A Nursing Case Study on

TYPE 2 DIABETES MELLITUS

In Partial Fulfillment of the

Requirements in NCM 218 – RLE

EMERGENCY NURSING ROTATION

Submitted to:
Marc Jade Adlawan, RN
Clinical Instructor

Submitted by:
Ma. Danica Grace A. Guba, St. N
Marielle Lorraine M. Gultiano, St.N
Maria Fernanda Inayangan, St.N
Abegail P. Lonquianas, St.N
Alyssa B. Lopez, St.N
Monica Vivien Ramillano, St. N
BSN 4D – Group 5 Subgroup 2

October 23, 2022

 TABLE OF CONTENTS

I. Introduction and Objectives..................................................................................... 1

II. Data Base ................................................................................................................ 4
a. Biographical Data .................................................................................. 4
b. Clinical Data ......................................................................................... 4
c. Family Health History ........................................................................... 5
d. Past Health History ............................................................................... 5
e. History of Present Illness ..................................................................... 6
f. Developmental Task ............................................................................. 6
III. Physical and Neurological Assessment ............................................................... 12
IV. Definition of Diagnosis .......................................................................................... 17
V. Anatomy and Physiology ...................................................................................... 18
VI. Pathophysiology .................................................................................................... 19
a. Etiology ............................................................................................... 19
b. Symptomatology ................................................................................ 29
c. Disease Process ................................................................................ 41
VII. Medical Management ............................................................................................ 49
a. Laboratory Tests ................................................................................ 50
b. Diagnostic Examinations ................................................................... 56
c. Therapeutics ...................................................................................... 62
d. Pharmacological Management .......................................................... 72
e. Surgical Management ...................................................................... 121
VIII. Nursing Management .......................................................................................... 130
a. Nursing Care Plans ........................................................................... 130
b. Nursing Theories .............................................................................. 180
c. Review of Related Literature ........................................................... 183
d. Discharge Planning .......................................................................... 186
IX. Prognosis ............................................................................................................. 193
X. References .......................................................................................................... 195
 I. INTRODUCTION AND OBJECTIVES
Emergency nursing involves the episodic care of people with physical
and/or psychological health problems. Emergency nurses encounter many
conditions with varying degrees of severity—ailments range anywhere from a
sore throat, Superficial injuries, to a heart attack. These health issues can be
brought on by disease or injury, are typically acute, and call for immediate
treatment. All ages of patients are cared for by emergency nurses, who also deal
with illnesses that could impact any organ system in the body. Emergency
nursing care is given in the same patient-centered manner as all nursing care,
with an emphasis on the particular patient and their particular needs, wants, and
preferences (Brooks, 2018).
According to Sapra and Bhandari (2022), Diabetes Mellitus (DM) is a
metabolic disease, characterized by inappropriately elevated blood glucose
levels. There are two main subtypes of diabetes mellitus which are the Type 1
and Type 2 Diabetes Mellitus. In type 1 diabetes, the body completely stops
making insulin or there is insufficient production of the hormone insulin.
Therefore, people with type 1 diabetes must take daily insulin injections to
survive. On the other hand, in type 2 diabetes the body produces insulin, but the
cells don’t respond to insulin the way they should; this is called insulin resistance.
In response to this insulin resistance, the pancreas should therefore make more
insulin, but in the case of type 2 diabetes, this does not happen. Because of
these two problems, there is not enough of an insulin effect to move the glucose
from the blood into the cells. Type 2 diabetes is more likely to occur in people
who are over the age of 40, overweight, and have a family history of diabetes
(Westman, 2021). Symptoms for type 2 DM may be similar to those of type 1 but
are often less marked with the classic symptoms of polyuria, polydipsia,
polyphagia and weight loss. As a result, the disease may be diagnosed several
years after onset or after complications have already arisen (Galicia-Garcia et
al.,fs2020).
DM is still regarded as a major global burden that negatively affects
human health and has significant financial consequences. The prevalence of

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T2DM has drastically increased during the past three decades in countries of all
income levels. With 60% of all cases of diabetes mellitus worldwide, Asia, the
largest and most populous continent in the world, is thought to be the epicenter
of the diabetes epidemic. As stated by the International Diabetes Federation, the
Philippines has 3.2 million cases of type 2 diabetes, with a prevalence rate of
5.9% among people aged 20 to 79, while around 1.7 million people with type 2
diabetes remained untreated. Locally, Davao City has around 18,000 residents
affected by diabetes in the year 2015 according to an article by Tacio (2017).
Moreover, based on the data presented by health Davao City.gov.ph, Diabetes
Mellitus is ranked fifth over fifteen causes of mortality.
This case study will provide an overall knowledge of Type 2 Diabetes
Mellitus, which is highly relevant to nursing education, nursing practice, and
nursing research. For nursing education, this case study aims to increase the
student nurse's awareness and understanding of diabetes mellitus type 2 on its
pathophysiology, diagnosis, and management. The information in this study can
further enhance the student's knowledge and skills in managing diabetic patients.
As for the nursing practice, this study can function as a roadmap for clinical
practitioners and student nurses, in terms of delivering effective nursing
interventions in order to achieve optimal health care delivery. Lastly, for nursing
research, this study can be used to perform further research to generate new
theories and conjectures regarding DM type II. Furthermore, the treatment
options currently available or mentioned would give us an idea on what to
possibly improve for future cases.

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General Objective
At the end of the 4 week Emergency Nursing Rotation, the student nurses
of BSN 4D Subgroup 2 will be able to formulate a comprehensive case study
regarding Diabetes Mellitus Type II. This will help contribute to the enhancement
of knowledge, skills and attitudes of the student nurses in terms of rendering care
for patients with Pleuropulmonary Blastoma in the clinical setting.

Specific Objectives
In order to achieve the general objective, the student nurse specifically aims to
a. present introduction that includes the concept of the disease, statistics of
the disease, and the nursing implications;
b. formulate objectives that follow specific, measurable, attainable, realistic
and time-bounded standards;
c. state the patient’s database, physical and neurological assessment;
d. discuss definition of diagnosis;
e. review the anatomy and physiology of the lungs;
f. identify the predisposing and precipitating factors that contribute to the
onset of the disease;
g. explain symptomatology, or what cues signify the presence of the said
disease;
h. trace the disease process of Diabetes Mellitus Type II through a schematic
diagram;
i. determine actual and potential diagnostic and laboratory tests for the said
disease;
j. enumerate appropriate therapeutic, surgical, and nursing management of
the disease;
k. present prognosis or the predicted outcome of the disease; and
l. cite books, journals, internet websites, and other references
not later than 5 years from publication that were used as sources of
information for this case study.

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II. DATA BASE
a. Biographical Data
Name: R. H.
Age: 62 years old
Sex: Male
Date of Birth: March 11, 1960
Address: 54-A Leon Garcia St. Davao City
Place of Birth: Davao City
Nationality: Filipino
Religion: Catholic
Occupation: Retired Highschool Teacher; Businessman
Educational Level: College graduate; Bachelor of Secondary
Education (BSED)
Marital status: Married
Number of Dependents: 5 children
Social Economic Status: Middle class

b. Clinical Data
Chief Complaint: Non-healing wound right foot
Date and Time of Admission: October 10, 2022; 7:20PM
Ward and Room Number: St. Luke room 443-2
Attending Physician: Dr. Arao
How admitted: Wheelchair
Admitting diagnosis: Non-healing wound right foot 2° to DM 2
uncontrolled

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 c. Family Health History

Patient R.H.'s grandfather on the paternal side had Diabetic Mellitus and is
deceased while her grandmother died from a Heart Disease. On the other hand,
the patient’s grandfather on the maternal side has Arthritis while his grandmother
has a lung problem and both are deceased. The patient’s father also has
Diabetes Mellitus while his mother has Arthritis. It is also seen from the
genogram above that the patient’s aunties and uncles on both sides of the family
have numerous illnesses which includes Diabetes Mellitus, Hypertension, Heart
Disease, Arthritis, Cancer, and PCOS. As seen in the genogram, Diabetes
Mellitus genetically runs in the family. Moreover, one of the patient’s sons has
borderline diabetic or prediabetes according to the patient.

d. Past Health History

The patient was born on March 11, 1960 via NSVD in the hospital. The
patient received polio, BCG, Hep-B, DPT, and measles immunizations; however,
he does not recall when exactly he had these immunizations done. While
growing up, the patient had no significant childhood illnesses other than common

5
coughs and colds. The patient’s medical history includes Diabetes Mellitus and
Septic Arthritis. In the year 2021, he was admitted in the hospital with a diagnosis
of sepsis due to septic arthritis and soft tissue abscess left leg; for his treatment
he was given Clindamycin for 9 weeks. In the same year, he was diagnosed with
DM type II. The patient has no known drug or food allergies. He is a previous
smoker and drinker. As stated by the patient he usually consumes 8 packs of
cigarettes a year and he occasionally drinks alcohol. The patient has a negative
travel history and has no contact with COVID-19- positive individuals. He is fully
vaccinated with the Sinovac vaccine with no additional boosters.

e. History of Present Illness

2 weeks prior to admission, the patient sustained a wound on his right big
toe after cleaning their house. The patient experienced no fever. Interim, the
patient noted yellowish pus on the wound. The patient cleaned the wound with
alcohol but no improvement was noted. Thus, he sought consultation with an
attending physician and was given clindamycin for 2 weeks. On the day of
admission, the patient consulted with surgery AP, the wound was cleaned and
the patient was then advised for admission. The patient has negative chest pain,
difficulty of breathing, cough, and colds.

f. Developmental Task
Developmental task is one that arises predictably and consistently at or
about a certain period in the life of the individual. The concept of developmental
tasks assumes that human development in modern societies is characterized by
a long series of tasks that individuals have to learn throughout their lives. In this
case study, Erik Erikson’s theory of Psychosocial Developmental Task and
Robert Havighurst Developmental Task Theory were utilized.

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 DEVELOPMENTAL TASK ERIK ERIKSON

Stage Crisis Met or Justification

Unmet

Middle Generativity vs. Met According to Erik Erikson,

Adulthood Stagnation
people reach this stage
(40-65 yrs old)
when they establish their
professional identities, start
a relationship, start families,
and feel a sense of
community (Lewis, 2022). In
our adult years, we continue
to create our lives, giving our
families and careers top
priority. Successful people in
this stage are pleased with
themselves because they
are improving their lives at
home and in their
community. However, if
these areas don't get good
feedback, individuals might
remain stagnant. They could
feel disengaged as a result
of their frustration at being
unable to support their
families, perform effectively
at work, or give back to the
community (Legg, 2020).

According to the patient’s

7
responses during our brief
conversation, he found
happiness and contentment
in both his personal and
professional life. The client
claims that before he retired
from his teaching profession,
he's satisfied with his job as
teaching students brings joy
to him. He and his son are
currently co-managing their
new business, and he
expressed satisfaction with
his new job. He was a
devoted father and a loving
husband, according to his
son. He raised his children
well by instilling in them the
values of responsibility and
self-care from an early age.
He added that he is the
family's head and supports
them by providing for their
daily needs. He puts a lot of
effort and efficiency into his
work in order to provide for
his family. In addition to his
job and family obligations,
he occasionally lends a hand
in their barangay, as when

8
 he volunteered to distribute
relief goods during the
government's relief operation
at the beginning of the
pandemic.

DEVELOPMENTAL TASK ROBERT HAVIGHURST

STAGE:Middle Age (36-60 years old)

TASK ACHIEVED OR NOT JUSTIFICATION

ACHIEVED

Achieving adult civic and Achieved The patient participated

social responsibilities in the government’s
relief operation during
the beginning of the
pandemic. Moreover, as
stated by the patient, he
joins seminars and
outreach programs
conducted by the school
where he was previously
working. Aside from this,
he paid taxes during his
teaching career and for
his new business and
was able to participate in
the voting for the 2022
Philippine general
election, which took
place on May 9, 2022.

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 Establishing and Achieved The patient, who was
maintaining a standard formerly employed as a
of living high school teacher, is
currently working with
his son to manage the
family business. The
client's financial
condition is stable, and
they have maintained a
good living situation at
home. He makes sure
he can meet his family's
daily needs in his role as
a father.

Assisting teenage Achieved The patient let his oldest

children to become son manage their
responsible and happy business while he was
adults working as a teacher in
order to teach his son to
be responsible and in
order for him to provide
a living for his own
family.

Developing adult leisure- Achieved According to the patient,

time activities ever since he stopped
working as a teacher, he
tries to spend time with
his family over the
weekend such as they

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 would plan to go to the
beach or watch movies
together with his wife.

Relating oneself to one’s Achieved As stated by the patient,

spouse as a person he has a close
relationship with his
family. The patient's son
expressed that his father
and his mother, who is
currently a housewife,
have a good
relationship. The son
mentioned that he never
witnessed his father
yelling or shouting at
their mother and that
they always worked
things out through
communication.

Accepting and adjusting Achieved The patient accepts and

to physiological changes adjusts to his changes,
or middle age especially since he was
diagnosed with DM type
II. As verbalized by the
patient, “Karon na idaran
nako, mas masakiton na
jud ko. Dili diay lalim noh
kay daghan na jud
ginabati ingani na idara”.

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 Moreover, he mentioned
that he was quickly
getting tired as he aged.
The patient also
accepted the fact that
since he has DM type II,
he needs to make
healthy food choices,
stay at a healthy weight,
move more every day as
much as possible, and
take medicine even
when he feels good.

III. PHYSICAL ASSESSMENT

A. GENERAL SURVEY

A 62-year-old male patient was presented to San Pedro Hospital last October 10,
2022; 7:20 PM, with the complaints of non healing wounds on the right leg. His
height is 5’9 and weighs 72kgs with a normal BMI of 23.4.According to him, he
lost 2 kilograms in just one year. He had previous admission last 2021 due to
sepsis and soft tissue abscess on the left leg .There is also a family history of
Diabetes. Upon assessment, the client was awake, coherent, and not in
respiratory distress. The vital signs of the client are as follows:

Vital Signs Normal Range Result

Temperature 36.5 – 37.4 degrees 36.5

Celsius

Heart rate 60 – 100 bpm 84

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 Pulse Rate 60 – 100 bpm 82

Respiratory rate 16 – 20 cpm 19

Blood pressure 120/80 – 130/80 mmHg 110/80

B. Skin
The client's general body color is brown with a dry texture and poor skin
turgor. A blanch test was done with a capillary refill time of >2 seconds. There are
also brown pigments noted in upper and lower extremities. The nails are trimmed
but not clean. There are no other unusualities noted upon assessment.

C. Head and Face

The client's head is normocephalic. There were no lesions, depressions,
bumps, or parasites noted upon assessment. The scalp is clean, and there was
no scaling noted. Hair is dry, thick, messy, and black in color. Facial movements
such as the raising of the eyebrows are symmetrical upon assessment.

D. Eyes
The client's eyes are brown. His pupils are equal, black, round, reactive to
light, and accommodate to distance. The client’s eyebrows are symmetrically
aligned and showed equal movement when asked to raise and lower eyebrows.
Eyelashes appeared to be equally distributed and curled slightly outward. There
were no presence of discharges, no discoloration and lids close symmetrically
with involuntary blinks approximately 15-20 times per minute. The Bulbar
conjunctiva appeared transparent with few capillaries evident. Cornea is
transparent, smooth and shiny and the details of the iris are visible.

E. Ears
The earlobes are bean-shaped, parallel, and symmetrical.The upper
connection of the ear lobe is parallel with the outer canthus of the eye.Skin is the
same in color as in the complexion.No lesions noted on inspection.The auricles

13
have firm cartilage on palpation.The pinna recoils when folded. The ear canal
has cerumen upon inspection. No discharges or lesions noted at the ear canal
upon inspection. During the assessment of the Whisper test, the client was able
to hear the word correctly.

