A Case of Type II Diabetes

Mellitus

In partial fulfillment of the requirements for the subject:

NUR1217 - Medical Surgical Nursing RLE

Presented by:
Anchuelo, Avy Liezel
Aranas, Yobhel Marie
Basco, Hannah Dominique
Berciles, Edlaine Kate
Cabral, Sean Philippe
Calderon, Kristin Lea

BSN 305 - Group 1A

Submitted to:
Ms. Julie Danofrata, RN, MAN.

March 22, 2021

I. DEMOGRAPHIC PROFILE
Name: Patient JC
Address: Malate, Manila City
Age: 22 years old
Birth Date: Jan. 25, 1999
Birth Place: San Juan, La Union
Gender: Male
Religion: Roman Catholic
Race/Ethnic Origin: Filipino
Occupation: BPO Employee
Educational Attainment: College graduate
Marital Status: Single
Name of Spouse: N/A
Number of Children: N/A
Chief Complaints: He reported unquenchable thirst, and the repeated need to urinate upon
questioning. One day prior to admission, he complained of vague abdominal pain, which was
worse on the morning of admission.
Date of Admission: March 9, 2021
Room & Bed Number: 1A
Attending / Admitting Physician: Dr. Meredith Grey
Admitting/Final Diagnosis: Type II Diabetes Mellitus
Medical Insurance: PhilHealth

II. NURSING HEALTH HISTORY

A. History of Present Illness

Mr. JC, a 22-year old male patient was brought to the infirmary after passing out
during his graveyard shift at a BPO company. He has a complaint of vague stomach pain,
which became worse on the morning of admission, and also reported to vomit once. During
the examination, he was oriented but tachypneic, pale-looking, dehydrated with dry mucous
membranes, and poor skin turgor. His respiratory rate was 36 breaths per minute, wherein
deep, laborious breathing was noted. His heart rate was 138 beats per minute and his blood
pressure was 90/60 mmHg. His chest was clear and the tones of his heart were normal. There
was a generalized abdominal tenderness noted which is otherwise soft to palpation, and no
rebound. Generalized muscular hypotonia was also present; the deep tendon reflexes were
present but rather weak.

His laboratory test, on the admission day revealed glucose levels of 560 mg/dL,
potassium levels of 6.5 mM/L, bicarbonate of 10 mM/L, chloride levels of 90 mM/L, BUN
levels of 38 mg/dl, and creatinine levels of 2.5 mg/dl. Urine samples showed a 4+ for glucose
and had "large" acetone. HbA1c has a percentage of 14%, and serum acetone was 4+
undiluted. Right away, he was treated with insulin and saline solution intravenously with
100cc/hour. After four hours of administration, potassium chloride was added to the IV at a
rate of 15 mEq/hour.

On the second day of the admission, the patient was active, alert, properly hydrated
and cheerful. Showing that he was doing exceptionally well, the patient ordered for the
discontinuation of his IV fluids. His doctor wanted to turn his insulin to subcutaneous
injections and to initiate a liquid diet. He was then given a diabetic maintenance diet and
treated with one injection of Human Lente insulin in the morning.

On the third day of admission, the patient had repeated bouts of hypoglycemia
throughout the day with blood sugar of 100-140 mg/dl and HbA1c of 9 percent. He was
eventually given three injections of daily insulin/day and a bedtime intermediate period
(Lente) of insulin. He was also taught of blood glucose self-monitoring and started on 5 mg
of glyburide once a day. He was advised to be on an 1,800 calorie diet. He was also advised
to avoid candy, colas, and juices. The doctor will instruct the patient to go home the
following day if there are no signs and symptoms.

B. Past Health History

Mr. JC reported that for the past weeks, he had experienced severe weakness,
dizziness, and drowsiness that persist during his four-week graveyard shift. Three weeks prior
to the admission day, the patient experienced drowsiness and generalized tiredness, and was
taken to the infirmary. Saline solution was administered to him intravenously, with the
diagnosis of dehydration. Upon interrogation, he reported an unquenchable thirst and a
repeated urge to urinate. He also stated that even though he ate all of his food rations on time,
he claimed to have lost 19 pounds.

The patient had a flu vaccine shot last August 2020 as mandated by the company he is
working with, in compliance with the safety measures during COVID-19 pandemic. As a
child, he had chicken pox when he was around 10 years old, but overall he described himself
as a healthy child because he was never hospitalized before due to illness or undergo any
surgical procedures. But he stated that he is aware that his family had a history of Type I
diabetes mellitus, heart diseases, and hypertension that he may acquire later on.

C. Occupational History

Inclusive Dates/Year Occupation

2020- present Customer Service Representative

 The patient graduated and got a college degree last 2019. He started working as a
customer service representative in a well-known BPO company in Manila during the
pandemic. He stated that because of the pandemic, his parents are unable to work because of
their health conditions, that’s why he decided to find a job to support them. He is currently
new to his job but he described it as a well-paying job that is enough to sustain himself and
his family. His working environment is stressful due to constant client complaints that he is
receiving everyday and flexible work schedule which means night shift and graveyard shift
are considered as his normal working hours. However, he is still getting used to his working
environment overtime and so far, he is enjoying his job and satisfied with the work incentives
and benefits.

D. Genogram
 According to the client, he doesn’t know much about his grandparents because they
are only able to see them every time their family visits their provinces in Bicol and La Union.
But he is aware that his grandfather on his father side died having type I diabetes while his
grandfather on mother side died before he was even born because of cardiac arrest. In terms
of his parents, they are both the only child of their families. His father is suffering from
diabetes type I and is managed through taking insulins and strict diet, while his mother is
hypertensive and taking Losartan 50mg as her maintenance. The patient is the youngest child
among the three siblings.. His older brother is hypertensive and has a daughter who has Type
I diabetes, while her sister suffers from polycystic ovarian syndrome and was diagnosed 4
years ago.

III. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

HEALTH PERCEPTION AND MANAGEMENT PATTERN

Upon admission, the client reported vague abdominal pain in which he rated the pain
using a scale of 1 to 10, 10 being the highest and 1 is the lowest as 8/10, moving makes pain
more severe. The patient describes his health during the past weeks as unhealthy and worst
because of the symptoms that he endured prior to admission such as sleepiness, tiredness,
dizziness, and pain. The patient also added that he notices that there is some increase in urine
output. Aside from that, he has irregular sleeping patterns due to work demands and he has
an unrestricted diet even though he is at risk of familial diseases such as diabetes and
hypertension. He also added that he does not have any time to exercise and preferred to relax
by playing video games during his free time.
According to the patient, he doesn’t have any hospitalization because he asserted that
he is not sickly before having a job. If he experiences fever or mild symptoms, he tends to
self medicate such as drinking paracetamol or ibuprofen for pain. If he cannot manage the
symptoms anymore, that is the time he goes to the clinic for check-up. His last immunization
is the flu vaccine shot last August 2020, and doesn’t take any vitamins for he sometimes
forget to take them. The client also added that he doesn’t have any food allergy and doesn’t
smoke, however, he drinks alcohol occasionally.
ANALYSIS: Ketones builds up in the blood in diabetic ketoacidosis, seriously altering the
natural composition of the blood and intervening with the function of various organs. This
causes vomiting and stomach pain by turning the blood acidic. During a ketoacidosis episode,
sugar levels are so elevated that excess sugar moves into the urine. When sugar is excreted in
the urine, water, sodium, and potassium are brought into the urine for each sugar molecule,
and the body loses vast amounts of fluid and electrolytes, minerals that are essential for cell
work. starting to cause significantly more urine to be produced than normal. According to
Pamungkas et. al., individuals' presumed susceptibility to disease plays an important role in
understanding their health-related behavior. Some adults stated that they could not regulate
their blood glucose levels when dealing with diabetes. They ate whatever they liked and did
not avoid any foods. This implies that perception of an individual about the disease and its
seriousness, and taking precautionary steps is important. Perceptions and belief of an
individual are important in influencing the views and management of Type II Diabetes
Mellitus. (Pamungkas, R., Chamroonsawasdi, K., Vatanasomboon, P., & Charupoonphol, P.,
2019. Barriers to Effective Diabetes Mellitus Self-Management (DMSM) Practice for
Glycemic Uncontrolled Type 2 Diabetes Mellitus (T2DM): A Socio Cultural Context of
Indonesian Communities in West Sulawesi. European Journal of Investigation in Health,
Psychology and Education. 10. 250-261. 10.3390/ejihpe10010020)
INTERPRETATION: DEVIATION FROM NORMAL

