. A week after he noticed that
there is no progression upon using an ointment. They decided to seek for medical
attention. The patient Mr. E. A. together with his sister went to IDH for
consultation. H e was admitted on that hospital for 2 weeks .Due to financial
constraints, he decided to be discharged against medical advice. He was given
discharge instructions including his take home medication but unfortunately there
is no compliance at all, instead they were using betadine solution for his wound
dressing. Three weeks prior to admission, patient noticed swelling after he
scratched his wound at the left medial distal side of left foot. Eventually,
secretions noticed oozed out of the ulcer. They only used betadine solution for
dressing knowing that it will lessen the secretion from ulcer until such time that
the wound tissue became necrotic. They opted to seek for admission at West
Visayas State University Medical Center. Last April 7, 2010 a date of admission,
the patient was admitted at the emergency room of the said hospital. He was seen
and examined by Doctor O. MROD. Laboratory tests were ordered and carried
out (CBC, urinalysis, and fecalysis). His vital signs was checked and recorded by
NOD as follows: Temperature: 36˚C, Pulse Rate: 100, Respiration: 27, BP:
100/70. He was then brought to MMSW by the ER nurse per wheelchair and was
endorsed to the NOD.
Medications: Macrodantin, Metronidazole, Cefexime
Clinical Inspections: T-35.5, P-111, RR-34, BP-100/80
 PAST MEDICAL HISTORY:

Patient is a known diabetic since 20

years. His medication includes
Diametron and Metformin and was used
irregularly. He stopped his medications
5 months prior to his admission due to
financial problem. According to his
folks, their family history of Diabetes
Mellitus was originated from his mother
side.
Physical Assessment:
Vital Information

Name: Mr. E.A

Age: 60 y.o.

Sex: Male

Civil Status: Married 

Religion: Roman Catholic

Nationality: Filipino

Address: Villa Hermosa Subd., La Paz, Iloilo City

Chief Complaint: Non­healing Left foot wound

Medical Diagnosis: BKA Right foot secondary to Diabetes Mellitus

Attending Physician: Dr. O. 
• Functional Area
•
• General Survey:
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Head

Face

Eyes
Ears

Nose

Mouth

Ear lobes are bean shape, parallel and symmetrical with each other; the upper
connection of ear lobes are parallel with the outer canthus of the eyes; no
lesions noted upon inspection ; minimal amount of serumen noted upon
inspection; pinna recoils when folded; auricles has firm cartilage and not
tender upon palpation; with intact cranial nerve number 8.

Nose is at the midline, smooth, and color is the same with the face; with
pinkish nasal mucosa; swelling and tenderness not noted; with o2 at 2lpm via
nasal cannula; with intact cranial nerve number 1.
Neck

Heart and Vessels

Thorax and lungs

Neck is straight; jugular vein is not distended; lymph nodes are slightly
palpable; thyroid is not palpable.

With blood pressure of 100/70 mmhg taken at left arm with the patient on flat
position(with one pillow under the head); with cardiac rate of 112 bpm, regular
in rate and rhythm, synchronous with pulse rate; slightly tachycardic.

With respiratory rate of 27bpm ,spontaneous and labored; difficulty of

breathing noted; tachypnic; with equal chest expansion; with o2 at 2lpm via
nasal cannula; pain not noted upon palpation.
LABORATORY
RESULTS
Date Procedure Indication Normal Actual
Values Findings
4/7/2010 Chest AP Shows the The organs are Impression:
placement of examined in
view various medical normal To rule out
equipment can appearance Cardiomegal
be seen, such y
as, Nasogastric
Tubes (NGT)
Atherosclerot
ic aorta

4/8/2010 Clinical lab Measures renal BUN = 2.50- BUN = 9.32

function and the 7.10 mmol/L mmol/L
Specimen: degree of Above normal
Blood damage in the range, may
renal system indicate a renal
failure.
Date Procedure Indication Normal Actual
Values Findings
4/22/10 Hematology laboratory Thrombocyte 538x10 g/L
analysis
Specimen: performed on a 150,0000 – Above normal
range, may
Blood blood sample 400,000 indicate
that is used to thrombocythemi
determine a
physiological
and biochemical
states