F. Nose
The client's nose is symmetrical, there is no nasal flaring as observed.
Septum is intact and in the midline.Nasal mucosa is moist and pink; both nostrils
are patent. There were no further unusualities found upon assessment.

G. Mouth
The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. The client was able to purse his lips when asked to whistle. The
buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening
and with elastic texture. The tongue of the client is centrally positioned. It is pink
in color, moist and slightly rough. There is a presence of thin whitish coating.
Upon inspection there is a presence of caries and discolorations noted. Gag
reflex was also present

H. Neck
There is no difficulty in head movement and difficulty in head control
noted. No masses and lumps were noted. The trachea is midline with
non–palpable lymph nodes.

I. Thorax
There were no unusualities of the thorax noted. Breathing pattern is
normal with clear breath sounds and has a symmetric chest movement where
chest and abdominal movements are synchronized during respiration.

14
J. Heart
The external chest is normal in appearance without lifts, heaves, or thrills.
PMI is not visible and is palpated in the 5th intercostal space at the midclavicular
line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are
auscultated. S1 and S2 are heard and are of normal intensity. Cardiac rate
ranges from 60 – 100 bpm.

K. Abdomen
Abdomen is soft, symmetric, and non-tender without distention. There are
no visible lesions or scars. The aorta is midline without bruit or visible pulsation.
Umbilicus is midline without herniation. Bowel sounds are present and
normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly
are noted.

L. Lower Extremities
Upon assessment, there is a Black ulcerations noted on the Right Big toe,
2nd toe with irregular borders and yellow-greenish pus on Plantar surface

NEUROLOGICAL ASSESSMENT
GLASGOW COMA SCALE

Behavior Response Score

4. Spontaneously 4
Eye opening 3. To speech
response 2. To pain
1. No response

Verbal response 5. Oriented to time, person and place 5

4. Confused
3. Inappropriate sounds
2. Incomprehensible
1. No response

Motor Response 6. Obeys command 6

5.Moves to localized pain
4. Flex to withdraw from pain
3. Abnormal flexion

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 2. Abnormal Extension
1. No response

Total 15/15

CRANIAL NERVES

I: Olfactory Client was able to describe the odor of the materials

used.

II: Optic Client was able to read with each eye and both eyes.

III: Oculomotor PERRLA (pupils equally round and reactive to light and
accommodation)

IV: Trochlear Both eyes are able to move as necessary.

V: Trigeminal Client was able to elicit corneal reflex, sensitive to pain

stimuli and distinguish hot from cold.

VI: Abducens Both eyes move in coordination.

VII: Facial Client performed various facial expressions without any

difficulty and able to distinguish varied tastes.

VIII: Client was able to hear tickling in both ears.

Vestibulocochlear

IX: Client was able to elicit gag reflex and able to swallow
Glossopharyngeal without difficulty.

X: Vagus Client was able to swallow without difficulty and speak

audibly.

XI: Accessory Client was able to shrug his shoulders and turn his
head from one side to the other.

XII: Hypoglossal The client was able to move tongue in different

directions.

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IV. DEFINITION OF DIAGNOSIS

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by

persistent hyperglycemia. Three major metabolic defects contribute to
hyperglycemia, leading to Type 2 diabetes which includes: increased hepatic
glucose production, impaired pancreatic insulin secretion, and peripheral tissue
insulin resistance (Fried & Carlton, 2019). Type 2 diabetes mellitus (T2DM),
accounts for around 90% of all cases. In T2DM, the response to insulin is
diminished, and this is defined as insulin resistance. During this state, insulin is
ineffective and is initially countered by an increase in insulin production to
maintain glucose homeostasis, but over time, insulin production decreases,
resulting in T2DM. T2DM is most commonly seen in persons older than 45 years.
Still, it is increasingly seen in children, adolescents, and younger adults due to
rising levels of obesity, physical inactivity, and energy-dense diets (Papadakis et
al., 2022). According to the National Institute of Diabetes and Digestive and
Kidney Diseases (2018), symptoms of type 2 diabetes often develop over the
course of several years and can be so mild that one might not even notice them.
Many people have no symptoms. Some people do not find out they have the
disease until they have diabetes-related health problems, such as blurred vision
or heart disease. Some of the symptoms of T2DM include increased thirst and
urination, increased hunger, feeling tired, blurred vision, numbness or tingling in
the feet or hands, sores that do not heal, and unexplained weight loss. It is a
lifelong condition that can affect a person’s everyday life. According to Walker
(2020), for many people with T2DM, reversal, also called remission or
suppression, of their diabetes is possible. One may need to change their diet,
take medicines, and have regular check-ups in order to manage this condition
(NHS, 2020).

17
 V. ANATOMY AND PHYSIOLOGY
Understanding Diabetes Mellitus requires a thorough and comprehensive
understanding of the physical parts involved. This condition develops when the
demand for and production of the insulin hormone are out of balance. The
pancreas is one of the organs that plays a significant role in Diabetes Mellitus.
According to Saladin (2018), the pancreas is a
long, slender organ with a pistol-like shape that
is between 6 and 10 inches in length. It is
mostly found behind the stomach's lower half.
The pancreas contains endocrine cells, despite
being largely an exocrine organ that secretes a
range of digesting enzymes. The hormones
glucagon, insulin, somatostatin, and pancreatic
polypeptide are secreted by the pancreatic
islets, which are clumps of cells that were once referred to as the islets of
Langerhans. The pancreatic islets each
include four different types of cells: (1)
The alpha cell, which constitutes around
20% of each islet and is responsible for
glucagon production. Low blood sugar
levels cause glucagon to release. (2) The
beta-cell, which makes up around 75% of
each islet and produces the hormone
insulin. Increased blood glucose levels cause insulin to be released. (3) The
peptide hormone somatostatin is secreted by the delta cell, which makes up 4%
of the islet cells. Moreover, the hypothalamus stomach and intestines also
release somatostatin. An inhibiting hormone, pancreatic somatostatin inhibits the
release of both glucagon and insulin. Lastly, (4) the pancreatic polypeptide cell,
which accounts for about 1% of islet cells and secretes the pancreatic
polypeptide hormone. It is thought to play a role in appetite, as well as in the
regulation of pancreatic exocrine and endocrine secretions. Pancreatic

18
polypeptide released following a meal may reduce further food consumption;
however, it is also released in response to fasting.
A small amount of insulin is continually
released into the bloodstream under normal
circumstances, and this release increases
when food is consumed. As seen in the
illustration, insulin facilitates the transfer of
glucose from the bloodstream across the cell
membrane to the cytoplasm of the cell.
Glucose is broken down by cells to provide
energy. Skeletal muscle and adipose tissue
are categorized as insulin-dependent tissues
because they have particular insulin receptors. These receptor sites must be
"unlocked" by insulin in order for glucose to be transported into the cells and
utilized as energy. Although other tissues (such as the brain, liver, and blood
cells) do not directly depend on insulin for glucose transport, they nevertheless
need a sufficient amount of glucose to operate normally.
Insulin resistance and inadequate insulin production are both present in
type 2 diabetes. In most cases, the pancreas produces some endogenous
(self-made) insulin. But the body either doesn't produce enough insulin, doesn't
utilize it well, or does both (Harding et al., 2019).

VI. PATHOPHYSIOLOGY
A. Etiology
I. Predisposing Factors
PREDISPOSING PRESENT RATIONALE

Age ✓ As people become older,

type 2 diabetes and
prediabetes are more
common. The following
reason for this is

19
 because of two most
significant causes of
hyperglycemia:
age-related declines in
insulin production and
increasing insulin
resistance brought on by
alterations in body
composition and
sarcopenia
(Menopauzalny, 2018).

Ethnicity X Type 2 diabetes is more

likely to develop in those
with Black African,
African Caribbean, and
South Asian (Indian,
Pakistani, Bangladeshi)
ancestry from a younger
age. This is because
white people often have
more potassium in their
bodies than
African-Americans do. A
lower intake of
potassium is associated
with an increased risk of
type 2 diabetes. At the
same time,
African-Americans may
generally be better at

20
 producing insulation than
White people (Khatri,
2021).

Family History ✓ Compared to type 1,

type 2 diabetes has a
stronger connection to
family history and
genealogy. The proteins
necessary for insulin
synthesis or the body's
ability to utilise insulin
are affected by the
genetic abnormalities
that cause diabetes.
Mutations cause the
proteins to function
improperly. In addition,
parents may pass on
bad health practices to
their children in addition
to a genetic
predisposition to
diabetes because
diabetes is frequently
tied to lifestyle decisions
(Tettey, 2020).

Sex ✓ Interestingly, a
meta-analysis showed
how sex hormones affect

21
 both men and women
and found that people
with sex hormone
imbalance had a higher
chance of developing
type 2 diabetes. T2DM
risk was higher in males
with low testosterone
levels, whereas
relationships between
high testosterone levels
and diabetes risk were
identified in women
(Harreiter and Willer,
2018).

II. Precipitating Factors

PRECIPITATING PRESENT RATIONALE

Obesity X Obesity is a significant

risk factor for type 2
diabetes and
prediabetes because it
results in both insulin
resistance and b cell
dysfunction. This is
especially true when
obesity is accompanied
by increased
intra-abdominal and
abdominal fat distribution

22
 as well as increased
intrahepatic and
intramuscular triglyceride
content. That is why,
your muscle and tissue
cells become more
resistant to your own
insulin hormone the
more extra weight you
carry (Cleveland Clinic,
2020).

Physical Inactivity One's risk of having type

2 diabetes can increase
if they don't engage in
adequate physical
activity. Increased
glucose levels, insulin
resistance, and type 2
diabetes are the results
of the excessive free
fatty acid generated by
adipose tissue, which
also causes a reduction
in the insulin sensitivity
of muscle, fat, and liver
(Epidemiol, 2019).

Diet ✓ Your chance of

developing diabetes
increases with a diet

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 high in fat, calories, and
cholesterol. Regardless
of BMI, evidence
suggests that carbs and
fat quality are important
risk factors for diabetes.
For instance, higher
intake of a diet high in
fiber, which includes
fruits and vegetables, is
linked to a lower risk of
developing diabetes, but
glycemic load and
trans-fat are significantly
linked to an increased
risk (Familydoctor.org,
2020).

Stress X High levels of stress

hormones may prevent
insulin-producing cells in
the pancreas from
functioning properly and
cause them to produce
less insulin. This could
ultimately lead to the
emergence of type 2
diabetes (Jones, 2020).

Alcohol ✓ Regularly consuming

large amounts of alcohol

24
 can decrease the body's
sensitivity to insulin,
which can lead to type 2
diabetes. In addition,
chronic pancreatic
inflammation brought on
by excessive alcohol use
may impair the
pancreas' capacity to
release insulin and even
bring on diabetes (Falck,
2019).

Smoking ✓ The chemicals in

cigarettes cause
inflammation and
damage to your body's
cells. Additionally, this
prevents cells from
reacting to insulin. Even
if they are not
overweight, those who
smoke have a higher risk
of developing belly fat,
which raises their risk of
developing type 2
diabetes (Centers for
Disease Control and
Prevention, 2022).

25
Polycystic Ovary X PCOS patients
Syndrome (PCOS)
frequently experience
reproductive issues, yet
it is not impossible to
become pregnant.
However, women with
the illness who do
become pregnant need
to be aware that the risk
for type 2 diabetes is
increased. This is
because women with
PCOS frequently have
insulin resistance, which
increases the risk of type
2 diabetes despite the
fact that their bodies can
produce insulin (Centers
for Disease Control and
Prevention, 2022).

Hypertension X Hypertension causes the

sympathetic nervous
system to become more
active, which reduces
the body's capacity to
absorb glucose. This
eventually leads to type
2 diabetes and insulin
resistance. Skeletal
muscle vasodilation is

26
 hindered in hypertension
due to increased
sympathetic nervous
system activity.
Consequently, muscle
glucose uptake
decreases when type 2
diabetes finally develops
(Akalu, 2020).

Lack of Sleep X When you don't get

enough sleep, your body
secretes more stress
hormones, which keeps
you awake, but insulin
can't do its function well
after you eat. Your
chance of acquiring type
2 diabetes rises when
your blood glucose level
is too high (Reid Health,
2022).

Depression X The relationship

between depression and
the emergence of T2DM
may be explained by
potential
pathophysiological
causes. Depression is
linked to metabolic

27
 alterations such as
central obesity resulting
in insulin resistance and
T2DM, as well as HPA
axis dysregulation, which
results in high cortisol
and catecholamine
levels (Deleskog, 2019).

COVID-19 X According to several

studies, adults who get
COVID-19 may be more
likely to develop
diabetes. It has been
demonstrated that
children and teenagers
with COVID-19 have an
increased chance of
getting diabetes more
than 30 days after
contracting the virus.
Infected beta cells
produce less insulin,
according to a study, and
the researchers
discovered evidence that
SARS-CoV-2 can cause
beta-cell death
(Americans Diabetes
Association, 2022).

28
 B. Symptomatology

SIGNS & SYMPTOMS PRESENT RATIONALE

Polydipsia (increased ✓ Polydipsia is one of the

thirst) earliest signs of type II
diabetes. This is
because there is an
increase of high glucose
levels that can cause
kidneys to increase urine
production to eliminate
excess glucose present
in the body; therefore,
the loss of fluids will
increase the patient's
thirst. Furthermore,
osmotic diuresis
increased urination due
to excess glucose
entering the kidney
tubules, which can't be
reabsorbed, leading to
increased water in the
tubules (Garcia, 2020).

Polyuria (increased ✓ Polyuria is one of the

urination) main indicators of type II
diabetes. Your body will
try to eliminate some of
the excess glucose
when blood sugar levels

29
 are excessively high
through urination, and
consuming too much
fluid, this will cause you
to urinate too much. The
average person excretes
1-2 liters of pee each
day (1 liter equals 4
cups). More than 3 liters
of urine are produced by
polyuric individuals each
day (Garcia, 2020).

Polyphagia (increased X The increased hunger is

hunger) still one of the signs and
symptoms of Type II
Diabetes. Diabetes
prevents glucose from
entering cells where it
would be used as
energy. Insulin
resistance or low insulin
levels may be to blame
for this. The body will
continue to send signals
to the brain that it is
hungry because it
cannot turn this glucose
into the energy it
requires from the food
that has already been

30
 consumed (Garcia,
2020).

Hyperglycemia ✓ High blood sugar, often

known as
hyperglycemia, is a sign
of diabetes. Insulin
resistance, which occurs
in type 2 diabetes,
occurs when the body's
cells reject the action of
insulin, which is to
absorb and utilize
glucose from the blood
for producing energy
(Mayo Clinic, 2022).

Glycosuria X It becomes challenging

to consume glucose as
the body becomes
resistant to insulin and
ceases to respond to the
hormone. Glycosuria
happens when blood
glucose (blood sugar)
passes into the urine, it
occurs. Normally, any
liquid that passes
through the kidneys
causes them to absorb
blood sugar back into

31
 the blood vessels. When
there is glycosuria, the
kidneys might not be
able to remove enough
blood sugar from the
urine before it leaves the
body (Garcia, 2020).

Unintended weight ✓ In type 2 diabetes, the

loss body fails to utilize
insulin as it should,
resulting in a buildup of
glucose in the blood
instead of being
transported to the cells.
The body reacts as
though it is starving
when the glucose
doesn't reach the cells
and seeks a means to
make up for it. It
produces energy by
quickly metabolizing
muscle and fat. Due to
this, you lose weight
mysteriously (Hardy,
2022).