NUTRITION AND METABOLIC PATTERN

March 7, 2021 March 8, 2021 March 9, 2021

 BREAKFAST: BREAKFAST: BREAKFAST:
1 cup of instant coffee 2 pcs. pancake pc. Mashed potato
1 pc. of burger 2 tbsp. maple syrup 1 small apple
1 serving of french fries 1 cup of black coffee with 3 glasses of water
(salted) sugar
3 glasses of water LUNCH:
2 glasses of water
1 serving steamed chicken
LUNCH: breast
LUNCH:
1 small bowl of chicken adobo 1 pc. fried chicken ½ cup brown rice
1 ½ cups of white rice 1 pc of banana
3 cups of white rice
1 can of soft drinks 2 glasses of water
3 glasses of water
3 glasses of water
DINNER: DINNER:
SNACK
2 servings of carbonara 1 small platter of steamed
1 pc. of white bread
2 pcs. of garlic bread mixed vegetables
1 can of soft drinks 1 can of energy drink
½ cup of plain yogurt
1 glass of water 3 glasses of water
3 glasses of water
SNACK: DINNER:
1 slice of chocolate cake
1 glass of orange juice
NONE

Upon examination, the client has dry mucous membrane and poor skin turgor, which
demonstrates dehydration. He stated that he eats at least thrice a day and doesn’t skip meals
but he noticed that he still lost 19 pounds. He prefers fast food meals due to minimal
preparation time, in which he can save time in preparing foods. The patient also verbalized
that “Mahilig ako uminom ng kape, softdrinks, at energy drink para maiwasan ko na antukin
sa trabaho lalo na kapag hating-gabi”. According to the patient, he is aware that he is at risk
for diabetes but he doesn’t have any diet restriction, because he eats what food he likes or
food that is available in the canteen to save much time. He drinks at least 6-10 glasses of
water a day however, he feels thirsty regardless of how much fluid he intake. The night
before admission, he is not able to eat dinner because he is not feeling well caused by
abdominal pain. On the admission day, he cannot eat much because his abdominal pain
worsened, weakness, dizziness and reported vomiting once. His doctor put him on a liquid
diet on the second day of his admission, and on the third day, he was told to follow a diabetes
maintenance diet (1800 kcal) and to avoid chocolate, colas, and powdered juices.

ANALYSIS: Evidence indicated a correlation between soft drink consumption and obesity
and diabetes, owing to massive quantities of high fructose corn syrup used in soft drink
production, which increases blood glucose levels and BMI to unsafe levels.has claimed that
diet soft drinks contain glycated chemicals that markedly augment insulin resistance. Food
consumption has been closely related to obesity, not just in terms of quantity but also in diet
composition and consistency. Consumption of red meat, candy, and fried foods increases the
risk of insulin resistance and Type 2 diabetes mellitus. In addition, there was an inverse
association found between vegetable consumption and type 2 diabetes mellitus. Intake of
fruits and vegetables may help to prevent the progression of type 2 diabetes mellitus because
they are high in nutrients, fiber, and antioxidants, both of which act as a defense mechanism
against the disease. (Sami, W., Ansari, T., Butt, N. S., & Hamid, M., 2017. Effect of diet on type 2
diabetes mellitus: A review. International journal of health sciences, 11(2), 65–71.)

INTERPRETATION: DEVIATION FROM NORMAL

ACTIVITY AND EXERCISE PATTERN

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

MORNING: MORNING:
● Eating breakfast ● Eating breakfast
● Sleeping ● Watching television
● Going to restroom ● Going to restroom
● Walking inside the room or in the
AFTERNOON: corridors
● Eating lunch
● Going to restroom AFTERNOON:
● Goes back to sleep/napping ● Eating lunch
● Having a nap
EVENING: ● Play cellphone games
● Watching television or playing ● Have a shower
video games
● Surfing the net
● Taking a shower EVENING
● Eating dinner ● Watching television
● Eat dinner
MIDNIGHT ● Bed rituals
● Going to work/commuting ● Sleeping
● Working

According to the client, he is not physically active because he doesn’t have time to go
to the gym or to walk in the neighborhood during daytime. He added that he is too tired and
busy due to work that’s why he doesn’t have any time or energy to work out. However, upon
waking up, he said that he prefers to relax by playing games and watching movies rather than
exercising. When going to work, he rides a tricycle going to the bus terminal even though it is
only a 10 minute walk from his home. He explained that he doesn’t like to walk because he
saves his time to arrive early to work, besides it is dangerous to walk alone at night. He added
that he is completely aware that he is at risk of diabetes and hypertension but cannot do
something about it due to a busy working schedule.

ANALYSIS: Anjali and Sabharwal (2018) reported that most young adults were constantly
aware that they could exercise however did not do so due to a number of impediments to
physical activity. Some of them were aware of what they ought to do to become much more
physically involved, but they were simply "exhausted." After a hard working day and travel
time, the majority of respondents suggested that they had little room left for physical
exercise. Furthermore, participants find it impossible to participate in physical exercise due to
a hectic workload as well as other responsibilities and desires. (Anjali, & Sabharwal, M.,
2018. Perceived barriers of young adults for participation in physical activity.
http://dx.doi.org/10.12944/CRNFSJ.6.2.18). Sedentary behaviour with minimum energy
consumption has a widespread and important impact on cardiometabolic health. Sedentary
time is associated with increased mortality and morbidity, largely regardless of involvement
in moderate-to-vigorous physical activity.) According to the findings of Sami et al., physical
exercise raises insulin sensitivity. Physical exercise was shown to significantly increase
abnormal glucose tolerance when the cause was insulin resistance rather than a lack of
circulating insulin. Aside from that, physical exercise is likely to be more effective in
avoiding the development of Type 2 Diabetes Mellitus during the early stages, before insulin
treatment is needed. (Sami, W., Ansari, T., Butt, N. S., & Hamid, M., 2017. Effect of diet on type 2
diabetes mellitus: A review. International journal of health sciences, 11(2), 65–71.)
INTERPRETATION: DEVIATION FROM NORMAL

ELIMINATION PATTERN
The client mentioned he noticed increased urine output and urge to urinate, regardless
of his fluid intake within the day, in which he is experiencing for several weeks and affects
his work for he cannot hold his bladder for too long. He reported the color of his urine as dark
yellow that has a sweet and fruity smell and urinates for no less than 7 times a day with
usually ¼ to half cup amount of urine per output. He asserts that he defecates once daily with
brown, soft, formed stool with no unusual odor, blood, excess perspiration nor pain upon
defecation.

ANALYSIS: According to Bristol stool form scale, the normal stool consistency may be
defined as type 3 or 4. The patient has a type 3 stool type which is sausage type, but with
cracks on surface. Fecal elimination greatly varies among individuals, but regular elimination
is with soft formed stools and brown in color. Although people’s pattern of urination is highly
individual, most people voids about 5 or more times a day. (Fundamentals of Nursing, Kozier
and Erb 4th Edition, p. 1397, 1439-1440). Diabetic patients often have sweet or fruity
smelling urine. This is attributed to the body's attempt to eliminate extra blood sugar by
excreting glucose from the urine. This process often flushes out vital hydrating fluids from
the body, leaving diabetics peeing excessively and dehydrated. (Frequent urination and
diabetes: Warnings to look for. (n.d.). Retrieved March 14, 2021, from
https://www.healthline.com/health/frequent-urination-diabetes)
INTERPRETATION: DEVIATION FROM NORMAL

SLEEP AND REST PATTERN

As stated by the client, for the past four weeks, he has not been getting a good sleep
due to consecutive weeks of having a graveyard shift. He also noticed how tired and sleepy
he was during work hours even though he gets some sleep after going home from work. His
usual sleeping pattern for the past weeks is from 9 am to 4 pm, but reported to feel tired and
cannot think clearly due to sleepiness. The patient added that he has interruption during his
sleep every time he needs to eat or pee. He sometimes dreams about his family and work but
he always forgot the details after waking up. He mentioned that he always prays before going
to sleep.