Leukocyte 28.1x10 g/L

5000 to Above normal
range, may
10000 indicate
infection.
Diabetes
.
Mellitus – is a
metabolic disorder characterized
by presence of hyperglycemia. It
happens due to defective insulin
secretion, insulin action, or both
resulting in defects of
carbohydrates, protein and fat
metabolism.
Causes:
1.Total/Partial
insulin
deficiency

1.Insensitivity of
cells to insulin
2.
TYPES:
a. Type 1 “Insulin dependent Diabetes Mellitus”
> experienced by patients with no
production of insulin at all
> associated with destruction of β cells.
> common among patients who are not obese
> common among children

b.Type 2 “Non-Insulin dependent Diabetes Mellitus

> results from partial deficiency of
insulin or insensitivity of cells to insulin

c.Gestational Diabetes Mellitus

> develops during pregnancy related to
action of hormones towards insulin.
 Manifestations:
v Polydypsia
v Polyphagia
v Polyuria
v Fatigue
v Blurred vision
v Increase susceptibility
to infection
-
-
 Diagnostic Tests:
1.FBS – Fasting Blood Sugar
2.Post – Prandial Blood Sugar
3.Glycosylated Hgb
1.
 Management:
1.Administration of insulin or
oral hypoglycemics.
Type 1 – insulin exogenous
Type 2 – oral
hypoglycemics
Types of insulin :
a. rapid acting “regular
insulin”
b. intermediate “lente”
c. long acting “ultra
lente”
 Onset Peak Duration

Rapid ½ to 1 hour 2 to 4 hours 6 to 12

acting hours

Intermediat 1 to 1 ½ 8 to 12 18 to 24
e hours hours hours

Long 4 to 8 hours 16 to 24 30 to 36
Acting hours hours
2. Monitor diet of the patient
( well balanced diet).
3. Monitor urine/sugar and acetone.
4. Observe for chronic
complications.
> Atherosclerosis associated
with CAD, CVD, MI
> Kidney disease
> Occular disorders (eg.
Diabetic Retinopathy)
> Impotence/Frigidity
Client Teaching:
> insulin administration
> emphasize single use of syringes
> insulin reactions:
a. allergic reactions
b. insulin lipodystrophy
c. dawn phenomenon
d. somogyi phenomenon
> blood glucose monitoring
> avoidance of alcohol, aspirin,
sulfonamides, COC’s, MAOI
> if patient has common colds, instruct not
to skip oral hypoglycemics
> cut nails straight
> avoid bare footing, seek consult
whenever there is cut
> wear medic alert band
Diabetes Mellitus
• is a metabolic disorder characterized by presence of
hyperglycemia. It happens due to defective insulin secretion,
insulin action or both resulting in defects of carbohydrates,
protein, and fat metabolism.
•
PATHOPHYSIOLOGY

Predisposing Factors:
- age: 30 and above (patient is 60 years old)
- sedentary lifestyle

Precipitating Factor:
- hyperglycemia – the presence of abnormally high concentration of
glucose in the blood.

Causes:
1.Total or partial insulin deficiency
2.Insensitivity of the cells to insulin
DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Risk for infection After 8 hours of Independent: After 8 hours of

related to increase proper nursing proper nursing
in WBC and intervention client 1.Monitor vital 1.To asses intervention client
traumatized tissue will be able to: signs baseline data. was able to:
secondary to appropriately. 1.Verbalize
below the knee 1.Verbalize understanding of
amputation right understanding of 2.Stress hand 2.A first line individual
foot. individual washing defense against causative/ risk
causative/ risk techniques in nosocomial factors.
factors. dealing with infection/cross
2.Identify patient. contamination. 2.Identify
interventions to interventions to
prevent/reduce prevent/reduce
risk of infection risk of infection.
3.Demonstrate 3.Change 3.To reduce the 3.Demonstrate
techniques, surgical/other spread of techniques,
lifestyle changes wound infection. lifestyle changes
to promote safe dressings, as to promote safe
environment. indicated, using environment.
proper Goals partially
technique for met.
changing/disposi
ng of
contaminated
materials.