Fatigue and weakness X Patients with type II

diabetes may feel weak
and fatigued. This is

32
 because of several
factors: 1) It is brought
on by the catabolic state
of insulin insufficiency,
hypovolemia, and
hypokalemia, which
results in muscle
wasting. 2) Other signs
of diabetes and
hypoglycemia, a
potential adverse effect
of diabetes drugs (Bass
Medical Group, 2022).

Infections ✓ Diabetes patients are

more likely to contract
infections because
elevated blood sugar
levels can make the
body's immune system
defenses less effective.
The body is more
susceptible to infection
as a result of some
diabetes-related health
problems, such as nerve
damage and decreased
blood supply to the
extremities. Additionally,
the elevated sugar levels
in the blood and tissues

33
 encourage germs to
flourish and hasten the
development of diseases
(Dansinger, 2021).

Slow wound healing ✓ With diabetes, slow

wound healing may
happen because there
will be a reduced blood
flow and altered
circulation, which makes
it more challenging for
the body to provide
nutrients to wounds. The
number of immune
fighter cells sent to heal
wounds, and their ability
to take action, is often
reduced. As a result, the
wounds might not heal at
all or rather slowly
(Rhee, 2022).

Headache X Patients with diabetes

may also experience
headaches as a result of
fluctuations in blood
sugar levels. When
blood sugar levels are
excessively high,
hyperglycemia may

34
 manifest as a headache.
They can also happen
when blood sugar levels
are very low due to
hypoglycemia (Basina,
2022).

Muscle Spasms X Muscle cramping is a

reasonably frequent DM
symptom. Electrolyte
imbalances,
hypoglycemia, peripheral
artery disease with
arterial insufficiency,
and/or peripheral
neuropathies can all
contribute to it. Leg
cramps are typically
more frequent in the
lower limbs and are
more frequent at night
(Mayo Clinic, 2022).

Increase in X Eccrine sweating

Temperature problems are linked to
both Type 1 and Type 2
diabetes mellitus, and
they significantly reduce
the body's ability to
sweat away heat. With
no changes in the onset

35
 threshold, this is mostly
explained by a
decreased
thermosensivity and a
lower maximal or plateau
amount of sweating
(Snouffer, 2021).

Dry skin ✓ The majority of

diabetes-related skin
issues are brought on by
high blood glucose
levels (hyperglycemia).
The body must remove
fluid from cells in order
to create enough urine to
flush out too much
sugar, which causes the
skin to become dry
(xerosis) (Cleveland
Clinic, 2021).

Blurred vision X High blood sugar levels

in diabetics can cause
fluid to enter and exit the
eye. Vision blur may
develop from the lens of
the eye swelling as a
result of this. When
blood sugar levels drop,
this momentary problem

36
 usually goes away.
Uncontrolled diabetes
can also cause damage
to the tiny blood vessels
in the eyes, which can
result in blurriness, by
raising blood sugar
levels (Griffith, 2021).

Darkened and ✓ Sometimes the first

thickened areas of the indication of type 2
Skin diabetes is a darkish
band of thicker, velvety
skin, particularly in folds
at the groin, back of the
neck, or armpits; this is
due to insulin resistance
(Mayo Clinic, 2021).

Memory loss X Having type II diabetes

may make you more
likely to suffer from
memory loss and other
cognitive issues. Blood
vessels, glial cells, and
nerve cells in both
peripheral and central
nervous systems of the
body and the brain can
be harmed by blood
glucose levels that are

37
 above normal (LONI,
2022).

Dehydration ✓ Excess glucose, a form

of sugar, builds up in
your blood when you
have type II diabetes. To
filter and absorb the
extra glucose, your
kidneys must put in extra
effort. You get
dehydrated when your
kidneys can no longer
handle the extra glucose
that is discharged into
your urine along with
fluids from your tissues
(Mayo Clinic, 2022).

Dysgeusia X In patients with type II

diabetes, dysgeusia may
occur. Dysgeusia is a
taste disorder or oral
health issue that can
give people a metallic,
bitter, or sweet
aftertaste. Oral thrush is
what happens when your
saliva has too much
sugar and your mouth is
dry (Basina, 2021).

38
Tachycardia X By lengthening the QT
interval, the
hyperglycemic state can
directly affect the cardiac
electrophysiological
status, raising the risk of
VT and other significant
cardiac arrhythmias that
might cause tachycardia
in the patient with
diabetes (Tran, 2018).

Hyperventilation X People with diabetes

who have hyperglycemia
or hypoglycemia, often
known as high blood
sugar or low blood
sugar, may have
shortness of breath. It
happens when there is
an absolute or relative
lack of insulin, which
prevents glucose from
entering cells to be used
as metabolic fuel. As a
result, the liver quickly
breaks down fat into
ketones to use as fuel,
which may cause
hyperventilation (Hamdy,
2021).

39
Peripheral Neuropathy ✓ Peripheral neuropathy is
caused by uncontrolled
high blood sugar levels
that harm nerves and
impair their capacity to
transmit messages.
Additionally, high blood
sugar damages the
capillary walls that carry
oxygen and nutrients to
the nerves (Mayo Clinic,
2022).

40
C. Schematic Tracing

41
42
43
44
45
 D. Narrative

The predisposing and precipitating aspects are the two main sources from which
Type 2 Diabetes Mellitus develops. Predisposing factors, or the unavoidable factors,
increase the likelihood that an issue may arise in a person's life. Age, sex, race, and
family history are risk factors for DM. While the triggering events, the modifiable factors
relate to a particular incident or trigger that led to the emergence of the current issue,
diet, obesity , Physical inactivity, smoking, alcohol use, stress, hypertension, PCOS,
depression, and even COVID-19 are all risk factors.
To give an overview, when a person eats, the food's carbohydrates normally
break down into simple sugars called glucose. The small intestine will subsequently
absorb this glucose, allowing it to enter the bloodstream. When the beta cells in the
pancreas detect a rise in blood glucose, they rapidly generate insulin, a hormone that
regulates the body's glucose levels. Now that insulin and glucose have left the
bloodstream, they can enter body cells by way of tissues. In Type 2 DM, the chain of
events takes place in a different way.
Insulin resistance and reduced insulin secretion are the two main issues with
insulin in type 2 diabetes. An impaired tissue response to insulin is referred to as insulin
resistance. Normally, insulin attaches to distinct receptors on cell surfaces and starts a
chain of processes vital to the metabolism of glucose. These intracellular processes are
slowed down in type 2 diabetes, making insulin less effective at promoting glucose
uptake by tissues and controlling glucose release by the liver. Although the
above-mentioned factors are considered to have a part, the precise mechanisms that
cause insulin resistance and decreased insulin secretion in type 2 diabetes are
unknown.
Increased insulin secretion is necessary to combat insulin resistance and prevent
the development of glucose in the blood while keeping the glucose level within normal
range (normoglycemia). However, type 2 diabetes sets in if the beta cells are unable to
keep up with the increased demand for insulin. There will be less ATP produced as part
of the system if the cell's ability to absorb glucose is reduced, and ATP is what gives
cells their energy. The lack of food and energy will result in cellular starvation, which will

46
make them feel exhausted or drained. In order to cope with hunger, the cells will send
hunger signals to the brain, which will result in polyphagia, or overeating.
On the other side, the blood will become overly concentrated due to an excessive
rise in the level of glucose. Blood becomes more viscous the more concentrated it is.
Blood flow decreases as a result of increased viscosity, which also increases the blood's
flow resistance. Since hemoglobin in the blood carries oxygen as one of its
components. The other organs then receive less oxygen, which over time leads to
systemic problems. The CNS, renal, EENT, integumentary, cardiovascular, respiratory,
and musculoskeletal systems/organs are severely affected.
The buildup of the macromolecule sugar inside the blood vessels causes
atherosclerosis, which results in the narrowing of the blood arteries in the CNS. This
finally results in atrophy and nerve injury when the perfusion to the nerves declines.
Additionally, high blood sugar raises the concentrations of neurotransmitters in the
brain. Neurotransmitters continuously maintain the brain's functionality, particularly in
terms of the person's ability to learn and concentrate. It has been demonstrated that
neurons are impacted by a constant fluctuation in neurotransmitters. The absence of a
glycogen store in the brain should also be noted. As a result, the brain eventually runs
out of energy, which damages the neurons.
Through a process known as osmosis, in which fluid is transferred from a lower
concentration to a higher concentration in a semipermeable membrane, the body tries
to reduce the blood viscosity for the renal system. The fluid in the intracellular space
(ICS) moves to the intravascular space as a result (IVS). The cell becomes dehydrated
as a result of the fluid escape by osmosis, alerting the brain to thirst. The brain's
reaction causes the person to drink more, which is known as polydipsia. The person will
feel excessively thirsty and drink more than usual as a result.
Contrarily, the fluid shift builds up in the IVS before entering the kidneys for
filtration. The glomerulus in the renal system will be able to improve its filtration rate
when more fluid and glucose enter the kidneys. Because of the sharply increased
glomerular filtration rate (GFR), glucose escapes from the nephrons, resulting in
glucosuria, a condition where there is glucose present in the urine. The pathogens have
a favorable environment for growth due to the high sugar content. In addition, the

47
increased GFR leads to greater production. which, if not controlled, can cause
dehydration, will be expelled by urine often and in large volumes.
The sugar may also become stuck inside the nephrons, the kidneys' filtering
organs. This obstruction will harm the nephrons, lowering the rate of glomerular filtration
in the kidneys (GFR). Poor kidney function, indicated by a low GFR, makes the kidney
permeable. Hyperosmolarity results from the blood becoming excessively concentrated.
In hyperosmolarity, the circulation draws water from the tissues, leading to dehydration.
Moreover, sugar reduces the blood supply to certain nerves, including the
olfactory, vestibulocochlear, and optic neurons. Over time, this leads to deteriorated
hearing, taste, smell, and sense of sight. Meanwhile, in the integumentary system, a
lack of oxygen causes the skin's sensibility, known as peripheral neuropathy, to diminish
or disappear. The person is more vulnerable to damage due to the loss of feeling in the
skin. Inadequate nutrients in the circulation cause a delay in healing, and if the condition
is not treated right once, the affected extremities may eventually necrotize and need to
be amputated.
In the cardiovascular system, the increased pumping action (tachycardia) of the
affected organ serves as a compensation mechanism for the decreased blood supply.
As the heart overcompensates, the contractility of the cardiac muscles gradually
declines. Tachycardia causes the heart output to spike, which boosts blood flow. In
addition, the presence of large amounts of sugar also narrows the arteries by harming
their inner linings. Later, elevated peripheral resistance will cause hypertension, or high
blood pressure. Severe cardiac arrest or cerebrovascular accidents may result from
uncontrolled hypertension if it is not treated.
The accumulation of sugar that reduces oxygenation also affects the respiratory
system. Therefore, if the lungs are not receiving enough oxygen, they will compensate
by breathing more quickly, a condition known as hyperventilation. Increased breathing
can cause respiratory acidosis, which, if untreated, can cause respiratory arrest.
Additionally, C-Reactive Protein levels rise in type 2 diabetes because the majority of
patients are overweight or obese. Inflammation in the body is caused by this CRP,
which is produced by fat cells. Therefore, an increase in CRP levels leads to a mild lung
inflammation that also affects lung function.

48
 Last but not least, the body tries to make up for the lack of oxygen supply in the
musculoskeletal system by using anaerobic metabolism, which uses muscle glycogen
that has been stored. The body turns fats, lipids, and other substances into glucose. An
individual loses weight when their anaerobic metabolism decreases the number of these
components, which make up their weight. Additionally, lactic acid is a waste product of
anaerobic metabolism. Metabolic acidosis may develop from an increase in lactic acid in
the circulation.
The clients can be given treatment options, such as medical, surgical, and
nursing management, if these consequences are avoided. Medical management may
also involve pharmaceutical therapies, dietary changes, and adjustments to activity
levels. Metabolic/Bariatric surgery and gastric banding are examples of surgical
management. both a gastric bypass and a sleeve gastroplasty. To further support the
improvement of health and wellbeing, it is crucial to carry out nurse management
effectively and individually.
If any of these underlying problems are left untreated, they will eventually have a
negative impact on the person, leading to sepsis and multi-organ failure or even death

VII. MEDICAL MANAGEMENT

A. Laboratory Tests

Laboratory tests can aid in the detection of a condition, the identification of a

diagnosis, the planning of therapy, the monitoring of treatment effectiveness, and the
long-term monitoring of a condition. The following are actual and possible laboratory
tests used to determine if a person is prone to or has diabetes mellitus. A doctor might
order these tests as part of a routine examination, or they may be performed to monitor
the health of a diabetic patient.

49
 i. Actual Laboratory Examinations
Date Test Normal Rationale Result Significance Nursing
Result Responsibility

10/11/2 Coagulatio Prothrombi The ● Protime Diabetes ● Important

2 n n Time prothrombin Control: increases the signs to
Control: 11 time 13.2 sec risk of plaque note are
to 13.5 measures buildup in the prolonged
seconds the amount ● APTT:41.5 arteries, bleeding
of time it sec which can from cuts or
aPTT: 30 to takes in cause gums,
40 seconds seconds for dangerous hematoma
Critical clot blood clots. at a
Value: none formation. Although puncture
or >70 blood clots site,
seconds Activated routinely form bruising
partial as a normal easily,
thromboplas function of blood in the
tin time blood cells to stool,
(APTT) repair persistent
evaluates damaged epistaxis,
the function blood vessel heavy or
of the walls, clots prolonged
contact become a menstrual
activation problem flow, and
pathway and when they shock.
coagulation prevent blood ● Monitor vital
sequence by from flowing signs, aPTT
measuring through an levels,
the amount artery or vein unusual
of time it inappropriatel ecchymosis
requires for y. Therefore, , occult
recalcified routine blood,
citrated examinations severe
plasma to of PT & APTT headache,
clot after are important unusual
partial to assess dizziness,
thromboplas coagulation and
tin is added impairment in neurological
to it. DM in order changes.
to prevent
thromboembo
lic CVD in DM
(Guadalupe
Regional
Medical

50
 Center,
2022).

08/30/ Chemistry ● Serum People with ● Serum Uric A blood ● Instruct the
22 Uric type 2 Acid: 0.43 chemistry patient to
Acid: diabetes mmol/L H study is a fast for 8
0.208 - often have procedure in hours before
0.428 high levels ● HDL: 0.75 which a blood the test.
mmol/L of uric acid mmol/L L sample is ● Apply direct
in their checked to pressure to
● HDL: blood, which measure the the
0.77 - could be due amounts of venipuncture
1.81 to extra fat. certain site until
mmol/L If an substances bleeding
individual is released into stops.
overweight, the blood by ● Inform the
their body organs and patient that
creates tissues in the he may
more insulin. body. An resume his
That makes unusual usual diet
it harder for amount of a and
their kidneys substance medications
to get rid of can be a sign stopped
uric acid, of disease in before the
which may the organ or test.
lead to gout. tissue that
makes it.
Having low
levels of
HDL
cholesterol
is of
concern, as
it can
indicate that
the person is
at risk of
developing
heart
disease.
Low levels
can occur
due to
genetic
factors, type
2 diabetes,
and
smoking.