Sleep Diary

MARCH 7, 2021 MARCH 8, 2021 MARCH 9, 2021

Time went to bed

9:30 am 9:15 am 3 am
 Approximately time went asleep 1 hour and 15 minutes
45 minutes (eat lunch) 5 minutes

Sleep interruptions (time & duration) 11 am- 1:30 pm- wakes up to 6 am- eat breakfast
2 pm- eat lunch to pee 8am- wakes up to
pee

Time woke up
6 pm 4 pm 11 am

Feeling after waking up

Tired Tired Tired

Naps (time & duration) 6 pm- 1 hour 2 pm- 2 hours

None 9 pm- 45 minutes 7 pm- 45 minutes
9 pm- 30 minutes

Activities done before bed

Pray None Pray

Bed rituals
Half bath, changed None Brushed teeth,
clothes, brushed washed face
teeth

ANALYSIS: Young adults need an average of 6 to 8 ½ hours of sleep every day. Dream is
said to be functionally important to learning, memory processing, and adaptation to stress.
The ability to describe a dream and interpret its significance sometimes helps resolve
personal concerns or fears. But mostly, people forget their dreams, few have dream recall or
do not believe they dream at all. (Fundamentals of Nursing 9th Edition, Potter and Perry, p.
994, 998). Sleep disturbances are slightly more frequent in people with diabetes than in non-
diabetic people. Several factors can contribute to sleep in diabetic patients, including pain or
symptoms associated with peripheral neuropathy, sudden changes in blood glucose levels
throughout the night contributing to hypoglycemic and hyperglycemic episodes, nocturia, and
associated depression. (Kalra, S., Khandelwal, D., Dutta, D., & Chittawar, S. (2017). Sleep
disorders in type 2 diabetes. Indian Journal of Endocrinology and Metabolism, 21(5), 758.
doi:10.4103/ijem.ijem_156_17). Work that involves night shifts has a significant negative
impact on health, sleepiness, efficiency, and risk of injury. A major cause of shift work
schedule induced sleepiness and sleep disturbance is believed to be a misalignment between
internal circadian physiology and the necessary work schedule. (Booker, L. A., Magee, M.,
Rajaratnam, S. M., Sletten, T. L., & Howard, M. E. (2018). Individual vulnerability to
insomnia, excessive sleepiness and shift work disorder amongst healthcare shift workers. a
systematic review. Sleep Medicine Reviews, 41, 220-233. doi:10.1016/j.smrv.2018.03.005).
INTERPRETATION: DEVIATION FROM NORMAL
COGNITIVE AND PERCEPTUAL PATTERN
According to the client, he doesn’t have any hearing or visual difficulty or using any
gadgets. However, he sometimes experienced headaches after his work duty that he managed
by taking paracetamol and drinking a lot of water. Upon interview, the patient is alert and has
organized thought and speech.

ANALYSIS: According to Piaget’s Cognitive theory, the patient belongs to the Formal
Operative stage wherein abstracts and theoretical reasoning are involved. Most adults at this
age group enjoy their good vision and optimal health of senses. These systems development
is completed by the early 20s and normally remain steady through 30s. (Fundamentals of
Nursing 4th Australian Edition, Kozier and Erb p. 1773)
INTERPRETATION: NORMAL

SELF PERCEPTION AND SELF CONCEPT PATTERN

Upon the interview, the client described himself as a friendly, ambitious and family-
oriented person. He stated that he is content with his physical appearance however, he feels
different due to the life changes brought by diabetes. However, he has a positive outlook that
he can manage and adapt to these changes with the help and support of his family and friends.

ANALYSIS: The patient belongs to the stage of intimacy vs. isolation, based on the
psychosocial development of Erik Erickson, wherein intimacy necessitates the freedom to
share aspects of yourself with others, as well as the ability to listen to and encourage others.
When this occurs effectively, you receive another person's support, affection, and
companionship. But things don't always go as planned. You may be rejected or get other
comments that allow you to withdraw. It can weaken your self-esteem and confidence,
leaving you cautious of putting yourself out there again in the future (Erik Erikson's Stages of
Psychosocial Development, 2020). Living with diabetes is likely to have an effect on both of
the patient's and their family's life-course choices. The patient may wonder whether he or she
should continue to engage in daily activities considering the current health condition.
Diabetes management, self-care habits, and metabolic outcomes are improved by high-quality
relationships with and diabetes treatment assistance from relatives. (Young-Hyman, Deborah;
de Groot, Mary; Hill-Briggs, Felicia; Gonzalez, Jeffrey S.; Hood, Korey; Peyrot, Mark
(2016). Psychosocial Care for People With Diabetes: A Position Statement of the American
Diabetes Association. Diabetes Care, 39(12), 2126–2140. doi:10.2337/dc16-2053)
INTERPRETATION: NORMAL

ROLE AND RELATIONSHIP PATTERN

The client stated that he has a good relationship with his family but he is rarely able to
spend some time with them because of his work schedule, fortunately his family fully
understands his work situation. Even though they have minor misunderstandings, they make
sure to resolve immediately. In his work, he claimed to have a lot of new friends that he can
hang out with and they are nice and accommodating to him.

ANALYSIS: The family plays a crucial role in the creation and maintenance of its members'
identity. A certain individual significantly receives acknowledged norms from their family
members and friends for thinking, feeling and acting. Furthermore, positive communication
fosters good self-esteem and well-being within families and friends. (Fundamentals of
Nursing 9th Edition, Potter and Perry, p. 706).
INTERPRETATION: NORMAL

SEXUALITY AND REPRODUCTIVE PATTERN

As reported by the client, he was circumcised at the age of 11, which is done in a
medical mission in their barangay. He stated that he is single for two years and is not sexually
active, but he admits having sexual relationships before. Currently, he does not think of
having a romantic relationship as for the moment due to workloads and family
responsibilities.

ANALYSIS: Despite physical maturation, young people strive to explore and mature
emotionally in relationships. Affection and sexuality are concerns for all young
people, regardless of whether they are in a romantic relationship, choose to abstain
from sex, choose to stay unmarried, are gay, or are widowed. In many ways, people
are sexually healthy. (Fundamentals of Nursing 9th Edition, Potter and Perry, p. 717)
INTERPRETATION: NORMAL
COPING AND STRESS PATTERN
During the interview, the client stated that he feels better unlike his first few days at
the hospital. However, he feels anxious about his job and how his hospitalization and illness
can affect his work performance. In addition, he worries about the hospital bills and
medications expenses that they need to pay afterwards, since their family is on a tight budget
during this pandemic. But he is trying his best to stay calm and clear his mind to avoid
himself from being stressed during hospitalization. According to the client, when he is
stressed, he tends to go out with his friends, staying at home watching movies, or going to the
gym as his way of diverting this attention to other things and coping with stress.

ANALYSIS: One example of positive coping mechanisms is staying calm in spite of pain and
anxiety. The type of stress, people's goals, feelings about themselves and the world, and
personal resources determine how people cope with stress. These resources include problem-
solving ability, financial status, social skills, family and friends' encouragement, physical
attractiveness, health and energy, and personal stress management strategies such as
optimism and awareness. Most individuals use a mix of problem- and emotion-focused
coping mechanisms in stressful situations. In other words, when a person obtains information
under stress, he takes action to alter the situation (problem-focused) and regulates feelings
linked to stress (emotion-focused). In certain situations, people stop thinking about it or
modifying the way they think about the situation without altering the actual situation itself.
(Fundamentals of Nursing 9th Edition, Potter and Perry, p. 773-774).
INTERPRETATION: NORMAL

VALUES AND BELIEF PATTERN

The client was raised in a religious family of Roman catholic and his family used to
go to church every Sunday. However, when he started working, he seldom joined his family
in attending mass due to different working schedules. Even though he can’t go to church, he
makes sure that he prays before going to work and before going to sleep.

ANALYSIS: According to the Fowler’s Stages of Faith, the patient belongs to stage 4 which
is the Individuative-Reflective faith. This stage emphasized a period of imbalance in which
unexamined assumptions and values are challenged and contrasted to new value systems.
Individuality, liberty, and self-actualization are highlighted. Individuals form their own views on
values and beliefs. Religious symbols, rituals, and Bible stories that were formerly recognized
could be deemed naive. At this point, people can fully reject all aspects of traditional religion.
(James Fowler’s Spiritual Development: Stages of Faith, 2013). Spirituality is a broad
concept and it depends on the culture, growth, life experiences, beliefs and life ideas of an
individual. It gives individuals the strength they need to discover themselves, cope with
difficult situations, and maintain health. The energy that is generated by spirituality helps
patients feel well and guides choices they made throughout lives (Fundamentals of Nursing
9th Edition, Potter and Perry, p. 734).
INTERPRETATION: NORMAL

IV. PHYSICAL ASSESSMENT

A. General Survey

AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS

Observe for signs of No distress noted. Facial and body distress DEVIATION FROM
Distress was noted. NORMAL

Healthy appearance. Analysis:

Note obvious signs of How the patient and what it
health illness means for someone to look
sick. It would mostly derive
from how the patient looks
excessively thin or
cachectic, as well as
temporal wasting, presence
of paleness, presence of
diaphoretic, and wincing of
pain or presence of distress.
 The presence of distress is
the evident state in which
the patient elicits physical
action and behavior of
being in pain such as
guarding action, wincing of
pain, and facial distress.

Reference: Weber, J. R., &

Kelley, J. H. (2018). Health
Assessment in Nursing.
Philadelphia, United States
of America: Wolters
Kluwer Health. P. 121

Height- 172 cm; NORMAL

Observe body build, Weight- 68 kgs
height and weight in Analysis: The patient’s
relation to the client's BMI: 22.8 (Normal) body is seen to be
age, lifestyle and proportionate to her height.
health. The height of the patient is
172 cm. The weight of the
patient is 68 kgs. His BMI
Proportion varies with is 22.8 Body Mass Index of
lifestyle. 18.5 - 24.9 is considered
healthy.