4.Turn patient 4.For

every 2 hrs. mobilization of
respiratory
secretion and to
prevent
complication.
Dependent:

1.Maintain adequate
nutrition.
2.Give madications
as ordered:
a.Antivirals
b.Antibiotics

Collaborative:

1.Monitor laboratory 1.Identifies

data and relay organisms so
results. that most
appropriate
drug therapy
can be
instituted
NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Disturbed body After 8 hrs. of Independent: After 8 hrs. of

image related to effective nursing effective nursing
loss of body part, intervention, 1.Monitor own 1.They need to intervention,
possibly client will be able facial expression convey client was able
evidence by to: and other non- acceptance and to:
verbalization of verbal behavior. not evulsions
feeling of 1.Verbalize when the client;s 1.Verbalize
powerlessness, understanding of appearance is understanding of
grief and trauma body changes. affected. body changes.
to nonfunctioning 2.Recognize and 2.Note signs of
part. incorporate body grieving/indicator 2.To evaluate 2.Recognize and
image change s of severe or need for incorporate body
into self-concept prolong counseling image change
in accurate depression and/or into self-concept
manner without medications. in
negating self 3.Reposition
esteem. patient every 2 3.To prevent bed
hrs. sores.
3.Verbalize relief 4.Discuss 4.A small loss accurate manner
of anxiety and meaning of may have a big without negating
adaption to loss/change to impact. A change self esteem.
actual/altered client. in function (such
body image. as immobility) 3.Verbalize relief
4.Verbalize maybe more of anxiety and
acceptance of difficult for some adaption to
self in situation. to deal with than actual/altered
change in body image.
appearance.
4.Verbalize
5.Different acceptance of
situation are self in situation.
5.Listen to upsetting to Goals unmet.
client’s different people,
comments and depending on
responses to individual coping
the situation. skills and past
experiences.
6.Note 6.Maybe normal
withdrawn response to
behavior and situation or
the use of maybe
denial. indicative of
mental illness.
METRONIDAZOLE
•GENERIC:
•Metronidazole

•BRAND NAME:

•Flagyl

•DOSAGE:

•500mg, 1tab

•ROUTE:

•Oral

•FREQUENCY:

•TID

•TIMING:

• 
• 
CLASSIFICATIONS:
•
ANTI INFECTIVES
 Indication
Amoebiasis . Giardiasis .
Urethritis & va g init is d ue t o
Tr ichom ona s, Ur e t hr it is d ue t o
Tr ichom ona s Men , N onsp e cif ic
vaginitis, Treatment of anaerobic
infection, Surgical chemoprophylaxis,
Prophylaxis of post-op anaerobic
infection, Intestinal & hepatic
amoebiasis.
CONTRAINDICATION

In patients hypersensitive to penicillin.

 Side effects
GI effects, hypersensitivity reactions,
peripheral sensory neuropathy, headaches,
convulsion, dizziness, ataxia, psychotic
disorders including confusion, hallucinations,
transient visual disturbances. Very rarely,
hematological effects, abnormal liver function
tests, cholestatic hepatitis
 Nursing
Responsibility

-Before giving the drug, ask patient

about past allergic reactions.
- Ask patient Discontinue therapy
immediately if symptoms of CNS
toxicity.
-Lab tests: Obtain total and differential
WBC counts before, during, and after
therapy, especially if a second course is
necessary.
- Don’t give to pregnant women.
Macrodantine
•GENERIC:
•Nitrofurantoin macrocrystals

•BRAND NAME:

•Macrodantine

•DOSAGE:

•100 mg 1 cap

•ROUTE:

•Oral

•FREQUENCY:

•QID

•TIMING:

•  
•
CLASSIFICATIONS
•

URINARY ANTI-SEPTICS
•
Indication

UTI due to susceptible strains of E coli,

S aureus & certain susceptible strains
of Klebsiella, Enterobacter & Proteus
spp
CONTRAINDICATIONS
In patients with Anuria, oliguria And
Hypersensitivity to the drug.
Side effects
Nausea, emesis, anorexia,
•

abdominal pain, diarrhea,

pulmonary hypersensitivity
reaction, peripheral
neuropathy, exfoliative
dermatitis, erythema
multiforme, lupus-like
syndrome, urticaria, rash,
agranulocytosis, leukopenia,
granulocytopenia.
Cefixime
•GENERIC:
•Cefixime trihydrate

•BRAND NAME:

•Axetef

•DOSAGE:

•200MG 1 CAP

•FREQUENCY:

•BID

•TIMING:
CLASSIFICATIONS:
CEPHALOSPORINS
•
INDICATION
Treatment of patients with gonorrhea,
otitis media, pharyngitis, lower resp
tract infections eg bronchitis & UTI.
Side effects

GI disturbances eg severe diarrhea.

Nursing responsibility
should be taken with meals.
Watch out for drug reaction to anti
coagulants.
Calmoseptine
•GENERIC(contains)
•Per 3.5 g Zn oxide 555.7 mg, calamine

164.5 mg, menthol, Na bicarbonate,

phenol, lanolin, thymol, chlorothymol,
glycerin
•BRAND NAME:

•Calmoseptine

•DOSAGE:

•Cleanse skin, pat dry & apply 2-4 times

daily or as necessary.
•ROUTE:

•Skin preparations

•FREQUENCY:

•TID

•TIMING:

•  
Classifications
EMOLLIENTS AND SKIN
•

PROTECTIVES.
INDICATION:
Protects, soothes & helps promote healing in
those w/ impaired skin integrity related to:
Feeding tube site leakage; wound drainage;
urinary & fecal incontinence, bedsores;
ileoanal reservoirs, ileostomy, urostomy;
moisture eg perspiration, scrapes; fungal
infections, eczema & impetigo; diaper rash;
insect bites; burns due to flame, radiation or
chemicals; fistula, fissures, excoriation;
colonoscopy, external hemorrhoids; chafing,
chapping of skin; vag & rectal itchiness;
prickly heat.
Special precautions:
Tell patient its only for skin use, don’t
apply to sensitive parts of the body
such as lips,eye and tongue.
TRAMADOL
•GENERIC:
•Tramadol HCl

•BRAND NAME:

•Amaryll

•DOSAGE:

•50mg 1cap

•ROUTE:

•Oral

•FREQUENCY:

•Q6h

•TIMING:

• 
• 
Classification:
Analgesics(opiods)
•
Indication
For Acute & chronic pain and Moderate
to severe pain due to mild illness,
pain after diagnosis or post-op pain.
Contraindications
Acute alcohol intoxication; patients
under intoxication w/ hypnotic
analgesics or psychotropic drugs;
severe resp depression; patients w/ a
risk of stupor due to head injuries or
lesions; concomitant administration
w/ MAOIs.
Side effects
Resp depression, palpitations, chills,
chest pain, decrease in BP,
arrhythmia. Vomiting, nausea, GI
distension, borborygmi, pyrexia,
flushing, urticaria, inj site reactions,
excessive bronchial secretion. Cap GI
irritation, drowsiness, lethargy.
headache, tremor, irritability,
sweating, disorientation, depression.
Nursing precaution
Concomitant administration of morphine
or repeated administration, cholangia,
hepatic or renal disorders,
alcoholism, decreased resp reserve,
elderly or debilitated patients. May
affect ability to drive or operate
machinery.
 The team who
made this case
presentation
possible :
 Pranga , Crystal May
Pueyo , Philip Christoffer Delmar
Sabay , Sedric
Salvatierra , Ferna Shirl
Sarte , Ruel
Soltis , Ardy
Velez , Kennedy
Villasis , Rogie Joan
Villegas , Cristine
Yder , Rey Anthony
Zaballa , Michelle
Gimotea , Edna Marie
 THE

MAKING
Submitted to:
Ms. Estrella Fortuna, RN