51
08/30/ Complete ● RBC: Many ● RBC: 5.53 A complete ● Encourage
22 Blood 4.50 - patients with x 10^12/L H blood count, them to
Count 5.50 diabetes also known avoid stress
10^12/L have a ● WBC: 12.2 as a full blood if possible
10-15% H count, is a set because
● WBC: increase in of medical altered
5.0 – RBC ● Lymphocyt laboratory physiologic
10.0 diameter, es: 0.19 L tests that status
10^9/L increasing provide influences
blood ● Monocytes: information and changes
● Lympho viscosity. 0.11 H about the normal
cytes: This results cells in a hematologic
0.20 – from an person's values.
0.35 % influx of blood. The ● Explain that
glucose CBC fasting is not
● Monocyt which indicates the necessary.
es: 0.03 flattens the counts of However,
– 0.05 % biconcave white blood fatty meals
disk and cells, red may alter
bloats the blood cells some test
cells. and platelets, results as a
the result of
High white concentration lipidemia.
blood cell of ● Instruct to
count is hemoglobin, resume
associated and the normal
with a hematocrit. activities and
worsening of diet after the
insulin test.
sensitivity
and predicts
the
development
of type 2
diabetes. It
may also
indicate
infection or
inflammation
in the body.

52
10/11/2 Urinalysis ● 0 to 0.8 Glycosuria is ● Glucose: Urine tests ● Instruct the
2 mmol/L a condition +++ only detect patient to
in which a very high void directly
person's blood sugar. into a clean,
urine This is dry
contains because the container.
more sugar, body doesn't ● Sterile,
or glucose, generally get disposable
than it rid of sugar in containers
should. It the urine are
typically recommende
occurs due d.
to high blood ● Instruct to
sugar levels have a
or kidney clean-catch
damage. specimen.
Glycosuria is
a common
symptom of
both type 1
diabetes and
type 2
diabetes.

53
ii. Possible Laboratory Examinations
Date Test Normal Result Rationale Result Significanc Nursing
e Responsibilities

N/A Glucagon ● 50 to 100 Glucagon is ● >100 The α-cells ● Instruct the

pg/mL a hormone pg/mL = in type 2 patient to fast
that is (+) diabetes for at least 12
involved in diabetes become hr before
controlling resistant to specimen
blood sugar insulin, collection for
(glucose) much like baseline
levels. It is liver, fat and values.
produced by muscle. ● Patients with
the alpha The result diabetes
cells, found is that should have
in the islets glucagon good glycemic
of release is management
Langerhans no longer before testing.
. inhibited
during the
mealtime
rise in blood
glucose,
and this
leads to
elevated
levels of the
hormone in
type 2
diabetes.

54
N/A Serum mIU/mL It is a ● High = (+) In type 2 ● If a single
Insulin peptide Insulin diabetes, sample is to
● Fasting: <25 hormone Resistance the be collected,
that allows pancreas the patient
● 30 minutes the body to ● Low = Not makes should have
after glucose metabolize enough insulin, but fasted and
administration and use insulin the cells refrained, with
: 30-230 glucose. In produced don't medical
type 2 by the beta respond to direction, from
● 1 hour after: diabetes, cells as it as they taking insulin
18-276 insulin is seen in should. This or other oral
ranged from diabetes I is called hypoglycemic
● 2 hours after: normal to and insulin drugs for at
16-166 high, pancreatiti resistance. least 8 hr
signifying s When before
● >3 hours insulin glucose specimen
after: <25 deficiency can't get collection.
or improper into cells, ● If serial
use the blood specimens are
(endogenou sugar level to be
s and rises. Then collected, the
exogenous). the patient should
Moreover, pancreas be prepared
insulin works as for a
resistance harder to standard oral
might be make even glucose
present more tolerance test
secondary insulin. over a 5-hr
to the period.
formation of
antibodies.

55
 N/A Total ● Less than 0.6 Ketones in ● 0.6 to 1.5 Low to ● As
Serum mmol/L the blood = Low to moderate appropriate,
Ketone may Moderate result provide the
indicate a means a required urine
life-threateni ● 1.6 to 3.0 person has collection
ng condition = High a slightly container and
called increased specimen
diabetic ● Greater risk of DKA collection
ketoacidosis than 3.0 = and he instructions.
. It mostly Very high should test ● An elevated
affects again in 2 level of ketone
people with hours. High bodies is
type 1 result evidenced by
diabetes. means a fruity-smelling
person is at breath,
an acidosis,
increased ketonuria, and
risk of DKA. decreased
Very high level of
result consciousness
indicates .
that a
person has
DKA.

B. Diagnostic Examinations
Experts advise frequent testing for type 2 diabetes, especially if certain risk
factors exist. Type 2 diabetes can also develop in children. They also advise evaluating
adolescents and teenagers aged 10 to 18 who are overweight or obese and have at
least one other risk factor. Adults and children who have had normal test results should
be retested every three years.
In the emergency room, a fingerstick glucose test is appropriate for almost all
diabetic patients. All subsequent laboratory investigations should be tailored to the
specific clinical situation.

56
 i) Actual Diagnostic Examinations
Date Test Normal Rationale Result Significance Nursing
Result Responsibiliti
es

08/30/2 Glycosylate ● HBA1C The A1C ● HBA1C HbA1c not ● Inform the
2 d (Nyco): test—also (Nyco): only provides patient that,
Hemoglobin 4.5 - 6.3 known as the 7.0 % a reliable unlike
(HbA1c) % hemoglobin H measure of fasting or
Test A1C or HbA1c chronic post-meal
test—is a hyperglycemi blood sugar
simple blood a but also tests, no
test that correlates special
measures your well with the preparation
average blood risk of is needed
sugar levels long-term for an
over the past 3 diabetes HbA1c test.
months. complications. He does not
Elevated need to fast.
HbA1c has He can
also been have the
regarded as test sample
an at any time
independent of the day.
risk factor for ● Instruct that
coronary he should
heart disease not miss his
and stroke in medicines
subjects with on the day
or without of getting
diabetes. The tested.
valuable
information
provided by a
single HbA1c
test has
rendered it a
reliable
biomarker for
the diagnosis
and prognosis
of diabetes.

57
08/30/2 Fasting ● FBS: This measures ● FBS: A fasting ● Ensure that
2 Blood Sugar 4.10 - your blood 4.84 blood sugar the patient
(FBS) Test 5.90 sugar after an mmol/L level of 99 is fasting
mmol/L overnight fast. mg/dL or overnight or
lower is for at least 8
normal, 100 hours.
to 125 mg/dL ● Get the
indicates you glucose
have level of the
prediabetes, patient by
and 126 using a
mg/dL or glucometer.
higher ● Prick the
indicates you patient’s
have finger at the
diabetes. side part.
● Do not use
the first
drop of
blood for
the test.

10/11/22 Capillary ● between A blood ● 5 AM: Higher than ● Get the

Blood 70 glucose test is 173 H normal results glucose
Glucose mg/dL a blood test ● 3 PM: could indicate level of the
(CBG) Test (3.9 that screens 70 pre-diabetes patient by
mmol/L) for diabetes by ● 4:20 or diabetes. using a
and 100 measuring the PM: glucometer.
mg/dL level of 114 H ● Prick the
(5.6 glucose ● 6:12 patient’s
mmol/L). (sugar) in a PM: finger at the
person’s 100 side part.
blood. ● Do not use
10/17/2 ● 185 H the first
2 drop of
blood for
the test.

ii) Possible Diagnostic Examinations

Date Test Normal Rationale Result Significance Nursing
Result Responsibilitie
s

58
N/A Oral ● 139 Once the mg/dL If the glucose ● Inform the
Glucose mg/dL fasting blood ● 140 to 199 = level patient that
Tolerance or sugar level is Prediabetes measured is for the test,
Test below measured, an above normal, he must
(OGTT) oral glucose ● 200 or above this can mean drink a
tolerance test is = Diabetes that the sugar syrupy
done afterward may not have solution after
to identify how been not eating for
well the body absorbed a while
can handle a enough by the (fasting).
large amount of cells of the ● Inform the
sugar. This test body. This can patient that a
is executed by also indicate few blood
making the that the samples are
patient drink a person has taken to see
sugary liquid diabetes or how his body
(usually 75 gestational is handling
grams), and the diabetes. the sugar in
glucose level is the drink.
tested for the
next two hours.

There are two

standard
variations of the
test that are
used for
screening and
diagnosis:

● A two-hour
oral glucose
tolerance
test: This
version is
done with
two blood
draws and is
used to
diagnose
diabetes or
prediabetes
in
non-pregnan
t adults and
children.
8-ounce
solution with

59
 75 grams of
sugar.

● A three-hour
oral glucose
tolerance
test: This
version is
done with
four blood
draws and is
used to
screen for
gestational
diabetes.
8-ounce
solution with
100 grams
of sugar.

60
N/A Random ● Less The RPG test is ● 200 mg/dL A random test ● Inform the
Plasma than another and above = is performed patient that
Glucose 200 procedure that Diabetes by a diabetic fasting is
(RPG) mg/dL checks the patient outside needed and
Test amount of his normal that he could
sugar or testing take this test
glucose schedule. at any time.
circulating in Random ● Get the
the testing is an glucose level
bloodstream. important part of the patient
The test is of diabetes by using a
performed by management. glucometer.
the doctors to If random
determine if glucose levels
additional are
testing is acceptable,
needed for the his strategy is
patient who is probably
presumed to working. Wide
have diabetes. swings in his
levels suggest
that he may
need to
change his
management
plan.

61
 C. Therapeutics
Date Ordered Order Rationale

October 10, 2022 Pls. admit under the To maintain a constant care for
@ 8:00 pm service of Dr. Arao (PC) the patient and have constant
Secure consent to care supervision.
W q4
I&O qshift
Diet: Diabetic

IVF: PNSS 1L 140cc/hr Used because it has little to no

effect on the tissues and the IV
is used to restore fluid,
minimum carbohydrate
calories, and sodium chloride
as required by the patient’s
condition

62
Lab: The laboratories are used as a
- CBC baseline so that the
- S. elec + MG management will be accurate
- S. crea to the patient’s need
- 12 L ECG
- BCS x2
- CXR PAL
- BCG q6 AC
- Urinalysis
- RT-PCR-OPD
- R foot APO xray en
route
- PT, APTT
- Round GSCS c/o
surgery
- SGPT

63
 Meds: Medication used to treat the
- HTIG 250 IV IM now primary complaint of the
- Insulin patient. The HTIG and to
degludec/aspart prevent tetanus, Insulin
(Ryzodeg) 26 units (Ryzodeg) and RI for lowering
SQ OD AC blood sugar levels, and
- RI 4 units SQ for Pregabalin for treating the
BCG >180 nerve damage due to diabetes.
- Pregabalin Also, TMZ for chest pain,
75mg/cap BID Rosuvastatin for lowering the
- TMZ 35mg/tab BID amount of cholesterols, and
- Rosuvastatin MRSA as antibiotic.
10mg/tab OD
- Plan to add MRSA
coverage if o/c with
AP
- Inform SROD of
referral
- Inform DR. SS
Agbayani once at
room
- Refer

October 10, 2022 Conferred with Dr. Arao Referring to another doctor to
@ 8:30 PM Refer to Dr. S. Vega for help further evaluation of the
IDS eval health problem. Waiting and
Will await labs prior to CP informing will help NOD to
Clearance report a new update to the
Inform once with send for doctor.
OR

64
October 10, 2022 Start Ceftriaxone 2g IV Medication used to treat the
@ 8:50 PM now then q24 primary complaint of the
Start Vancomycin 1g IV patient. Ceftriaxone and
now then q12 Vancomycin to treat bacterial
To run as infusion x2 hours infections. Run through
infusion for faster and
higher concentrations than oral
antibiotics.

Send specimen for tissue For examination, which tissue

GSCS intra-op is removed and test if there is a
present disease problem.

October 10, 2022 Surgery Can help the doctor to see

@ 11:00 PM Thank you for this referral patients’ cases in a different
PT. seen & examine H perspective. Dakin's solution
HR for killing the germs and
Labs noted preventing growth of germs in
GSCS done, Please if up wounds.
Dr. Chavez informed
Hold Cliostazol
Please bring extra Dakin's
Solution
Noted

65
October 10, 2022 Confirmed with DR. Since the patient will undergo a
@ 11:05 PM Chavez surgery, NPO is scheduled for
Schedule for NPO & Post preventing risk of vomiting or
Disarticulation, R foot tom bringing up food into the throat.
@ 1PM, inform OR Post Disarticulation as the type
of surgery will be done to the
patient, which is a surgical
removal of a part in the lower
part of the body.

October 11, 2022 May confirm doct until 5 Small amount of water for
@ 12:15 AM AM meds for avoiding vomiting and
8tps of water for meds until nausea. Ensuring the IVF
10AM, NPO thereafter patency will result that the line
Ensure IVF patency is open and not blocked to
Inform once with AC/CP allow fluid flow directly into the
Let pt. void prior to patient’s vein. Voiding before
transport the surgery can prevent
Refer according post-op urinary retention.

66
October 11, 2022 CBG q hourly intra op refer Monitoring the blood sugar
@ 2:00 AM to MROD level of the patient to help
Under cardiac monitoring determine if there are any
intra op abnormal changes in his sugar
CBG q6 (5-11-5-11) level. While monitoring the
Maintain IVF @ 140 cc/hr cardiac during intra op will
avoid any life-threatening
conditions that could be
present.

Still for urinalysis This will help the patient to

know the remaining lab test
that is not done or taken.

DM diet A diabetic diet is a healthy

eating plan that is high in
nutrients while being low in fat
and calories. Fruits,
vegetables, and whole grains
are important components of
this type of diet. The strategy
assists the diabetic individual in
controlling their blood glucose,
weight, and risk factors for
heart disease such as high
blood pressure and high blood
fats.

67
October 11, 2022 Confirmed with Dr. Arao Cardio-pulmonary (CP)
@ 3:00 AM Will see patient first prior to clearance is the essential
CP clearance preoperative preparation in all
Continue Ceftriaxone & patients getting general
Vancomycin anesthesia for those who
would undergo surgical
intervention. Physician visited
the patient before CP
clearance to assess him before
preparing for surgery.

Ceftriaxone and Vancomycin

given to continue treating
bacterial infections.

October 11, 2022 For CP AC meals To facilitate documentation of

@ 5:30 AM Inform NOD once complete consent because the nurse is
responsible and accountable
for verification of witnessing
that the patient or the legal
representative has signed the
consent

October 11, 2022 Maintain on NPO NPO allows time for gastric
@ 9:00 AM emptying to occur, thereby
reducing the risk of aspiration
pneumonitis during anesthesia

Pantoprazole 40mg IVTT Pantoprazole increases plasma

NPO gastrin and insulin levels,
Facilitate OR today

68
 Continue meds thereby improving the glycemic
control in type 2 diabetes

October 11, 2022 Rounds of Dr. Arao Oral agents and long acting
@ 10:55 AM No absolute insulin are usually discontinued
contraindication for the before surgery to decrease the
completed procedure risk of a problem called lactic
The patient is on NPO D/C acidosis
giving RI dose

May give Degludec 10u To improve glycemic control in

SQ OD tonight while the body`
patient is on NPO

69
October 11, 2022 Surgery of Disarticulation A bacterial wound culture is
@ 4:30 PM of 1st toe r foot deb of 2nd to primarily used, along with a
4th toe R Gram stain and other tests, to
Specimen sent for GSCS, help determine whether a
Please follow up results wound is infected and to
For change of dressing identify the bacteria causing
tomorrow, Please prepare the infection.
the FF materials by 6:30
AM Dakin's solution is used to kill
- Dakin's Solution germs and prevent germ
- Bandages 10x10 cm growth in wounds.
- Iris
- NSS Pack Ceftriaxone+Vancomycin is
- Dressing Pack used in the treatment of
- Trash bag small bacterial infections. They work
- Elastic bandage 2 by preventing the formation of
inch the bacterial protective
- Elevate r foot w 1 covering which is essential for
pillow always the survival of bacteria in the
- Continue human body.
Ceftriaxone &
Vancomycin as
ordered
- Refer

70
October 11, 2022 Post-op Orders: The patient shall be observed
@ 4:50 PM - To PACU and monitored by methods
- VS q15mins x2 appropriate to the patient’s
bolus, qhourly x4 medical condition. Particular
bolus then q4 hours attention should be given to
thereafter monitoring oxygenation,
- O2 @ 2L/min via ventilation, circulation, level of
NC while @ PACU consciousness and
- May resume diet temperature. During recovery
with strict aspiration from all anesthetics, a
precaution quantitative method of
- IVF: D5LR 1L @ assessing oxygenation such as
140cc/hr pulse oximetry shall be
- IVF TF: PNSS @ employed in the initial phase of
140cc/hr recovery.
Meds:
- Tramadol + Fixed-dose
Paracetamol tramadol/paracetamol is a
(Dolcet) tabs, with rapidly-acting, longer-duration,
tab TID multimodal analgesic, which is
- Cont. all meds as effective and generally well
ordered tolerated in patients with
- Monitor I&O q8 moderate to severe pain.
hours; must be able
to void @ 9-10 PM Urinary retention is a common
- Monitor CBG q6 complication that arises after a
hours & record patient has anesthesia or
please; CBG prior to surgery.
PACU trans out &
relay result please

71
 - Watch out for any Intensive glucose control
unusualities decreased overall
- Please inform main postoperative complications
service of the
conclusion of the
procedure & for
further orders
- Refer

October 11, 2022 Elevate r foot 1-2 pillows Elevating the foot will allow the
@ 7:00 PM Refer blood to circulate back to the
heart without fighting gravity.