Reference: Jensen, S.
(2019). Nursing Health
Assessment: A best practice
approach (3rd ed.).
Philadelphia, USA: Wolters
Kluwer Health.

B. Vital Signs
AREA TO BE NORMAL ACTUAL FINDINGS INTERPRETATION
 ASSESSED FINDINGS
CR (Cardiac Rate) 138 BPM DEVIATION FROM
NORMAL

90 – 100 Beats per

Analysis:
minute
Rates above 100 beats/min
(tachycardia) is typically
abnormal.

Temperature (Axillary) 35.4-37.0 °C N/A N/A

RR (Respiratory Rate) 36 cycles per minute DEVIATION FROM

NORMAL

Analysis:
Tachypnea is a respiratory
24-25 breaths/min
rate greater than 20 breaths
per minute. It can be caused
by various factors,
including fever, fear, or
activity.

BP (Blood Pressure) 90/60mmHg DEVIATION FROM

NORMAL

Analysis:
A decrease in systolic
blood pressure greater than
20 mm Hg and symptoms
85-100 / 60-70 mmHg such as dizziness indicate
orthostatic (postural)
hypotension. Diastolic
pressure may also decrease.
This may be caused by a
fluid volume deficit, drugs
(e.g., antihypertensives), or
prolonged bed rest.

O2 Saturation 95-100% N/A N/A

 Reference:
Wilson, S. F., & Giddens, J. F. (2013). Health Assessment for Nursing Practice (5th ed.). Canada: Elsevier
Mosby.

C. Cephalocaudal Assessment

AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
Head is normocephalic Head is normocephalic NORMAL
Inspect and Palpate the and symmetric. and symmetric.
Head

Face is normally Face is normally NORMAL

proportionate and proportionate and
Inspect and palpate the symmetric. Movements symmetric. Movements
face. are equal bilaterally. are equal bilaterally.
Parotid glands are Parotid glands are
normal size. normal size.
Reference:
Weber, J. R., & Kelley, J. H. (2018). Health Assessment in Nursing (6th Ed.). Philippines Wolters Kluwer
Publications. Pp. 794

SKIN

AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS

NORMAL
Skin color ranges from
The skin color of the
Inspect for color, pale white with pink,
patient is pale white,
uniformity of color in yellow, brown, or olive
and uniform throughout
skin tones to dark brown or
the body..
black.

Inspect for skin turgor. DEVIATION FROM

When pinched, the skin The skin should be NORMAL
springs back to its elastic (i.e., move easily Poor skin turgor is noted if
 “tenting” is observed or the
skin slowly recedes back
previous state. when
into place.
lifted) and return to
Decreased turgor may result
place immediately when
from dehydration or may be
released.
a finding in an individual
who has experienced
significant weight loss.

DEVIATION FROM
Skin thickness varies
NORMAL
based on age and area
of the body. Typically
Analysis:
skin thickens until
An increase in skin thickness
adulthood and There is a presence of
Inspect for skin is seen
decreases in thickness increased thickness in
thickness. in patients with diabetes
after age 20. The skin is the skin of the patient.
mellitus and
thickest over the palms
is thought to be caused by
of hands and soles of
abnormal
feet and thinnest over
collagen resulting from
the eyelids.
hyperglycemia.

NORMAL
The patient have no
Some birthmarks, some
birthmarks and no
Inspect, palpate, and flat and raised nevi; no
lesions
describe lesions. abrasions or other
lesions.

NORMAL

Inspect and palpate for

No presence of edema No presence of edema
presence of edema.
 There is moisture in NORMAL
skin folds
Observe and palpate
Moisture in skin folds
skin moisture

References:
Weber, J. R., & Kelley, J. H. (2018). Health Assessment in Nursing (6th Ed.). Philippines Wolters Kluwer
Publications. Pp. 793

Wilson, S. F., & Giddens, J. F. (2013). Health Assessment for Nursing Practice (5th ed.). Canada: Elsevier
Mosby.

NAILS
AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
Inspect fingernail and NORMAL
Highly vascular, pink Highly vascular, pink
toe nail bed color

Palpate fingernail and NORMAL

Smooth texture Smooth texture
toenail texture
Reference:
Kozier, B. et al. Fundamentals of Nursing (8th Ed.). Pearson Education South Asia Pte Ltd.
Pp. 583-584

EYE STRUCTURES AND VISUAL ACUITY

AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
Inspect the palpebral Shiny, smooth, and Shiny, smooth, and NORMAL
conjunctiva pink or red pink or red
Reference:
Kozier, B. et al. Fundamentals of Nursing (8th Ed.). Pearson Education South Asia Pte Ltd.
Pp. 588
MOUTH AND OROPHARYNX
AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
DEVIATION FROM
NORMAL

Inspect the outer lips

Uniform in color, soft, Lips are pale, dry, and Analysis:
for symmetry of
moist, smooth texture. have little cracks. Pale lips may indicate anemia
contour, color, and
Ability to pursue lips or shock. Dry, flaking, or
texture
cracked lips may be caused by
dehydration or exposure to
dry air or wind.

Gums appeared to be DEVIATION FROM

reddish and dry NORMAL
Teeth are stained.
Gums are pink, moist Analysis:
Inspect the teeth and and firm Darkened or stained teeth may
gums while examining Smooth, white, shiny occur secondary to coffee,
the inner lips and tooth enamel. medications, poor dental care,
buccal mucosa. Pink gums or frequent vomiting.
Moist, firm texture to Redness, edema, and bleeding
gums. of the gums may occurs
secondary to gingivitis,
systemic disease, hormonal
changes, and drug therapy

Reference:
Wilson, S. F., & Giddens, J. F. (2013). Health Assessment for Nursing Practice (5th ed.). Canada: Elsevier
Mosby.

NECK
AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
 No enlargement or No enlargement or NORMAL
Palpate tonsillar nodes. tenderness is present. tenderness is present.

There is no swelling or No presence of swelling DEVIATION FROM

Palpate the lymph
enlargement and no or enlargement and no NORMAL
nodes.
tenderness. tenderness.
Reference:
Weber, J. R., & Kelley, J. H. (2018). Health Assessment in Nursing (6th Ed.). Philippines Wolters Kluwer
Publications. Pp. 295

ANTERIOR THORAX
AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
The patient has deep, DEVIATION FROM
laborious breathing. NORMAL
Use of accessory
muscles (sternomastoid
Analysis:
and rectus abdominis)
In the patient’s case, his
is not seen with normal
breathing is characterized as
respiratory effort. After
laborious. Meaning, he’s using
Observe the use of strenuous exercise or
accessory muscles when
accessory muscles. activity, clients with
breathing. His chest wall also
normal respiratory
rises and expands
status may use neck
asymmetrically and then
muscles for a short
relaxes with effort, which is
time to enhance
interpreted as abnormal
breathing.
findings.

References:
Weber, J. R., & Kelley, J. H. (2018). Health Assessment in Nursing (6th Ed.). Philippines Wolters Kluwer
Publications. Pp. 380

Wilson, S. F., & Giddens, J. F. (2013). Health Assessment for Nursing Practice (5th ed.). Canada: Elsevier
Mosby.

POSTERIOR THORAX
 AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
No adventitious sounds, No adventitious sounds, NORMAL
such as crackles such as crackles
(discrete and (discrete and
Auscultate for
discontinuous sounds) discontinuous sounds)
adventitious sounds
or wheezes (musical or wheezes (musical
and continuous), are and continuous), are
auscultated. auscultated.

Reference: Doenges, Moorhouse, Murr Nursing Care Plan (10th Ed.) Pp. 148

MUSCULOSKELETAL
AREA TO BE NORMAL
ACTUAL FINDINGS INTERPRETATION
ASSESSED FINDINGS
Patient was unable to DEVIATION FROM
perform all ROM tests. NORMAL
Patient reports to have
muscular hypotonia and Analysis:
his deep tendon reflexes Inability to perform full ROM
Performs well and has
Test for range of were very weak. may be due to contractures,
done it without any
motion. pain
difficulties.
associated with trauma or
inflammation, or
neuromuscular
disorders.

Reference:
Jensen, S. (2019). Nursing Health Assessment: A best practice approach (3rd ed.). Philadelphia, USA: Wolters
Kluwer Health.

V. LABORATORY/DIAGNOSTIC EXAMINATIONS

Diagnostic Test for Diabetic Ketoacidosis (DKA)

 Urinalysis
Chemistry Result

Laboratory/ Normal Actual Clinical Interpretation &

Diagnostic Values Results Analysis
Examination

Glucose 70-114 mg/dl 560 mg/dl Clinical Interpretation:

Abnormal

Analysis: Fasting blood

glucose levels greater than 126
mg/dL on two or more
occasions may be considered
diagnostic of diabetes mellitus
if other possible causes of
hyperglycemia are eliminated
as sources of elevation

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 107

Sodium 136-146 154 mM/l Clinical Interpretation:

mM/l Abnormal

Analysis: Increased sodium

can mean: dehydration, severe
vomiting and diarrhea, CHF,
Cushing’s diseases, hepatic
failure, high-sodium diet, and
others. Increased osmolality is
associated with a fluid volume
deficit, dehydration, Clinical
sodium overload, or
hyperglycemia.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
 of Laboratory and Diagnostic
Tests, page 171

Potassium 3.5-5.3 mM/l 6.5 mM/l Clinical Interpretation:

Abnormal

Analysis: Potassium is another

of the important electrolytes in
the body. Our body is quite
sensitive to abnormal levels of
potassium. Cardiac
arrhythmias and neurological
disturbances are seen with high
or low levels of this
electrolyte. Hyperkalemia can
be caused by renal failure and
other causes.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 193

pH 7.35-7.45 7.25 Clinical Interpretation:

Abnormal

Analysis: pH reflects the

number of hydrogen ions in
the body and is influenced
primarily by the ratio of
bicarbonate ions to carbonic
dioxide in the blood. When the
hydrogen ion concentration
increases, the pH falls.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 207
Bicarbonate 20-32 mM/l 10 mM/liter Clinical Interpretation:
Abnormal

Analysis: Bicarbonate is the

major extracellular buffer in
the blood; it functions with
carbonic acid in maintaining
acid-base balance where loss
of bicarbonate produces
acidosis.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 198

Chloride 98-108 mM/l 90 Clinical Interpretation:

Abnormal

Analysis: Chloride is the most

abundant anion in extracellular
fluid. It participates with
sodium in the maintenance of
water balance and aids in the
regulation of osmotic pressure.
In certain form of metabolic
acidosis, serum chloride levels
may fall in response to
decreased serum bicarbonate
levels.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 196

BUN 7-22mg/dl 38 mg/dl Clinical Interpretation:

Abnormal
 Analysis: High value of BUN
can indicate that a person has
kidney injury or a disease.
Kidney damage can cause by
diabetes or high blood pressure
that affects the kidney. This
can also mean low blood flow
in the kidney which is cause by
dehydration or other disease.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 429

Creatinine 0.7-1.5 mg/dl 2.5 mg/dl Clinical Interpretation:

Abnormal

Analysis: Creatinine is the

product of creatine
metabolism. Daily generation
of creatinine remains constant
unless crushing injury or
degenerative diseases occurs.
In the absence of disorder
affecting muscle mass,
elevated creatinine levels
indicate decreased real
function.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 122

HbA1c 4%-6.2% 14% Clinical Interpretation:

Abnormal

Analysis: High levels of

HbA1c means that a person
 has too much sugar in their
blood. This will likely develop
into diabetes complications.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 462

Urine Sample

Laboratory/ Diagnostic Actual Result Clinical Interpretation &

Examination Analysis
Glucose 4+ Clinical Interpretation:
Abnormal

Analysis: The most common

cause of glycosuria is
uncontrolled diabetes
mellitus. In addition to
diabetes mellitus, many other
disorders can result in
glycosuria. In general, these
disorder all into two general
categories: those in which the
blood sugar is elevated and
those in which the blood
sugar is not elevated but in
which renal tubular
absorption of glucose is
impaired.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 226

Acetone Large

Hb1Ac 14% Clinical Interpretation:

Abnormal

Analysis: High levels of

HbA1c means that a person
has too much sugar in their
blood. This will likely
develop into diabetes
complications.

Reference: Bonita Morrow

Cavanaugh’s Nurse’s Manual
of Laboratory and Diagnostic
Tests, page 462
Serum Acetone 4+ Undiluted
VI. DRUG STUDY

Name of Mechanism of Indication Contraindication Side Effect Adverse Effect Nurse’s Responsibility
Drug Drug

Generic Replaces To prevent ● Contraindicated ● Nausea CNS: Paresthesia Teach patient how to
Name: potassium and hypokalemia in patients ● Vomiting of limbs, prepare powders and how
Potassium maintains hypersensitive to ● Diarrhea listlessness, to take drug. Tell patient to
Chloride potassium level Adult: Initially, 16 potassium confusion, take with or after meals
● Gas
in the body. to 24 mEq of chloride or weakness or with full glass of water or
Brand Name: potassium components of ● Stomach pain heaviness of limbs, fruit juice to lessen GI
Sylvite supplement P.O. the formulation, ● Stomach flaccid paralysis distress
Daily, in divided in patients with bloating
Route: doses. Adjust renal failure, and ● Tingly CV: Postinfusion Teach patient signs and
IV dosage, as needed, in those with feeling phlebitis, symptoms of hyperkalemia
based on potassium conditions in ● Irregular arrhythmias, heart and tell patient to notify
Order for the levels. Patient which potassium block, cardiac prescriber if they occur.
heartbeats
PX: should take no more retention is arrest, ECG
15 mEq/hour than 20 or 25 mEq present. ● Chest pain changes, Tell patient to report
at a single dose. hypotension. discomfort at I.V insertion
● Use cautiously Site
Hypokalemia in patients with GI: Nausea,
cardiac disease, vomiting, Warn patient not to use salt
Adult: 40 to 100 renal abdominal pain, substitutes concurrently,
mEq P.O. in two to impairment, and diarrhea. except with prescriber’s
five divided dose acid-base permission
daily. Patient should disorder Metabolic:
take no more than Hyperkalemia Tell patient not to be
20 or 25 mEq at a concerned if wax matrix
single dose. Respiratory: appears in stool because the
Maximum does of Respiratory drug has already been
diluted I.V. paralysis absorbed
potassium chloride
 is 40 mEq/L at 10 Skin: Injection-
mEq/ hour. Do not site reaction
exceed 200 mEq
daily. Further does
are based on
potassium levels
and blood pH. Give
I.V potassium
replacement only
with monitoring of
ECG and potassium
level

Reference:

Potassium Chloride: Wolters Kluwer’s Nursing 2020 Drug Handbook Volume 2, pages 1302 to 1303
 Name of Mechanism of Indication Contraindication Side Effect Adverse Effect Nurse’s Responsibility
Drug Drug

Generic Lowers blood Adjust-a-dose: ● Contraindicated ● Sweating. CV: Peripheral Regular insulins are
Name: glucose level by Individualize during episodes ● Dizziness or edema. generally used in regimens
Insulin stimulating dosage based on of hypoglycemia ● Shakiness. that also include an
peripheral metabolic needs, Metabolic: intermediate – or long-
● Hunger.
Brand Name: glucose uptake blood glucose ● Contraindicated Hypoglycemia, acting insulin.
Humulin R by binding to monitoring, and in patients with ● Fast heart hypokalemia,
Humulin R U- insulin receptors glycemic control. a history of rate weight gain. Monitor blood glucose
500(concentra on skeletal hypersensitivity ● Tingling level and adjust insulin
ted) muscle and in fat Adjust dosage as to drug or its sensations Skin: Injection-site dosage as needed for
KwikPen, cells and by needed in patients components. ● Trouble reactions, patient-specific goals.
Novolin R inhibiting hepatic who are elderly, Severe, life- concentrating lipodystrophy,
glucose have renal or threatening, pruritus Monitor patient carefully
● Blurred
Route: production; also hepatic dysfunction, generalized when initiating therapy.
I.V. inhibits lipolysis or have changes in allergic vision Other: Allergic Time course of insulins
and proteolysis, physical activity or reactions, reactions, varies with each patient.
Order for the and enhances meal patterns, and including anaphylaxis,
PX: protein synthesis. in those who are anaphylaxis, can insulin antibody Monitor patient carefully
100 cc/hr concurrently taking occur with production. for signs and symptoms of
drugs that lower insulin product hypoglycemia, especially
blood glucose in long-standing disease.
● Use cautiously Treat according to
Adults and in patients individual facility policy if
Children: Total susceptible to necessary.
daily insulin hypokalemia,
requirements vary such as patient Mild episode of
and are usually who are fasting, hypoglycemia may be
between 0.5 and 1 are taking treated with oral glucose.
unit/kg/day subcut. potassium- More severe episodes of
In three or more lowering drugs, hypoglycemia, such as
decided doses. Give or are coma, seizure, or
30 minutes before concurrently neurologic impairment,
start of a meal. taking drugs that may be treated with I.M. or
may affect Subcut. Glucagon or
May give I.V. potassium level. concentrated I.V glucose.
under medical Untreated
supervision with hypokalemia can Assess patient and notify
close monitoring of cause respiratory prescriber for signs and
blood glucose and paralysis, symptoms of hypoglycemia
potassium levels to ventricular (sweating, shaking,
avoid hypoglycemia arrhythmias, and trembling, confusion) and
and hypokalemia. death. hyperglycemia
(drowsiness, fruity breath
● Hypoglycemia is odor, frequent urination,
the most thirst.
common adverse
reaction. Severe Monitor Potassium level in
hypoglycemia patients at risk for
can cause hypokalemia, including
seizures and those taking potassium-
may be life- depleting drugs.
threatening or
fatal.
Hypoglycemia
can occur
suddenly, and
symptoms may
differ. Risk in
increases with
intensity of
glycemic control
and changes in
glycemic
treatment, meal
patterns,
 physical activity,
and concomitant
medications and
in patient with
renal or hepatic
impairment.