D. Pharmacological Management
Actual Drugs given to the Patient
Generic Name Pregabalin

Brand Name Lyrica

Drug Classification Anticonvulsants

Date Ordered October 10, 2022

Suggested Dose 75mg/tab BID

72
Mode of Action Binds to calcium channel sites in CNS
tissue, inhibiting excitatory
neurotransmitter release. Exerts
antinociceptive, anticonvulsant activity.

Indications Pregabalin is used to treat pain that is

cause by nerve damage due to diabetes
(diabetic neuropathy).

Contraindications ● Hypersensitivity
● Suicidal thoughts
● Depression

Side Effects ● Weak or shallow breathing

● Blue-colored skin, lips, fingers, and
toes
● Skin sores
● Trouble concentrating
● Vomiting
● Lack of coordination
● Speech problems
● Constipation

Adverse Effects ● Visual impairment

● Heart Failure
● GI Bleeding Suicidal Ideation
● Fatigue
● Weight gain
● Pancreatitis

73
Drug Interactions Oral Diabetes Medicine:
● Pioglitazone
● Rosiglitazone
ACE Inhibitor:
● Captopril
● Perindopril
● Benazepril

Nursing Responsibilities 1. Assess Vital Signs

R: To have a baseline data of the
patient before and after taking
medication.
2. Assess pain using appropriate pain
scales.
R: To document changes in pain
and to help determine the
effectiveness of the drug
3. Instruct to report signs of
drowsiness, cognitive impairments,
and concentration difficulty.
R: Repeated symptoms may require
a change in dose or medication.
4. Assess body weight and body mass
index.
R: To have baseline data and to
document if there is an unexplained
weight gain or increase in body fat.
5. Instruct family to guard patients
against falls and trauma.
R: Balance is affected by
drowsiness or dizziness.

74
 6. Instruct patients to avoid alcohol.
R: There is an increased risk of
adverse effect when taking this
drug.
7. Instruct to immediately report any
signs of adverse effects.
R: To prevent further complications.
8. Instruct patients not to drive or
engage in potentially hazardous
activities.
R: The patient should know the
effect of the drug first to prevent an
accident.
9. Always wash hands thoroughly and
disinfect equipment.
R: To help prevent the spread of
infection

Generic Name Ceftriaxone

Brand Name Rocephin

Drug Classification Cephalosporin

Date Ordered October 10, 2022

75
Suggested Dose 2g IV q24

Mode of Action Ceftriaxone selectively and irreversibly

inhibits bacterial cell wall synthesis by
binding to transpeptidases, also called
transamidases, which are
penicillin-binding proteins (PBPs) that
catalyze the cross-linking of the
peptidoglycan polymers forming the
bacterial cell wall.

Indications Susceptible bacterial infections of the

lower respiratory tract, skin and skin
structure, bone and joint, acute otitis
media, UTIs, septicemia, pelvic
inflammatory disease (PID), intra
abdominal infections, meningitis,
uncomplicated gonorrhea.

Contraindications ● diarrhea from an infection with

Clostridium difficile bacteria.
● a type of blood disorder where the
red blood cells burst called
hemolytic anemia.
● liver problems.
● disease of the gallbladder.
● severe renal impairment.
● yellowing of the skin in a newborn
child.

Side Effects Injection site reactions (swelling,

redness, pain, a hard lump or soreness)

76
 Eosinophilia
Increase blood platelets (thrombocytes)
Diarrhea
Elevated liver transaminase
Low white blood cell count (Leukopenia)
Rash
Increase blood urea nitrogen (BUN)
Pain
Dizziness

Adverse Effects ● Eosinophilia

● Leukopenia
● Thrombocytes
● Anaphylaxis
● Serum sickness
● Pseudomembranous Colitis

Drug Interactions Aminoglycosides (Cephalosporins)

Calcium Salts

Nursing Responsibilities 1. Determine history of hypersensitivity

reactions to cephalosporins and
penicillin and history of other
allergies, particularly to drugs,
before therapy is initiated.
R: To gather subjective data from
the patient and/or the patient's family
so that the health care team and the
patient can collaboratively create a
plan that will promote health,
address acute health problems, and
minimize chronic health conditions.

77
2. Inspect injection sites for induration
and inflammation.
R: To rotate the sites and note IV
injection sites for signs of phlebitis
(redness, swelling and pain).
3. Instruct the patient to report
discomfort at IV insertion site.
R: Because if the patient complains
of pain it will lead to tenderness, or
discomfort at the IV insertion site.
4. Tell the patient to notify the
prescriber about loose stools or
diarrhea.
R: To rule out pseudomembranous
colitis and report onset of diarrhea
due to the side effects of medication
(ceftriaxone).
5. Monitor for manifestations of
hypersensitivity.
R: To report their appearance
promptly and discontinue drugs.
6. Always raise the side rails up.
R: To prevent any risk of falling or
injury due to dizziness.
7. Assess blood pressure periodically.
R: A sudden or sustained increase
in blood pressure may indicate
problems in diabetes management,
and should be reported to the
physician.

78
 8. Instruct to immediately report any
signs of adverse effects.
R: To prevent further complications.
9. Advise patients to notify health care
professionals if no improvement is
seen in a few days.
R: To monitor the response of
ceftriaxone.

Generic Name Human

Tetanus
Immunoglob
ulin

Brand Name HyperTET

Drug Classification Immune Globulins

Date Ordered October 10, 2022

Suggested Dose 250 IU IM

Mode of Action The immune globulin binds to tetanus

toxiod, interfering with the normal
interaction of the toxoid with human
tissue. This prevents the toxoid from
invading the nervous system and
producing painful muscle spasms as well
as autonomic dysfunction. The

79
 Clostridium tetani bacterium is killed
either via antibiotic treatment of the
host's immune system and immune
globulin-bound toxoid is likely broken
down by phagocytic immune cells.

Indications HTIG is administered in the event of

tetanus-prone wounds, e.g. wounds with
fracture, deep penetrating wounds, bite
wounds, wounds containing foreign
bodies, wounds contaminated with soil,
infected wounds, extensive tissue
damage (contusions, burns)

Contraindications ● Hypersensitivity to gamma globulin,

IgA, thimerosal

Side Effects ● Difficulty in breathing or swallowing

● hives
● itching, especially of soles or palms
● reddening of skin, especially around
ears
● swelling of eyes, face, or inside of
nose
● unusual tiredness or weakness,
sudden and severe

Adverse Effects fentanyl transdermal patches have been

developed to manage chronic pain
associated with diabetic neuropathy.

Drug Interactions Tetanus Immune Globulin has serious

interactions with the following drugs:

80
 ● axicabtagene ciloleucel
● brexucabtagene autoleucel
● ciltacabtagene autoleucel
● idecabtagene vicleucel
● lisocabtagene maraleucel
● tisagenlecleucel

Nursing Responsibilities 1. Provide immediate, short-term

protection against the bacteria that
cause teranus (lockjaw).
2. If discomfort occurs at the injection
site, apply warm compress.
3. Assess for any side effects such as
high fever, difficulty breathing, hives,
itching or swelling of eyes.
4. Assess previous immunization
history and history of
hypersensitivity.
5. Asses for history of latex allergy.
Some prefilled syringes may use
latex components and should be
avoided in those with
hypersensitivity.

81
Generic Name Fentanyl

Brand Name Sublimaze

Drug Classification Opioid Analgesics, Synthetic,

Opioids

Date Ordered October 10, 2022

Suggested Dose Injection solution: Schedule Il

0.05mg/mL

Mode of Action In the central nervous system (CNS),

fentanyl activates mu-opioid receptors,
which modifies how the body reacts to
pain. Different neurotransmitters,
including pain-sensitive-endorphin, may
release differently as a result of fentanyl.

Indications

Contraindications Hypersensitivity

Side Effects Fentanyl may cause side effects such

as:
● drowsiness
● stomach pain
● gas

82
 ● heartburn
● weight loss
● difficulty urinating
● Changes in vision
● Anxiety
● Depression
● Undusl thinking
● unusual dreams
● difficulty falling asleep or
● staying asleep
● drv mouth
● Back Dain
● chest pain
● pain, Sores, or irritation in the
mouth in the area where you
placed the medication
● swelling of the hands

Adverse Effects Nausea, vomiting , bradycardia,

oedema, CNS depression, confusion,
dizziness, drowsiness, headache
sedation, transient hypotension,
peripheral vasodilation pressure. High IV
dose may cause chest wall rigidity,
transdermal: Rash, erythema and
itching.

Drug Interactions Certain medications. such as CYP3A4

inhibitors like macrolide antibiotics or
azole-antifungal agents, and protease
inhibitors may increase plasma

83
 concentrations of fentanyl, extending the
opioid drug action and exacerbate the
opioid-induced respiratory depression,
should not be used concurrently with the
drug fentanyl.

Nursing Responsibilities 1. Keep an opioid antagonist on hand

for parenteral administration. as well
as resources for assisted
R: An antagonist is a drug that
inhibits opioids by binding to opioid
receptors but not activating them.
2. Prepare the area for transdermal
form for by cutting (not shaving) the
hair there; avoid using soap; and
wait until the skin is fully dry before
applying.
R: The application of a medicine or
drug through the skin is referred to
as transdermal. In its most basic
form, a drug is applied to the skin
and absorbed into the bloodstream.
The main advantage of transdermal
medications is their ease of
application.
3. Apply as soon as the transdermal
system is taken out the sealed
package; firmly press the
transdermal system in place for 10
to 20 seconds, making sure the
contact is complete

84
 R: This way the medicine will be
absorbed well by the skin and can
help with the healing process
4. Wearable for 72 hours straight. Any
system that has been ripped or
damaged shouldn't be used. Before
applying a new patch, remove ine
old one
R: To protect the surgical site from
infections.
5. Be aware that the patch takes time
to take effect. The entire therapeutic
impact may not be felt for up to 12
hours. Utilizing novel drugs is
necessary.
R: To be able to change the patches
in time and avoid the growing of
other microorganisms in the wound.

Generic Name Insulin

Degludec/
Insulin
Aspart

Brand Name Ryzodeg

Drug Classification Antidiabetics

Date Ordered October 10, 2022

85
Suggested Dose 10 units SQ OD AC

Mode of Action The blood glucose-lowering effect of

insulin is due to the facilitated uptake of
glucose following the binding of insulin to
receptors on muscle and fat cells and to
the simultaneous inhibition of glucose
output from the liver.

Indications A long-acting and a rapid-acting type of

insulin used to treat types 1 and 2
diabetes mellitus in both adults and
children. It provides a steady level of
insulin in the body for an entire day and
helps control blood sugar levels.

Contraindications Hypersensitivity reactions to insulin

degludec, insulin aspart, or one of the
excipients

Side and Adverse Effects - Hypoglycemia, allergic reactions,

injection site reactions, body fat
redistribution, itching, rash, swelling,
weight gain, pruritus, urticaria,
dyspnea, dizziness, drowsiness,
blurred vision

Drug Interactions ● Other insulin products:

- Beta-blockers, clonidine,
guanethidine, reserpine
● Other antidiabetic agents
- ACE inhibitors, angiotensin II
receptor blocking agents,

86
 disopyramide, fibrates, fluoxetine,
monoamine oxidase inhibitors,
pentoxifylline, pramlintide,
propoxyphene, salicylates

Nursing Responsibilities 1. Monitor signs of hypoglycemia,

especially during and after exercise.
R: Common neuromuscular
symptoms include anxiety,
restlessness, tingling in hands, feet,
lips, or tongue, chills, cold sweats,
confusion, difficulty in concentration
and drowsiness. Report persistent
or repeated episodes of
hypoglycemia to the physician.
2. Monitor signs of allergic reactions
and anaphylaxis, including
pulmonary symptoms (tightness in
throat and chest, wheezing, cough,
dyspnea) or skin reactions (rash
pruritus, urticaria).
R: Notify the physician immediately
if these reactions occur in order for
early actions.
3. Assess blood pressure periodically.
R: A sudden or sustained increase
in blood pressure may indicate
problems in diabetes management,
and should be reported to the
physician.
4. Assess body weight periodically.

87
 R: Changes in weight may
necessitate changes in insulin dose.
5. Assess injection site for redness,
swelling, or other reactions.
R: Make sure patients understand
the need to rotate injections site to
prevent local damage and
lipodystrophy.
6. Provide a source of oral glucose fruit
juice, glucose gels/tablets. Etc.) to
treat mild hypoglycemia. Call for
emergency assistance if symptoms
persist or in case of severe
hypoglycemia.
R: Emergency treatment typically
consists of IV glucose, glucagon, or
epinephrine.
7. Do not apply physical agents (heat,
cold, electrotherapeutic modalities)
or massage at or near the injection
site.
R: These interventions will alter
insulin absorption from
subcutaneous tissues.
8. Advise patient about symptoms of
hyperglycemia (confusion,
drowsiness, flushed and dry)
R: This medication can cause low
blood sugar. This may occur if you
do not consume enough calories

88
 from food or if you do unusually
heavy exercise. Symptoms of low
blood sugar include sudden
sweating, shaking, fast heartbeat,
hunger, blurred vision, dizziness or
tingling hands/feet.
9. Always raise the side rails up.
R: To prevent any risk of falling due
to dizziness and drowsiness.
10. Inject the insulin in the fats area of
the body.
R: To absorb insulin slowly and
predictably.

Generic Name Rosuvastatin

Brand Name Lustatin

Drug Classification HMG-CoA Reductase inhibitors

(STATINS)

Date Order October 11, 2022

Suggested Dose 10 mg /tab OD

89
Mode of Action Acts primarily in the liver, where
decreased hepatic cholesterol
concentrations stimulate the upregulation
of hepatic low-density lipoprotein (LDL)
receptors which increases hepatic
uptake of LDL

Indications It is to lower the cholesterol level and fats

to help diabetic people

Contraindications - Dehydration, alcoholism, liver

problems, bloody urine, acute
Kidney Failure

Side Effects - Headache, muscle aches & pain,

abdominal pain, weakness, nausea

Adverse Effects - Black, tarry stools, bloody urine, joint

swelling, skin rash

Drug Interactions - Vitamin K

- Cyclosporine
- Gemfibrozil

Nursing Responsibilities 1. Perform thorough physical

assessment.
R: To establish a baseline date
before administering the drug to
determine the effectiveness of
therapy.
2. Monitor patient response to therapy.