Reference:

Insulin: Wolters Kluwer’s Nursing 2020 Drug Handbook Volume 1, pages 847 to 851
 Name of Drug Mechanism of Indication Contraindication Side Effect Adverse Effect Nurse’s Responsibility
Drug

Generic Name: Promotes Diabetes Mellitus Diabetic ketoacidosis ● Altered taste EENT: Changes in Check serum glucose
Glyburide release of PO: ADULTS: with or without ● Dizziness accommodation or level
insulin from Initially 2.5–5 mg. coma, type 1 diabetes ● Drowsiness blurred vision.
Brand Name: beta cells of May in- crease by mellitus, concurrent Monitor serum glucose
● Weight gain
Apo-Glyburide pancreas, 2.5 mg/day at use with bosentan. GI: Nausea, level, food intake
DiaBeta increases weekly intervals. ● Constipation epigastric fullness,
Euglucon insulin Maintenance: 1.25– Cautions: ● Diarrhea heartburn. Assess for hypoglycemia
Novo-Glyburide sensitivity at 20 mg/day. Maxi- Adrenal or pituitary ● Heartburn and hyperglycemia
peripheral mum: 20 mg/day. insufficiency, ● Nausea Hematologic:
Route: sites. hypoglycemic ● Vomiting Leukopenia, Be alert to conditions
Oral ELDERLY: reactions, hepatic/ ● Headache hemolytic anemia, that alter glucose
Therapeutic Initially, 1.25–2.5 renal impairment, agranulocytosis, requirements
● Photosensitivity
Order for the Effect: mg/day. May G6PD deficiency. thrombocytopenia,
PX: Lowers serum increase by 1.25– ● Peeling of skin aplastic anemia. Prescribed diet is
5 mg O.D. glucose level. 2.5 mg/day at 1- to ● Pruritus principal part of
3-wk intervals. ● Rash Hepatic: treatment
Cholestatic
jaundice, hepatitis Check with physician
PO (Micronized when glucose demands
Tablets): Metabolic: are altered
ADULTS, Hypoglycemia,
ELDERLY: hyponatremia
Initially 0.75–3
mg/day. May in- Musculoskeletal:
crease by 1.5 Arthralgia, myalgia
mg/day at weekly
intervals. Skin: Rash,
Maintenance: 0.75– pruritus, other
 12 mg/day as a allergic reactions
single dose or in
divided doses. Other:
Dosage in Renal angioedema
Impairment Not
recommended for
pts with creatinine
clearance less than
50 ml/min.

Reference:

Glyburide: Wolters Kluwer’s Nursing 2020 Drug Handbook Volume 1, pages 742 to 744

Glyburide: Saunders’ Nursing Drug Handbook 2014, pages 547 to 548

VII. PATHOPHYSIOLOGY

A. Anatomy and Physiology

β-Cell dysfunction is initially characterized by an impairment in the first phase of

insulin secretion during glucose stimulation and may antedate the onset of glucose
intolerance in type 2 diabetes. Initiation of the insulin response depends upon the
transmembranous transport of glucose and coupling of glucose to the glucose sensor. The
glucose/glucose sensor complex then induces an increase in glucokinase by stabilizing the
protein and impairing its degradation. The induction of glucokinase serves as the first step in
linking intermediary metabolism with the insulin secretory apparatus. Glucose transport inβ
-cells of type 2 diabetes patients appears to be greatly reduced, thus shifting the control point
for insulin secretion from glucokinase to the glucose transport system. This defect is
improved by the sulfonylureas.

As chronic hyperinsulinemia inhibits both insulin secretion and action, and

hyperglycemia can impair both the insulin secretory response to glucose as well as cellular
insulin sensitivity. Moreover, in the majority of type 2 diabetic patients who are insulin
resistant, obesity is almost invariably present. As obesity or an increase in intra abdominal
adipose tissue is associated with insulin resistance in the absence of diabetes, it is believed by
some that insulin resistance in type 2 diabetes is entirely due to the coexistence of increased
adiposity. Additionally, insulin resistance is found in hypertension, hyperlipidemia, and
ischemic heart disease, entities commonly found in association with diabetes.

The ability of insulin to suppress hepatic glucose production both in the fasting state
and postprandially is normal in first degree relatives of type 2 diabetic patients. It is the
increase in the rate of postprandial glucose production that heralds the evolution of IGT.
Eventually, both fasting and postprandial glucose production increase as type 2 diabetes
progresses.
B. Overview of the Disease

The primary events are believed to be an initial deficit in insulin secretion and, in
many patients, relative insulin deficiency in association with peripheral insulin resistance.
Normally, the pancreatic beta cells release insulin due to increased blood glucose
concentrations. The brain in order for normal functions to occur continually requires glucose.
Hypoglycemia, or low plasma glucose levels, is usually caused by drugs used in the treatment
of diabetes, including insulin and oral antihyperglycemic.

Type 2 diabetes mellitus is a heterogeneous disorder with varying prevalence among

different ethnic groups. The pathophysiology of type 2 diabetes mellitus is characterized by
peripheral insulin resistance, impaired regulation of hepatic glucose production, and declining
β-cell function, eventually leading to β -cell failure.

C. Contextual Mapping / Schematic Diagram

VIII. ECOLOGIC MODEL

A. Hypothesis
1. Gender/sex and family history has an effect on Type 2 Diabetes Mellitus.
2. Unhealthy diet, sedentary lifestyle and environmental stress precipitates the
occurrence of Type 2 Diabetes Mellitus.

B. Predisposing and Precipitating Factors

1. Agent
a. Unhealthy diet
b. Sedentary lifestyle

2. Host
a. Sex (Male)
b. Family history or heredity

3. Environment
a. Environmental stress (Workplace)

C. Ecologic Model - The Web

 D. Analysis
Type 2 Diabetes Mellitus was presented on a web model since it has been shown to be
caused by a variety of factors. According to Leontis (2018), there are several causes
for this type of diabetes. The most significant factors, however, are genetics and
lifestyle. A combination of the two mentioned factors can cause insulin resistance,
which is the most prominent cause of type 2 diabetes. Furthermore, the client’s sex,
family history, environmental stress, sedentary lifestyle and unhealthy diet
precipitates the occurrence of the disease.

E. Conclusion and/or Recommendation

Type 2 Diabetes Mellitus is known to be the most prevalent type of diabetes. This
disease mostly affects middle-aged and older adults. However, this disease has no
exception since children and adolescents can also contract this disease as well. There
are several common known interventions for the mentioned disease like blood sugar
monitoring, insulin therapy, doctor prescribed medications, healthy diet and regular
exercise. According to Felson (2019), aside from the common interventions, there are
also alternative interventions such as acupuncture, biofeedback technique, guide
imagery and taking of natural dietary supplements. However, the efficacy of the
mentioned alternative treatments may differ as it may or may not be effective for
others.

REFERENCES
Leontis, L. M., & Hess-Fischl, A. (2018, July 6). Type 2 Diabetes Causes. Retrieved from
https://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-causes#:%7E:text=Type
%202%20diabetes%20has%20several,cause%20of%20type%202%20diabetes.&text=Type%202%20diabetes
%20can%20be%20hereditary.

Type 2 diabetes - Diagnosis and treatment - Mayo Clinic. (2021, January 20). Retrieved from
https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199

National Institute of Diabetes and Digestive and Kidney Diseases. (2021, March 16). Type 2 Diabetes.
Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/type-2-
diabetes

Felson, S. (2019, May 9). Natural Remedies for Type 2 Diabetes. Retrieved from
https://www.webmd.com/diabetes/natural-remedies-type-2-diabetes
 IX. PROBLEM IDENTIFICATION AND PRIORITIZATION

CUES NURSING DIAGNOSIS

Subjective: Fluid volume deficit related to polyuria and

unquenchable thirst secondary to
On the day of admission, the client hyperglycemia and irregular laboratory results.
complains of vague abdominal pain, and
vomited once. Symptoms of diabetes include increased thirst,
needing to urinate more often, increased hunger,
Objective: weight loss, fatigue, dizziness, and nausea. Other
times, diabetes might cause bladder problems
(+) unquenchable thirst
caused by neurogenic bladder or nerve damage
(+) polyuria (neuropathy) which happens if the blood sugar
levels are not treated. Managing fluids must be the
(+) weight loss top priority, both sensible and insensible fluid
losses, for it addresses the patient’s basic
(+) vomiting physiological needs.