90
 R: To assess the effectiveness of
drugs from the patient.
3. Monitor patients for any side effects
or adverse effects.
R: To immediately alleviate potential
problems.
4. Educate patients on drug therapy.
R: To promote compliance and
understanding.
5. Evaluate patient’s understanding of
drug therapy.
R: To ensure that the patient
understood drug therapy teaching.
6. Monitor patient’s compliance to drug
therapy.
R: To ensure that the patient is
properly taking the drug.
7. Do not crush, and dissolve in water.
R: Alteration of the drug's absorption
can result in sometimes fatal
overdose, or conversely
underdosing, rendering the
treatment ineffective.
8. Advise patients that he may
experience black and tarry stools
with bloody urine.
R: This is the side effects of taking
the medicine.
9. Advise patients to increase fluid
intake.

91
 R: To avoid being dehydrated and
prevent hyperglycemia.
10. Assess Vital Signs
R: To have a baseline data of the
patient before and after taking
medication.

Generic Name Tramadol

Brand Name Dolcet

Drug Classification Opioids

Date Order October 11, 2022

Suggested Dose 1-tab TID and 50mg ivtt q8

Mode of Action Inhibits the reuptake of natural

neurotransmitters norepinephrine and
serotonin, and also binds weakly to
opioid receptors, blocking the
transmission of pain signals to the brain.

Indications To relieve moderate to moderately

severe pain.

92
 It is also to relieve pain in inflammatory
sites or conditions.

Contraindications Contraindicated to all children younger

than 12 years of age
Patient who has epilepsy

Side Effects Dizziness

Headache
Drowsiness
Nausea and vomiting
Constipation
Lack of energy
Sweating
Dry mouth
Itching

Adverse Effects Fast heart rate

Lack of coordination
Agitation
High BP
Hallucinations

Drug Interactions Carbamazepine

Lithium
Diazepam
Lorazepam

Nursing Responsibilities 1. Assess pain using visual analogue

scales and other appropriate pain
scales when this drug is used to
treat neuropathic pain or other pain

93
 syndromes (fibromyalgia,
postherpetic neuralgia).
R: Document any charges in pain to
help determine the effects of drug
therapy.
2. Assess peripheral edema using girth
measurements, volume
displacement, and measurements,
volume displacement, and
measurement of pitting edema.
R:Report increased swelling in feet
and ankles or a sudden increase in
body weight due to fluid retention.
3. Assess dizziness that might affect
gait, balance, and other functional
activities.
R: Report balance problems and
functional limitations to the
physician, and caution the patient
and family/caregivers to guard
against falls and trauma.
4. Monitor vital signs and assess.
R: For orthostatic hypotension or
signs of CNS depression.
5. Monitor patients for drug
independence.
R: Tramadol can produce
dependence similar to that of codein
or dextroproxyphene and thus has

94
 potential to be abused, adverse
reactions and drug interactions.
6. Assess bowel and bladder function.
R: Report urinary frequency or
retention.
7. Monitor signs of allergic reactions,
including pulmonary symptoms
(tightness in the throat and chest,
wheezing, cough, dyspnea) or skin
reactions (rash, pruritus, urticaria).
R: Notify physicians if these
reactions occur.
8. Exercise caution with potentially
hazardous activities until response
to drug is known.
R: Tramadol oral tablets may cause
drowsiness. You should not perform
any heavy exercise.
9. Advise patients to increase fluid
intake.
R: To avoid being dehydrated and
prevent hyperglycemia.
10. Can be taken with or without meals
R: It will not make tramadol less
effective.

95
Generic Name Vancomycin

Brand Name Vancocin

Drug Classification Glycopeptide Antibiotic

Date Ordered October 11, 2022

Suggested Dose 1g ivtt q12

Mode of Action Binds to bacterial cell walls, altering cell

membrane permeability, inhibiting RNA
synthesis.

Indications Treatment of infections caused by

bacteria through killing and preventing
their growth.

Contraindications · Hypersensitive with the drug

· Renal Impairment
· Hearing Impairment
· Intestinal Obstruction or
inflammation

Side Effects · Phlebitis

· Thrombophlebitis
· Pain at Peripheral IV site
· Dizziness
· Vertigo
· Tinnitus

96
 · Chills
· Fever
· Rash
· Necrosis with Extravasation

Adverse Effects Nephrotoxicity such as acute kidney

injury, acute tubular necrosis, and renal
failure
Ototoxicity such as temporary or
permanent hearing loss

Drug Interactions Drug-to-drug:

· Aspirin
· Aminoglycosides
· Cyclosporine
· Cisplatin
· Loop Diuretics
Drug-to-lab values:
· May increase BUN

Nursing Responsibilities 1. Explain use and administration of

drugs to patients and families.
R: For them to be knowledgeable
about the said drug and for them to
be aware of its side effects.
2. Obtain specimens
R: For culture and sensitivity prior to
initiating therapy.
3. Always wash hands thoroughly and
disinfect equipment.
R: To help prevent the spread of
infection

97
4. Assess vital signs, specifically blood
pressure.
R: Vancomycin decreases blood
pressure and may cause
hypotension especially if the patient
experiences dizziness and fatigue.
5. Monitor IV site closely.
R: Vancomycin is irritating to tissues
and causes necrosis and severe
pain with travasation. Rotate infusion
site.
6. Monitor intake and output rations
and daily weight.
R: Cloudy or pink urine may be a
sign of nephrotoxicity.
7. Instruct the patient of the watcher to
report signs of hypersensitivity,
tinnitus, vertigo and hearing loss.
R: These are side effects and
adverse effects of the drug.
8. Advise patients to notify health care
professionals if no improvement is
seen in a few days.
R: To monitor the response of
vancomycin.
9. Assess hearing.
R: Drug may cause damage to the
auditory branch (not vestibular
branch) of eight cranial nerves, with

98
 consequent deafness, which may be
permanent.
10. Tell the family of the patient to
adhere to the drug regimen.
R: the full course of prescribed drug
therapy must be completed.

Generic Name Regular

Insulin

Brand Name Humulin R

Drug Classification Antidiabetic

Date Order October 11, 2022

Suggested Dose 4units SQ for CBG >180

Mode of Action Lowers blood glucose by stimulating

glucose uptake in skeletal muscle and
fat, inhibiting hepatic glucose production

Indications Control of hyperglycemia in patients with

diabetes mellitus.

Contraindications · Hypoglycemia

99
 · Allergy or hypersensitivity to a
particular type of insulin,
preservatives, or other additives.
· Use cautiously in Stress or
infection – may temporarily increase
insulin requirements;
· Concomitant use with
pioglitazone or rosiglitazone
(increased risk of fluid retention and
worsening HF)

Side Effects · Headache

· Hunger
· Weakness
· Sweating
· Tremors
· Irritability
· Trouble concentrating
· Rapid breathing
· Fast heartbeat
· Fainting
· Seizure

Adverse Effects · Hypoglycemia

· Hypokalemia
· Lipodystrophy
· Allergy
· Weight Gain
· Peripheral Edema

Drug Interactions Drug-Drug:

· Beta-blockers

100
 · Clonidine
· Reserpine may mask some of the
signs and symptoms of hypoglycemia
· Corticosteroids
· Thyroid supplements

Nursing Responsibilities 1. Monitor body weight periodically.

Changes in weight may necessitate
changes in insulin dose.
R: To prevent any problem such as
weight gain or loss.
2. Instruct patients on proper technique
for administration. Include type of
insulin, equipment (syringe,
cartridge pens, alcohol swabs),
storage, and place to discard
syringes
R: To have an effective
administering of the medication.
3. Caution patients not to share pen
devices with another person, even if
the needle is changed; may risk
transmission of bloodborne
pathogens.
R: It may cause any contamination
and passing of bacteria through that.
4. Explain to the patient that this
medication controls hyperglycemia
but does not cure diabetes. Therapy
is long-term.

101
 R: For patients not to just rely on the
insulin medication.
5. Emphasize the importance of
compliance with nutritional
guidelines and regular exercise as
directed by health care
professionals.
R: To minimize high glucose levels,
which are caused by food that are
sugary and starchy.
6. Instruct patients to notify health care
professionals of all Rx or OTC
medications, vitamins, or herbal
products being taken and to consult
a health care professional before
taking other Rx, OTC, herbal
products, or alcohol.
R: To avoid any drug interactions
that may cause severe side effects
to the patient.
7. Advise patient to notify health care
professional if nausea, vomiting, or
fever develops, if unable to eat a
regular diet, or if blood glucose
levels are not controlled
R: To take any actions immediately.
8. Instruct patients on signs and
symptoms of hypoglycemia and
hyperglycemia and what to do if they
occur.

102
 R: To avoid any other complications
or problems.
9. Insulin should be stored in a cool
place but does not need to be
refrigerated. Once opened, store at
room temperature. Follow
manufacturer’s instructions
regarding storage of insulin and
insulin pens before and after use.
R: To avoid losing effectiveness
when exposed to extreme
temperatures.
10. Emphasize the importance of
regular follow-up, especially during
the first few weeks of therapy
R: For further assessment of the
patient's current physical findings.

Generic Name Pantoprazole

Brand Name Protonix

Drug Classification Proton-pump inhibitors

Date Ordered October 11, 2022

103
Suggested Dose ● Granules for suspension: 40
mg/packet
● Injection, Powder for Reconstitution
(Protonix): 40 mg

Mode of Action Binds to an enzyme in the presence of

pacific gastric pH, preventing the final
transport of hydrogen ions into the
gastric lumen.

Indications ● Diabetes Mellitus. Pantoprazole

increases plasma gastrin and insulin
levels, thereby improving the
glycemic control in T2DM.
● Treatment, maintenance of healing
of erosive esophagitis associated
with gastroesophageal reflux
disease (GERD).
● Reduction of relapse rate of
heartburn symptoms in GERD.
● Treatment of hypersecretory
conditions including Zollinger-Ellison
syndrome

Contraindications ● Hypersensitivity to rabeprazole or

related drugs (benzimidazoles)
● OB: Should be used during
pregnancy only if clearly needed
● Lactation: Discontinue breast
feeding due to potential for serious
adverse reactions in infants.

104
Side Effects ● Diarrhea, headache, dizziness,
pruritus, and rash

Adverse Effects ● Hyperglycemia occurs rarely

Drug Interactions ● Drug-drug: Warfarin, clopidogrel

● Drug-lab values: Serum creatinine,
cholesterol, uric acid, glucose,
lipoprotein, and ALT.

Nursing Responsibilities 1. Check any history of drug allergy of

the patient.
R: A drug allergy may cause severe
reactions, including a
life-threatening condition that affect
multiple body systems
(anaphylaxis).
2. Educate the patient that medication
should not be crush, break, dissolve,
or divide tablets
R: Pantoprazole should not be
crushed because this will alter the
absorption or stability of the
medicine.
3. Question history of GI disease,
ulcers, GERD
R: Proper assessment is important
to ensure the right medication is
given to the patient.
4. Explain the use and administration
of the drug to the patient and family.

105
 R: For them to be knowledgeable
about the said drug and for them to
be aware of its side effects.
5. Give the drug before breakfast.
R: This is the best time to give the
drug for therapeutic response.
6. Evaluate therapeutic response.
R: To know the effectiveness of the
medication.
7. Tell the patient to report if side
effects of pantoprazole occur such
as nausea and vomiting.
R: These are the side effects of the
drug.

Generic Name Ampicillin/

sulbactam

Brand Name Unasyn

Drug Classification Pharmacotherapeutic: Penicillin

Clinical: Antibiotic

Date Ordered October 11, 2022

106
Suggested Dose ● IV, IM: Adults, Elderly, Children 13
years and older
- 1.5 g (1 g ampicillin / 500
mg sulbactam) to 3 g (2 g
ampicillin/ 1 g sulbactam)
every 6 hours
● IV: Children 12 years and
younger
- 100 to 400 mg
ampicillin/kg/day in divided
dose every 6 hours
● Neonates
- 100 mg/kg/day in divided
dose every 8 hours to 12
hours.

Mode of Action Ampicillin inhibits bacterial cell wall

synthesis. Sulbactam inhibits bacterial
beta-lactamase.

Indications Treatment of susceptible infections,

including intra-abdominal, skin/skin
structure, gynecologic infections, due to
beta lactamase-producing organisms
including H. influenzae, E. coli,
Klebsiella, Acinetobacter, Enterobacter,
S. aureus, and bacteroides.

Contraindications ● Dialysis, renal disease, renal failure,

renal impairment- Ampicillin should
be used with caution in patients with
renal disease or renal impairment

107
 since the drug is eliminated by the
kidneys.
● Asthma, carbapenem
hypersensitivity, cephalosporin
hypersensitivity, eczema, penicillin
hypersensitivity, serious rash,
urticaria- Ampicillin is a penicillin
and should not be used in patients
with a penicillin hypersensitivity.
Ampicillin should also be used
cautiously in patients with
cephalosporin hypersensitivity and
carbapenem hypersensitivity
● Antimicrobial resistance- Oral
ampicillin is contraindicated for the
treatment of infections caused by
penicillinase-producing organisms
due to antimicrobial resistance.

Side Effects ● Nausea

● Vomiting
● Diarrhea
● Stomach pain

Adverse Effects ● Shortness of breath

● Hives
● Swelling of face
● Burning eyes
● Cold feet and hands

108
Drug Interactions ● Allopurinol: Increased possibility of
skin rash, particularly in
hyperuricemic patients may occur.
● Bacteriostatic Antibiotics:
Chloramphenicol, erythromycins,
sulfonamides, or tetracyclines may
interfere with the bactericidal effect
of penicillins. This has been
demonstrated in view, however, the
clinical significance of this
interaction is not well documented.
● Oral Contraceptives: May be less
effective and increased
breakthrough bleeding may occur.
● Probenecid: May decrease renal
tubular secretion of ampicillin
resulting in increased blood levels
and/or ampicillin toxicity.

Nursing Responsibilities 1. Determine previous hypersensitivity

reactions to penicillins,
cephalosporins, and other allergens
prior to therapy.
R: To further understand the health
status of your patient and to
determine the possible drug
interactions and allergies

2. Monitor signs of
pseudomembranous colitis,
including diarrhea, abdominal pain,

109
 fever, pus or mucus in stool, and
other severe or prolonged GI
problems (nausea, vomiting,
heartburn).
R: To prevent further complications
3. Instruct the patient to take this drug
around-the-clock.
R: Omitted dose may cause
complications
4. Take the oral drug on an empty
stomach, 1 hour before or 2 hours
after meals; do not take with fruit
juice or soft drinks; the oral solution
is stable for 7 days at room
temperature or 14 days refrigerated.
R: Your body absorbs less ampicillin
when you take it with food or right
after a meal, which means the
medication is less effective.
5. Instruct the client that this antibiotic
is specific to his/her problem and
should not be used to self-treat
other infections.
R: Complications may arise
6. Inspect skin daily and instruct
patient to do the same
R: The appearance of a rash should
be carefully evaluated to
differentiate a nonallergenic

110
 ampicillin rash from a
hypersensitivity reaction
7. Report loose stools or diarrhea
promptly.
R: To prevent further complications
8. Monitor I&O when drug is given
parenterally and in those with renal
dysfunction.
R: It allows the health care provider
to prevent dehydration, fluid
retention, and other problems
related to fluid imbalance.
9. Tell the patient to take this drug
exactly as the doctor has prescribed
it. It should not be taken in greater
quantities or for longer than
recommended and the medication
label directions should be followed.
R: Taking your medicines as
prescribed is important because it
increases their effectiveness for
treating chronic diseases.
10. Emphasize the importance of
follow-up exams to evaluate
effectiveness of medication.
R: To determine the patient's
outcomes that have resulted from
the drug therapies and to determine
if there are any potential medication
changes

111
Possible Drugs given to the Patient:
Generic Name Metformin

Brand Name Glucophage

Drug Classification Antidiabetic

Suggested Dose ● Adult: PO 500 mg bid or 850 mg/day

initially, then 500 mg weekly or 850
mg q2wk up to 2000 mg/day in
divided doses with morning meal,
with dosage increased every other
week, max 2550 mg/day

Mode of Action Inhibits hepatic glucose production and

increases sensitivity of peripheral tissue
to insulin

Indications Used in treatment of type II diabetes

mellitu

Contraindications Contraindicated in patients with renal

disease or function, congestive heart
failure that requires pharmacologic
treatment, hypersensitivity to metformin,
acute or chronic metabolic acidosis
including with or without coma diabetic
ketoacidosis patients. Temporarily

112
 discontinue in patients who are
undergoing radiologic studies.

Side Effects ● Nausea

● Vomiting
● Diarrhea
● Stomach pain

Adverse Effects GI effects including anorexia, nausea,

vomiting and diarrhea; taste disturbance,
weight loss; impaired absorption of
various substances including vitamin
B12; lactic acidosis.

Drug Interactions ● Drug-drug:

- Dofetilide, Digoxin, Cimetidine,
digoxin, morphine, procainamide,
quinidine, ranitidine, triamterene,
vancomycin, Calcium channel
blockers, corticosteroids,
estrogens, oral contraceptives,
phenothiazines,
sympathomimetics, diuretics,
phenytoin, β- blockers; monitor
blood glucose

Nursing Responsibilities 1. Check any history of drug allergy of

the patient.
R: A drug allergy may cause severe
reactions, including a
life-threatening condition that affect

113
 multiple body systems
(anaphylaxis).
2. Verify pt has not received IV
contrast dye within the last 48 hrs.
3. Obtain CBC, renal function test,
fasting serum, glucose, Hgb A1c.
4. Monitor fasting serum glucose, Hgb
A1c, renal function, CBC.
5. Monitor folic acid, renal function
tests for evidence of early lactic
acidosis.
6. If pt is on concurrent oral
sulfonylureas, assess for
hypoglycemia (cool/wet skin,
tremors, dizziness, anxiety,
headache, tachycardia, numbness
in mouth, hunger, diplopia).
7. Be alert to conditions that alter
glucose requirements: fever,
increased activity, stress, surgical
procedure.
8. Report symptoms of lactic acidosis
(unexplained hyperventilation,
muscle aches, extreme fatigue,
unusual drowsiness).
9. Prescribed diet is the principal part
of treatment; do not skip, delay
meals.
10. Instruct the client to avoid alcohol.

114
 11. Report persistent headache,
nausea, vomiting,
diarrhea or if skin rash, unusual
bruising/bleeding,
change in color of urine or stool
occurs
12. Do not take dose for at least 48 hrs
after receiving
IV contrast dye with radiologic
testing

Generic Name Gliclazide

Brand Name Diamicron

Drug Classification Sulfonylurea

Suggested Dose For patients with Type 2 Diabetes

Mellitus:
● Adult: 40 to 80 mg daily. Daily
maximum of 320 mg. When the
daily dose is more than 160
milligrams, it is usually given in
two portions. In the form of an

115
 adjusted tab release: Start with 30
mg once a day and gradually
increase by 30 mg every month
(or after 2 weeks if no decrease in
blood glucose is observed). Daily
maximum of 120 mg. The 80 mg
regular tablet is equivalent to the
30 mg modified-release tablet. As
long as the person's blood sugar
levels are closely monitored, the
switch is allowable.

Mode of Action By acting on the beta cell sulphonylurea

receptor and perhaps also by influencing
intracellular calcium transport, gliclazide
increases insulin secretion. It helps with
both phases of insulin release, but even
more so in the first abnormal phase that
occurs in type 2 diabetes.

Indications Oral hypoglycemics, also known as

anti-diabetic drugs, like this one are
prescribed to patients with type 2
diabetes. This happens by stimulating
the pancreas, which leads to an increase
in the amount of insulin that is secreted.

Contraindications Patients with diabetic ketoacidosis,

severe liver and kidney damage, or an
allergic reaction should not take this
medicine.

116
Side Effects Common side effects:
- Stomach ache or indigestion,
nausea, vomiting, diarrhea, and
constipation
Serious side effects:
- At the beginning of treatment,
especially, your eyesight may be
temporarily impaired due to
fluctuations in blood sugar. Do not
operate any motorized vehicles,
bicycles, or heavy machinery until
the situation has improved. Get it
checked out by a doctor if your
worries aren't allayed.

Adverse Effects Hypoglycemia, increase liver enzymes,

photosensitivity, and rash

Drug Interactions Drug-drug:

- alcohol , angiotensin, converting
enzyme-inhibitors,
antituberculars, azole antifungals,
beta-blockers, clarithromycin,
clofibrate, disopyramide, H2 -
receptor antagonists, MOA
inhibitors, NSAIDs,
phenylbutazone, salicylates,
sulfonamides, warfarin, alpha
glucosidase inhibitors, biguanides
and insulin.

117
 - Chlorpromazine, corticosteroids,
danazol, diuretics, hormonal
contraceptives, ritodrine,
salbutamol, terbutaline, and
tetracosactrin.

Nursing Responsibilities 1. Observe for patient’s signs and

symptoms of hypoglycemia such as
hunger, weakness, sweating,
dizziness, tachycardia and anxiety.
R: Early detection of signs and
symptoms will help prevent further
complications
2. Assess the patient for allergy to
sulfonylureas.
R: Gliclazide is a second-generation
sulfonylurea; thus, it can trigger
hypersensitivity in the patient,
leading to harm to the patient.
3. Monitor serum glucose and
glycosylated hemoglobin periodically
during therapy.
R: It is to evaluate the effectiveness
of gliclazide in managing the
patient’s diabetes.
4. Monitor liver function periodically in
patients with mild to moderate liver
dysfunction.
R: Gliclazide may cause an increase
in AST, ALT, alkaline phosphatase,
and LDH of the patient.

118
5. Monitor renal function periodically in
patients with mild to moderate renal
dysfunction.
R: Gliclazide may cause an increase
in creatinine of the patient and can
result in hyponatremia.
6. Explain to the patient that this
medication does not cure diabetes
and must be used in conjunction
with a prescribed diet, and exercise
regimen, to prevent hypoglycemic
and hyperglycemic events.
R: To prevent confusion and allow
the patient to
play a bigger role in their own health
7. Monitor closely the glucose of the
resident during periods of stress or
illness and health care professionals
are notified if significant changes
occur.
R: Monitoring blood sugar will help
determine if the patient is at the right
glucose level, to reduce
complications
8. Review signs of hypoglycemia and
hyperglycemia with the patient. If
hypoglycemia occurs, advise the
caregiver of the patient to let the
patient drink a glass of orange juice
or ingest 2– 3 tsp of sugar, honey, or

119
 corn syrup dissolved in water or an
appropriate number of glucose
tablets and notify health care
professionals.
R: To increase blood glucose level
from low blood sugar in order for the
brain to have enough fuel to function
properly.
9. Instruct the caregiver of the patient
to let the patient take gliclazide as
directed at the same time every day.
R: Emphasize frequency of drug
intake to let the drug work properly
10. Instruct patient to avoid sun
exposure and to wear protective
clothing and sunscreen when
outdoors.
R: To protect your skin from the sun
as this medication causes
photosensitivity or makes your skin
sensitive to the sun.
11. Advise the caregiver of the patient to
notify health care professionals
promptly if unusual weight gain,
swelling of ankles, drowsiness,
shortness of breath, muscle cramps,
weakness, sore throat, rash, or
unusual bleeding or bruising occurs.
R: Health care professionals may be
able to advise you on methods to

120
 prevent or lessen some of these
effect.

E. Surgical Management

Foot debridement, which is widely practiced in diabetic foot care, may consist of
removal of skin, soft tissue, tendon and bone, which could include digit or ray
amputations.

i. Actual
PROCEDURE DEFINITION RATIONALE NURSING
RESPONSIBILITY

Debridement and Debridement is the Surgical Pre Operative

disarticulation of removal of dead debridement of a Assess the patients
right toe (necrotic) or diabetic foot ulcer level o1
infected skin tissue stimulates the edge understanding
to help a wound of the wound, R: Facilitates
heal. It’s also done releases growth planning of
to remove foreign factors and reduces preoperative
material from inflammation. teachinal programs.
tissue. It is a Removing dead, Identifies content
procedure for diseased and needs.
treating a wound in infected tissue
the skin which allows healthy Implement an
involves thoroughly tissue to heal. individualized
cleaning the wound Eliminates preoperative
and removing all conditions for teaching program
hyperkeratotic bacterial R: Enhances
(thickened skin or overgrowth and client's
callus), infected, other disease understanding and
and nonviable processes that control and can

121
(necrotic or dead) could lead to pain, relieve stress
tissue, foreign sepsis, and related to
debris, and residual eventually, the unknown or
material from amputation. The unexpected.
dressings. technique alters the
Debridement can environment of the Remove dentures,
be accomplished chronic wound and partial plates
either surgically or promotes healing. bridges
through alternate preoperatively per
methods such as protocol.
use of special R: Foreign bodies
dressings and gels. may be aspirated
Disarticulation, on during
the other hand, is endotracheal
the disconnection intubation and
of all or part of a extubation
limb from the body,
specifically through Validates that
a joint. This is in onerative consent
contrast to has been signed
amputation, which R: To protect the
is the disconnection patient from
or removal of the unsanctioned
structure through a surgery and protect
bone. the surgeon from
claims of an
unauthorized
operation.

Keep the patient

122
nothing by mouth
(NPO) before
surgery.
R: Being NPO
helps prevent
aspiration
during anesthesia
when the gag reflex
is
compromised.

Verifies completion
of preoperative
diagnostic testing
R: To help find
possible problems
that might
complicate the
surgery if not found
and treated early.

Intraoperative
care
1. Monitor vital
signs to ensure that
the patient remains
hemodynamically
stable.
2. Monitor the
patient's oxygen

123
level and provide
airway support and
maintenance as
needed.
3. Frequently
monitor the
patient's level of
consciousness and
immediately report
alterations to the
healthcare team.
Post-operative
Care
1. Frequently
assess the patient's
pain level using the
healthcare
organization's
approved pain
assessment scoring
tool.
2. When
administering
commonly ordered
post-op
medications, such
as analgesic,
opioid, and
anti-inflammatory
medications,

124
always assess for
potentiating effects.
3. Cleanse the
surgical incision
with an antiseptic
cleanser as
prescribed. Inspect
the surgical incision
line to ensure that
the tissue is healing
and well
approximated.
4. Frequently
assess skin
integrity at the
surgical site for the
presence of bloody
fluids.
5. Lightly palpate
the tissue to assess
for the presence of
abnormal firm
areas that may be
abscess pockets or
an evolving
hematoma.
6. To minimize post
Surgical
complications,
promote early

125
 ambulation and
progressively
increasing physical
activity

ii. Possible
Name of Definition Rationale Nursing
Procedure Responsibilities

Whole-Pancreas A pancreas Pancreas Pre-operative

Transplantation transplant is transplantation can Care
surgery to implant a be used as a 1. Patients
healthy pancreas treatment option for undergoing
from a donor into a patients with type 1 major surgery
person with diabetes. Usually, it are admitted to
diabetes. Pancreas is done for patients the hospital 2
transplants give the who have to 3 days
person a chance to end-stage kidney before surgery
stop taking insulin disease and have to optimize
injections. had or plan to have blood glucose
Pancreatic a kidney transplant. control.
transplantation is The 1-year survival 2. Sulfonylureas
performed in one of rate for patients is are
three ways: above 95%, with discontinued 1
pancreas transplant more than 83% of day before
alone (PTA), patients remaining surgery.
pancreas after free of insulin 3. Metformin
kidney (PAK) injection and diet (Glucophage)
transplant, and restrictions after 1 is stopped at
simultaneous year. least 24 hours
pancreas and before surgery

126
kidney (SPK) and restarted
transplant. SPK only after
transplant is the kidney function
ideal procedure for is normal.
patients with DM 4. Patients taking
and uremia. long-acting
insulin may
need to be
switched to
intermediate
acting insulin
forms 1 to 2
days before
surgery. 5.
Preoperative
blood glucose
levels should
be less than
200 mg/dL
(11.1 mmol/L).
6. Plan ahead
for pain control
after surgery

Intra-operative
Care
1. IV infusion of
insulin,
glucose, and
potassium is

127
 standard
therapy for
perioperative
management of
diabetes.
2. Monitor the
patient's
temperature—it
may be
lowered
deliberately in
some surgical
procedures and
inadvertently in
others.
3. Monitor arterial
blood gas
values for
acidosis.

Post-operative
Care
1. Maintain the
patient’s blood
glucose
between 140
and 180 mg/dL
(7.8 and 10.0
mmol/L) for
critically ill

128
 patients
2. Continue
glucose and
insulin
infusions as
prescribed until
the patient is
stable and can
tolerate oral
feedings.
3. Short-term
insulin therapy
may be needed
after surgery
for the patient
who usually
uses oral
agents

129
VIII. NURSING MANAGEMENT

i. Clustering of cues with the use of Gordon’s Functional Health Patterns

Clustered data Nursing diagnosis Priority
Health Perception and Management
● “Naglimpyo ko sa amoang balay
unya nasamad ko. Wala lang nako
gi huna huna kay abi nako wala ra.
Sa kadugayan natingala ko wala
siya gaayo unya galala” as
verbalized by the patient.
● CBG (N: 70 mg/dL - 100 mg/dL) Risk for Unstable Blood Glucose Level Medium priority - 1
- 10/11/22 at 5 AM: 173 H
- 10/11/22 at 12:00 PM - 156
H
- 10/11/22 at 3 PM: 70 N
- 10/11/22 at 4:20 PM: 114 H
- 10/11/22 at 6:12 PM: 100
borderline
- 10/17/22: 185 H
● HBA1C (Nyco) [N: 4.5 - 6.3 %]
08/30/22 : 7.0 % H
● FBS: 4.84 mmol/L (border line)

130
 ● Serum uric acid 08/30/22: 0.43 H
(0.208-0.428)
● aPTT 10/11/22: 41.5 sec H
● HDL 08/30/22: 0.75 mmol/L L
● RBC 08/30/22: 5.53 x 10^12/L H
● WBC 08/30/22: 12.2 H
- Lymphocytes: 0.19 L
- Monocytes: 0.11 H
● Medications:
○ Human regular insulin 4
units SQ
● Oct 11: Disarticulation and
Impaired physical mobility Medium priority - 2
debridement on Right toe
Situational self-esteem Low priority - 3

Risk for infection Low priority - 1

Risk for fall Low priority - 2

Nutritional/Metabolic
● “Gi kapoy na ko mag sigeg ihi Fluid Volume Deficit High priority - 1
maam natingala pud ko kay dili
man ko hilig mag inom og tubig
nganong mag sige sige gihapon” as

131
 verbalized by the patient
● “Nurse nabalaka pud mi ba kay
Imbalanced nutrition: less than body Medium priority - 3
nagbaba ug tulo ka kilo akong papa
requirements
na wala man na siya naga diet” as
verbalized by the patient’s son. Impaired Skin Integrity High Priority - 2

● Black ulcerations on the Right Big

toe
● 2nd toe with irregular borders
● Yellow-greenish pus on Plantar
surface
● Foul-smelling drainage from the
ulceration
● Weight = loss 4 kg
○ BMI = 23.4
○ Past month weight = 76kg
○ Current weight = 72kgs
○ Height = 5’9
○ Calorie intake
● Dry skin
● Decreased skin turgor = goes back
after 4 seconds
● Polydipsia - 2,200ml for the past 8

132
 hrs shift

Elimination pattern
● Polyuria - 2-3x per hour - Urine Fluid Volume Deficit
output = 1500 for the past shift
● Urine Glucose 10/11/22: +++

Activity/Exercise
● ECG = ventricular premature
contractions
● Vital signs:
○ T - 36.5
○ RR - 19
○ PR - 82
○ CR - 84
○ BP - 110/80
● Difficulty on moving
● Slow movement
● Dependent to others
● Limited range of motion
● Reluctant to move
● Mag lisud ko ug lihok na ako lang”

133
 A. Nursing Care Plans
1. Fluid Volume Deficit
Name of Patient: R.H Age/Sex: 62-M Room/ Bed No: 433-2
Chief Complaint: Non-healing wound right foot .Attending Physician: Dr. Arao .
Diagnosis (if Discharged): .