(+) appears pale

References:
(+) dehydrated with dry mucous Bladder and Bowel (n.d.). Diabetes and
membranes Incontinence. Retrieved from
https://www.bladderandbowel.org/associated-
(+) poor skin turgor illness/diabetes-incontinence/
(+) generalized tiredness Castera, M. & Borhade, M. (2021). Fluid
Management. Retrieved from
Abdomen:
https://www.ncbi.nlm.nih.gov/books/NBK532305/
(+) ill-defined generalized tenderness

(+) soft to palpate

-no rebound tenderness

Musculoskeletal:

(+) hypotonia

(+) weak deep tendon reflexes

Laboratory Tests:

Glucose: 560 mg/dL

Sodium: 154
Potassium: 6.5

pH: 7.25

Bicarbonate: 10 mm/L

Chloride: 90

BUN: 38 mg/dL

Creatinine: 2.5 mg/dL

Urine Sample:

>4+

> Large acetone

HbA1c: 14%

Serum Acetone: 4+ undiluted; still

positive at the 4th dilution

Impaired gas exchange related to metabolic

Objective: acidosis as manifested by dyspnea and
tachypnea secondary to tachycardia.
(+) severe weakness

(+) dizziness Hyperglycemia refers to elevated blood glucose

level that results in Diabetes Mellitus. Excessive
(+) generalized tiredness
blood sugar lowers the elasticity of the blood
(+) unquenchable thirst vessels and reduces the blood supply. Which will
lead to a decreased flow of blood and oxygen, an
(+) repeated need to urinate increase in the risk of elevated blood pressure and
damage to large and small blood vessels. Thus,
(+) vague abdominal pain affecting the airway and circulation of the body.
(Brunner & Suddarth’s Textbook of Medical-
(+) dehydration Surgical Nursing 13th Edition, p. 1416).

(+) dry mucous membranes

(+) poor skin turgor

(+) pale

Vital Signs:

RR: 36 cycles/min
HR: 138 bpm

BP: 90/60 mmHg

Laboratory Tests:

Glucose: 560 mg/dL

Sodium: 154

Potassium: 6.5

pH: 7.25

Bicarbonate: 10 mm/L

Chloride: 90

BUN: 38 mg/dL

Creatinine: 2.5 mg/dL

Urine Sample:

>4+

> Large acetone

HbA1c: 14%

Serum Acetone: 4+ undiluted; still

positive at the 4th dilution

Electrolyte imbalances related to hyperkalemia,

Objective: hypernatremia, and hypochloremia secondary
to hyperglycemia.
(+) vomiting

(+) frequent urination Diabetes mellitus are frequently linked with

electrolyte disorders which are usually due to
(+) dehydration
decompensated diabetics. Occurrence of
(+) abdominal pain hypernatremia co-exists with hyperglycemia-
related mechanisms which tend to make the serum
Abdomen: sodium shift paths. Hyperkalemia develops due to
hyperglycemia-related disorders such as impaired
(+) ill-defined generalized tenderness renal function, potassium-sparing drugs,
hypertonicity and insulin deficiency.
(+) soft to palpate

Reference:
-no rebound tenderness Liamis, G., et. al. (2016). Diabetes Mellitus and
Electrolyte Disorders. World Journal of Clinical
Musculoskeletal: Cases, 2 (10), 488-496. Doi 10.12998/
wjcc.v2.i10.488
(+) hypotonia

(+) weak deep tendon reflexes

Vital Signs:

RR: 36 cycles/min

HR: 138 bpm

BP: 90/60 mmHg

Laboratory Tests:

Glucose: 560 mg/dL

Sodium: 154

Potassium: 6.5

pH: 7.25

Bicarbonate: 10 mm/L

Chloride: 90

BUN: 38 mg/dL

Creatinine: 2.5 mg/dL

Urine Sample:

-4+

- Large acetone

HbA1c: 14%

Serum Acetone: 4+ undiluted; still

positive at the 4th dilution

Subjective: Syncope and powerlessness related to

hyperglycemia as manifested by irregular blood
The client complains about passing out chemistry and laboratory tests secondary to
during his shift and having repeated hypotonia and weak deep tendon reflexes.
severe weakness, dizziness, and
sleepiness.

Objective: Hyperglycemia refers to elevated blood glucose

level that results in Diabetes Mellitus. Excessive
(+) generalized tiredness blood sugar lowers the elasticity of the blood
vessels and reduces the blood supply. Which will
(+) drowsiness lead to a decreased flow of blood and oxygen, an
increase in the risk of elevated blood pressure and
(+) unquenchable thirst damage to large and small blood vessels. Thus,
affecting the airway and circulation of the body.
(+) repeated need to urinate
(Brunner & Suddarth’s Textbook of Medical-
(+) weight loss (lost 19 lbs.) Surgical Nursing 13th Edition, p. 1416).

Musculoskeletal: Additionally, diabetes mellitus patients tend to

have biochemical imbalances, such as electrolyte
(+) hypotonia imbalances due to hyperglycemia-related
disorders, like impaired renal function, potassium-
(+) week deep tendon reflexes sparing drugs, hypertonicity and insulin
deficiency. These changes affect the person’s
Vital Signs: mood and state.

RR: 36 cycles/min Reference:

Liamis, G., et. al. (2016). Diabetes Mellitus and
HR: 138 bpm Electrolyte Disorders. World Journal of Clinical
Cases, 2 (10), 488-496. Doi 10.12998/
BP: 90/60 mmHg
wjcc.v2.i10.488
Laboratory Tests:

Glucose: 560 mg/dL

Sodium: 154

Potassium: 6.5

pH: 7.25

Bicarbonate: 10 mm/L

Chloride: 90

BUN: 38 mg/dL

Creatinine: 2.5 mg/dL

Urine Sample:

>4+

> Large acetone

HbA1c: 14%

Serum Acetone: 4+ undiluted; still

positive at the 4th dilution

Objective: Imbalanced nutrition: less than body

requirements related to rapid weight loss and
(+) generalized tiredness dehydration as manifested by hyperglycemia.
(+) drowsiness Common symptoms of diabetes mellitus include
increased thirst and urination, fatigue, blurred
(+) unquenchable thirst
vision, unexpected weight loss, increased hunger,
(+) repeated need to urinate slow-healing sores and frequent infections, red,
swollen gums, and tingling or numbness in your
(+) weight loss (lost 19 lbs.) hands or feet. Increased blood glucose forces the
kidneys to work overtime and absorbs the excess
(+) dehydration glucose which makes the patient to urinate more
frequently, and feel extremely thirsty. Due to this
(+) dry mucous membranes increased frequency in urination, the body excretes
glucose and calories along with the urine. The
(+) poor skin turgor diabetes prohibits the needed glucose to reach the
cells which then cause hunger. Combination of
Musculoskeletal: these two have an effect on rapid and unintentional
weight loss.
(+) hypotonia

(+) week deep tendon reflexes

Reference:
Vital Signs: Mayo Clinic (n.d.). Diabetes Symptoms: when
diabetes symptoms are a concern. Retrieved from
RR: 36 cycles/min https://www.mayoclinic.org/diseases-
conditions/diabetes/in-depth/diabetes-
HR: 138 bpm symptoms/art-20044248

BP: 90/60 mmHg

Laboratory Tests:

Glucose: 560 mg/dL

Sodium: 154

Potassium: 6.5

pH: 7.25

Bicarbonate: 10 mm/L
Chloride: 90

BUN: 38 mg/dL

Creatinine: 2.5 mg/dL

Urine Sample:

>4+

> Large acetone

HbA1c: 14%

Serum Acetone: 4+ undiluted; still

positive at the 4th dilution

Subjective: Risk for impaired skin integrity related to

hyperglycemia secondary to syncope, dizziness,
According to the client, he passed out severe weakness and generalized tiredness.
during his shift and repeatedly
complained of severe weakness, Common symptoms of diabetes mellitus include
dizziness, and sleepiness. increased thirst and urination, fatigue, blurred
vision, unexpected weight loss, increased hunger,
Objective: slow-healing sores and frequent infections, red,
swollen gums, and tingling or numbness in your
(+) generalized tiredness
hands or feet. Due to increased blood glucose
(+) drowsiness levels, it causes poor blood flow and reduces
healing time for the diabetic patient. It, also,
(+) dehydration affects the nerve functions leading to symptoms of
tingling sensation, commonly felt at the
(+) poor skin turgor extremities, to losing of sensation, numbness, and
burning pain.
(+) weight loss (lost 19 lbs.)

Musculoskeletal: Reference:
Mayo Clinic (n.d.). Diabetes Symptoms: when
(+) hypotonia diabetes symptoms are a concern. Retrieved from
https://www.mayoclinic.org/diseases-
(+) week deep tendon reflexes conditions/diabetes/in-depth/diabetes-
symptoms/art-20044248
Vital Signs:

RR: 36 cycles/min

HR: 138 bpm

BP: 90/60 mmHg

 Laboratory Tests:

Glucose: 560 mg/dL

Sodium: 154

Potassium: 6.5

pH: 7.25

Bicarbonate: 10 mm/L

Chloride: 90

BUN: 38 mg/dL

Creatinine: 2.5 mg/dL

Urine Sample:

>4+

> Large acetone

HbA1c: 14%

Serum Acetone: 4+ undiluted; still

positive at the 4th dilution

X. NURSING CARE PLAN

NAME: . SECTION BSN 305- DATE: CONFORM:

AND SUBGROUP 1A
GROUP:

NURSING CARE PLAN

CUES NURSING ANALYSIS GOALS INTERVENTION RATIONALE EVALUATION

DIAGNOSIS AND
OBJECTIVES
XI. DISCHARGE PLAN

MEDICATION ● Advise to continue the prescribed home

medications to ensure optimum
recovery.

EXERCISE ● Encourage patient to go walking

● Meet the recommended minimum target
by going for a 30-minute walk five days
a week.

TREATMENT ● Instruct to monitor blood glucose levels

● Make a dietary management
 ● Maintain physical activity
● Keeping weight and stress under control
● Monitoring oral medications and, if
required, insulin use via injections or
pump.

HEALTH TEACHING ● Assess the client’s level of

understanding related to the diagnosis
of diabetes, self monitoring of blood
glucose (SMBG), and home blood
glucose goals.
● Instruct the patient on specific measures
for managing diabetes on sick days.
● Educate the patient on proper use and
disposal of needles and syringes.

OUTPATIENT ● Referral to an outpatient diabetes center

for follow-up check ups.

DIET ● Instruct client to eat fruit, vegetables,

whole grains, beans, nuts and lean
protein.
● Watch calories.
● Eat foods high in fiber, low in fat, and
with a low glycemic index.
● Advise to not skip meals; eat meals and
snacks at the same time each day.

XII. HEALTH TEACHING PLAN

TEACHING PLAN-FLUID VOLUME DEFICIT

The learner will be able to understand fluid volume deficit, what are the risk factors of it, and also the
learner will be able to know how to prevent fluid volume deficit.

LEARNING CONTENT METHODS OF TIME RESOURCES METHODS

OBJECTIVE OUTLINE TEACHING ALLOTTED OF
EVALUATIO
N

Following a
25 minute
teaching
lesson, the
learner will
be able to:
Define what Fluid volume deficit ● Lecture 4 mins ● Laptop Question and
is fluid describes the loss of ● PowerPoint ● Pamphlet Answer
volume extracellular fluid Presentation ● Supplement
deficit from the body. al Videos
Extracellular fluid is
the body fluid not
contained within
individual cells. It
constitutes about
20% of our body
weight and includes
blood plasma,
lymph, spinal cord
fluid, and the fluid
between cells.
Importantly, this
fluid isn’t just water
—it also contains
electrolytes and
other essential
solutes.

VIDEO LINK:
https://www.youtub
e.com/watch?
v=sO_bxHeGngc

Discuss the ● Blood loss from ● Lecture 5 minutes ● Laptop Question and
causes of cuts/wounds ● PowerPoint ● Pamphlet Answer
fluid volume ● Vomiting and Presentation
deficit diarrhea
● Abnormally
excessive
urination
(polyuria); can
be caused by
excessive intake
of diuretic
substances or
medications or
from renal
disorder.
● Excessive
sweating;
typically
sweating is more
likely to cause
dehydration than
 fluid volume
deficit because
the body
generally expels
far more water
than electrolytes,
but sweating can
also cause
deficient fluid
volume in some
cases.
● Bleeding
disorders
● Burns (because
the skin no
longer protects
against
excessive fluid
loss)

Enumerate Here are the signs ● Lecture 3 minutes ● Laptop Question and
the signs and and symptoms of ● PowerPoint ● Pamphlet Answer
symptoms of fluid volume deficit Presentation
fluid volume classified into three:
deficit
Mild Fluid Loss
-Orthostatic
hypotension,
Increased heart rate
-Restlessness
-Anxiety
-Weight loss

Moderate Fluid
Loss
-Confusion
-Dizziness
-Irritability
-Extreme thirst
-Nausea -Cool,
clammy skin
-Rapid Pulse
-Decreased urine
output (10-30 ml/hr)

Severe Fluid Loss

-Decreased cardiac
output
-Unconsciousness
 -Hypotension
-Weak or absent
peripheral pulses

Discuss the While fluid volume ● Lecture 3 minutes ● Laptop Question and
types of Fluid deficit refers to the ● PowerPoint ● Pamphlet Answer
Volume loss of both water Presentation
Deficit and solutes from the
body, there are three
major types of fluid
volume deficit:

● Isotonic: Caused
by losing fluids
and solutes
about equally;
solute
concentration in
the remaining
extracellular
fluid then
remains
relatively
unchanged

● Hypertonic:
Caused by
losing more
fluids than
solutes, leading
to increased
solute
concentration in
the remaining
fluid.

● Hypotonic:
Caused by
losing more
solutes than
fluid leading to
decreased solute
concentration in
remaining fluid.
This is the rarest
type.

Identify the ● Instruct the ● Lecture 5 minutes ● Laptop Question and

therapeutic patient to ● PowerPoint ● Pamphlet Answer
treatments to monitor weight Presentation
prevent fluid daily and
volume consistently, with
deficit the same scale,
and preferably at
the same time of
day. To facilitate
accurate
measurement and
follow trends.
Weight helps to
assess fluid
balances.
● Encourage the
patient to drink
prescribed fluid
amounts. To
replenish the
fluids lost from
polyuria and to
promote better
blood circulation
in the body.
● Instruct the
patient to
maintain proper
oral hygiene and
explain its
importance.
Promoting oral
hygiene gives
relief to the
dehydration
symptoms of
dried mucous
membranes that
keep the patient
feel thirsty all the
time.
● Instruct the client
to check blood
sugar levels
regularly.
Uncontrolled
levels of blood
glucose may lead
to serious
complications
such as
neuropathy or
 retinopathy.
● Instruct the
patient to take
prescribed
medication.
● Instruct the
patient to follow
the meal plan for
diabetic patients.
A meal plan for
diabetes focuses
on the
percentages of
calories that
come from
carbohydrates,
proteins, and fats.
Carbohydrates
consist of sugars
(e.g., sucrose)
and starches (e.g.,
rice, pasta, and
bread). Although
it is typically
high in fat and
lacks fiber,
vitamins and
minerals, it is not
totally eliminated
in the diet, but
should be eaten
in moderation (up
to 10% of total
calories) to avoid
high postprandial
blood glucose
levels. Fats. The
recommended
total intake in a
diabetic diet is
less than
300mg/day. This
approach may
help reduce risk
factors such as
increased serum
cholesterol levels,
which are
associated with
 the development
of coronary heart
disease- the
leading cause of
death among
people with
diabetes. Protein.
The meal plan
may include the
use of some non-
animal source of
protein (e.g.,
legumes, whole
grains) to help
reduce saturated
fat and
cholesterol
intake. Fiber.
Increased fiber in
the diet may
improve blood
glucose levels,
decrease the need
for exogenous
insulin, and lower
total cholesterol
and low-density
lipoprotein levels
in the blood.
Soluble fiber
such as legumes,
oats, and some
fruits play more
of a role in
lowering blood
glucose and lipid
levels. On the
other hand,
insoluble fiber is
found in whole-
grain breads,
cereals, and in
some vegetables.
● Educate patient
about possible
cause and effect
of fluid losses or
decreased fluid
intake.
 REFERENCES:
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of
Medical-Surgical Nursing (14th ed., Vol. 2). Market Street, Philadelphia, USA: Wolters
Kluwer.

McCammon, E. (2019, April 05). How to diagnose fluid volume deficit: Signs and care plan.
Retrieved March 16, 2021, from https://www.loyalmd.com/fluid-volume-deficit-signs-care-
plan/

XIII. EVIDENCE BASED NURSING