Date Cues Need Nursing Patient Nursing Imple Evaluation

& Diagnosis Outcome Interventions menta
Time tion

O Subjective: N Deficient fluid Within 8 hours 1. Monitor and 1 October 23, 2022
C “Gi kapoy U volume of nursing document vital @7am
T na ko mag T related to intervention, signs, especially “GOAL
O sigeg ihi R active fluid the patient will BP and HR. PARTIALLY MET”
B maam I loss: osmotic demonstrate R: A decrease in
E natingala T diuresis as adequate circulating blood Within 8 hours of
R pud ko kay I evidenced by hydration as volume can cause nursing
dili man ko O sudden evidenced by hypotension and intervention, the
23, hilig mag N weight loss, stable vital tachycardia. Alteration patient
inom og A increased signs (within in HR is a demonstrated
2 tubig L urine output, normal compensatory adequate
0 nganong - thirst, and range), good mechanism to maintain hydration as
2 mag sige M poor skin skin turgor, cardiac output. evidenced by
2 sige E turgor. and Usually, the pulse is stable vital signs

134
 gihapon” as T individually weak and irregular if of T= 36.5, RR
@11 verbalized A R: In appropriate electrolyte imbalance =18, HR = 80, BP,
PM by the B uncontrolled urinary output also occurs. 120/80, good skin
patient O Type 2 of 300-480cc. Hypotension is evident turgor with skin at
L Diabetes in hypovolemia. 2 the back of the
“Nurse I Mellitus, the 2. Assess skin hand snapping
nabalaka C blood is turgor and back to its normal
pud mi ba concentrated mucous position right after
kay P with more membranes, pinching, and with
nagbaba ug A glucose, with the addition slightly
tulo ka kilo T which makes of peripheral appropriate
akong papa T it more pulses and urinary output of
na wala E viscous. In an capillary refill. 950cc light yellow-
man na siya R attempt to R: Signs of colored urine.
naga diet” N dilute the dehydration are also
as increased detected through the
verbalised blood skin. The skin of
by the viscosity, elderly patients loses Maria Fernanda
patient’s there will be elasticity; hence skin Inayangan, St.N.
son. fluid shifting turgor should be
from the assessed over the
Objective: intracellular sternum or on the

135
● Diagno space to the inner thighs.
sis of intravascular Longitudinal furrows
DM space in a may be noted around
type II process the tongue. These are
since called indicators of level of
2021 osmotic hydration and
● Polyuria diuresis. The adequacy of circulating
(urinate body will try volume.
3
s 2-3 to get rid of 3. Monitor intake
times the excess and output
every glucose (I&O)


hour through R: Provides ongoing
with a frequent estimates of volume
urine urination, replacement needs
output which and effectiveness of
of eventually therapy. 

4
1500cc leads to large 4. Weigh clients
in the deficits of daily and watch
past 8 water. for sudden
hrs decreases,
shift) Reference: especially in the
Galicia-Garci presence of

136
(N: 30 to 60 a, U., decreasing
cc/hour) Benito- urine output or
● Weight Vicent active fluid loss.
loss of e, A., R: Provides the best
4kg Jebari, assessment of current
from S., fluid status and
76kg Larrea- adequacy of fluid
(past Sebal, replacement. Note:
month) A., Body weight changes
to 72 kg Siddiqi of 1 kg (2.2 pounds)
(admiss , H., represent a fluid loss
ion Uribe, of 1 L. Use the same
weight) K. B., weighing scale, and
● Decrea Ostola take note of the
se skin za, H., unnecessary objects
turgor & that would alter the
(goes Martín, weight. 

back C. 5. Commence a
5
after 4 (2020). thorough
second Pathop assessment of
s) hysiolo the patient’s
● Dry skin gy of history of risk

137
● Polydip type 2 factors for
sia diabet volume
(2,200 es depletion.
ml for mellitu R: Assessment of
the past s. these risk factors may
8 hrs Interna aid in determining the
shift) tional amount of fluid lost,
Journa which therefore aids in
Vital signs: l of determining how much
● T = 36.5 Molecu fluid must be replaced.
C lar 6. Provide oral 6
(N: Scienc fluids as
36.6-37.2) es, prescribed
● RR: 19 21(17), throughout the
bpm 6275. day.
(N: 14-22 https:// R: Distribute the
bpm) doi.org amount of fluids
● HR: 82 /10.33 throughout the entire
bpm 90/ijms day. Provide 2/3 of the
(N: 60-110 21176 fluids prescribed
bpm) 275 during the day and 1/3
at night. For example,

138
● BP: offer 1000ml during the
110/80 day shift and 500ml on
mmHg the night shift for a
(N: 90/60 total of 1500ml
-120/75 prescribed.
mmHg) 7. Emphasize the
10
importance of
Laboratory oral hygiene.
results: R: A fluid deficit can
● Seru cause a dry, sticky
m mouth. Attention to
uric mouth care promotes
acid: interest in drinking and
0.43 reduces the discomfort
(N: of dry mucous
0.208-0.428 membranes.
) 8. Teach the 11
● +++ patient and
urine family about the
gluco importance of
se appropriate food
and fluid intake.

139
● Dark R: Providing a
yello rationale promotes
w compliance and helps
color prevent the issue.
ed 9. Educate about
urine signs and
12
symptoms of
dehydration and
conditions that
increase the
likelihood of
becoming
dehydrated.
R: Knowledge about
these manifestations
allows the patient and
family to be proactive,
recognize states of
fluid loss early, and
when to contact the
healthcare provider.

140
 10. Administer
parenteral fluids
7
as prescribed.
Consider the
need for an IV
fluid challenge
with an
immediate
infusion of fluids
for patients with
abnormal vital
signs.

R: Fluids are
necessary to maintain
hydration status.
Determination of the
type and amount of
fluid to be replaced
and infusion rates will
vary depending on
degree of deficit and

141
individual client
response.
11. Monitor the
client's
8
response to
prescribed fluid
therapy,
especially
noting vital
signs (mean
arterial pressure
[MAP] >65 mm
Hg in the first 6
hours of
treatment,
systolic blood
pressure >100
mm Hg), urine
output, blood
lactate
concentrations,

142
 and lung
sounds.
R: A fluid challenge
can help the client with
deficient fluid volume
regain intravascular
volume quickly, but the
client must be carefully
observed to ensure
that he or she does not
go into fluid volume
overload because
excess fluid volume
can lead to organ
edema and increased
mortality.
12. Monitor
laboratory
9
studies, such
as: Hct,
BUN/Cr, Serum
osmolality,

143
 Sodium, and
Potassium
R: To rule out
worsening of
underlying condition or
development of
complications.

144
 2. Impaired Skin Integrity
Name of Patient: R.H. Age/Sex: 62 - Male .Room/ Bed No: 433-2
Chief Complaint: Non healing wound on the right foot Attending Physician: Dr. Arao_________________
Diagnosis (if Discharged): Type II Diabetes Mellitus

Date Cues Need Nursing Patient Nursing Interventions Impleme Evaluation

& Diagnosis Outcome ntation
Time

O Subjective N Impaired skin Within 8 hours ● Complete skin 1 October 23,

C cues: U integrity related of nursing assessment 2022 @ 7
T ● “Naglimpyo T to poor intervention, R: A thorough am, Goal
O ko sa R circulation of the patient will head-to-toe skin met
B amoang I the blood as assessment
display After 8 hours
E balay unya T evidenced by should be
improvement in of nursing
R nasamad I poor skin performed on
wound healing interventions
ko. Wala O turgor, dry skin, admission, transfer
as evidenced , the patient
2 lang nako gi N and black between units, and
3 huna huna A ulcerations on by good skin once per shift to was able to

, kay abi L the right big turgor, moist monitor and/or display

nako wala toe. skin and prevent skin improvemen

2 ra. Sa / healing breakdown. t in wound
0 kadugayan Rationale: ulceration on ● Assess skin turgor, 2 healing as
2 natingala ko M Infected areas the right big sensation, and evidenced

145
2 wala siya E heal toe. circulation by good skin
gaayo unya T slowly because R: Poor skin turgor, moist
@ galala” as A the turgor, decreased skin and
verbalized B damaged sensations (nerve healing
1 by the O vascular damage), and poor
ulceration on
1 patient. L system cannot circulation (lack of
the right big
P I carry sufficient blood flow
toe.
M Objective cues: C oxygen, white assessed via
- - Black blood cells, palpation of pulse
7 ulcerations nutrients and sites as well as
A on right big antibodies to observed by Alyssa B.
M toe the injured site. purplish or ruddy Lopez, St.N
- Foul-smelli Because of discoloration of
ng this, the poor lower legs)
drainage circulation can increase the risk of
from the make it difficult tissue damage.
ulceration for the wound ● Keep the area 3
- 2nd toe to heal. High clean/dry, carefully
with glucose levels dress wounds to
irregular can also slow prevent infection,
borders the healing and stimulate
- Dry skin process of an circulation to

146
- Decreased infected surrounding areas.
skin turgor wound. R: To assist body’s
- goes back natural process of
after 4 Reference: repair and remove
seconds Okano, J. non-viable,
- Vital signs (2018). Skin contaminated, or
taken: Barrier infected tissue.
○ T - 36.5 °C Dysfunctions ● Apply appropriate 4
○ RR = 19 with dressing and
cpm Impairment of practice aseptic
○ PR = 82 Epidermal technique for
bpm Integrity in cleaning or
○ CR = 84 Non-Wounded dressing.
bpm Skin of R: For wound
○ BP = 110/80 Diabetic. healing and to best
mmHg Retrieved meet needs of the
October 22, patient care
2022 from, setting.
https://www.nc ● Use gentle 5
bi.nlm.nih.gov/ moisturizers on the
pmc/articles/P foot as ordered by
MC5113047/ the physician.

147
 R: Moisturizers
soften and
lubricate dry skin,
preventing skin
cracking.
● Promote regular 6
turning or position
change.
R: To prevent
prolonged
pressure on one
area of the body.
● Encourage the 7
patient to provide
optimum nutrition
including vitamins
such as A,C,D,E
and increased
protein intake.
R: To provide a
positive nitrogen
balance to aid in

148
 skin or tissue
healing and to
maintain general
good health.
● Encourage 8
adequate fluid
intake.
R: Proper intake of
fluids increases
oxygen and
nutrient delivery to
the wound bed by
increasing the
blood volume.
● Instruct the family 9
to maintain clean,
dry clothes
preferably cotton
fabric.
R: Skin friction
caused by stiff or
rough clothes

149
 leads to irritation of
fragile skin and
increases the risk
for infection.
● Educate the 10
patient in
understanding and
following medical
regimen and daily
maintenance.
R: Enhances
commitment to
plan, optimizing
outcomes.

150
 3. Risk for Unstable Blood Glucose Level
Name of Patient: R.H. Age/Sex: 62 - Male .Room/ Bed No: 433-2
Chief Complaint: Non healing wound on the right foot Attending Physician: Dr. Arao_________________
Diagnosis (if Discharged): Type II Diabetes Mellitus

Time/ Cues Need Nursing Patient Nursing Imple Evaluation

Date Diagnosis Outcome Intervention ment
ation

O Subjective: N Risk for Unstable Within 8 hours of Independent October 23,

C “Nurse U Blood Glucose nursing ● Assess for signs 1 2022
T nabalaka T Level as evidenced intervention, the of hyperglycemia. @7am
O pud mi ba R by excessive patient will R: Hyperglycemia “GOAL MET”
B kay I weight loss. maintain a blood results when there
E nagbaba ug T glucose level of is an inadequate After 8 hours of
R tulo ka kilo I R: In people with less than 100 amount of insulin to nursing
akong papa O diabetes, mg/dL. glucose or when the intervention, the
23, na wala N insufficient insulin body can't use patient
man na siya A or resistance to insulin properly. maintained a
2 naga diet” L insulin prevents the Excess glucose in blood glucose
0 as - body from getting the blood creates an level of less
2 verbalized M glucose from the osmotic effect that than 100 mg/dL
2 by the E blood into the results in polydipsia, as evidenced
patient’s T body’s cells. This polyphagia, and by CBG result
@11 son. A results to glucose polyuria. The patient of 95 mg/dL.
PM B being continuously may also report
Objective: O accumulated in the nonspecific
● Weight L blood. When cells symptoms of fatigue
loss of I can’t get energy and blurred vision.

151
 4kg from C from glucose, the
76kg body starts burning ● Monitor and 3
(past P fat and muscle for document vital
month) to A energy, causing a signs, especially Marielle
72 kg T reduction in overall BP. Lorraine M.
(admissio T body weight. R: Diabetes with Gultiano, St.N.
n weight) E Unexpected weight untreated, high
R loss is often blood pressure can
Laboratory N noticed in people raise the patient’s
results: prior to a diagnosis risk for heart
● CBG (N: of type 1 diabetes disease and stroke.
70 mg/dL but it may also Vital signs are also
- 100 affect people with monitored to check
mg/dL) type 2 diabetes. patient’s response
10/11/22 to insulin
-5 AM: 173 medication.
H Reference:
-3 PM: 70 N Walker, R. (2020). ● Teach the patient 4
-4:20 PM: The Diabetes on measuring
114 H Handbook, 14-16. capillary blood
-6:12 PM: Dorling Kindersley glucose (CBG).
100 Limited. R: Capillary blood
borderline glucose monitoring
10/17/22: provides the patient
-185 H with immediate
● FBS (N: information about
4.10 - their own blood
5.90 glucose.

152
 mmol/L)
08/30/22: ● Educate the 5
4.84 patient about the
mmol/L proper ways of
taking prescribed
Vital signs: medications.
● T = 36.5 R: The patient with
C (N: diabetes needs to
36.6 - learn about taking
37.2) insulin or oral
● RR: 19 hypoglycemic drugs
bpm (N: to lower blood
14-22 glucose.
bpm)
● HR: 82 ● Assist the patient 7
bpm (N: in identifying
60-110 eating patterns
bpm) that need to be
● BP: modified.
110/80 R: This information
mmHg provides the basis
(N: 90/60 for individualized
-120/75 dietary instruction
mmHg) related to the clinical
condition that
contributes to
fluctuation in blood
glucose levels.

153
● Discuss the 8
importance of
balancing
exercise with
food intake.
R: Exercise
balances glucose
levels by facilitating
uptake of glucose
into cells. The
patient needs to
understand the
relationshipbetween
f exercise, food
intake, and blood
glucose levels.

● Review the 9
patient’s progress
toward goals
during the day
such as
adherence to
medications and
diet.
R: Patient
involvement in the

154
treatment plan
enhances
adherence to the
treatment plan.

● Check glucose 10
level through
CBG and FBS.
R: To rule out
worsening of
underlying condition
or development of
complications. This
is also done to
evaluate the
expected patient
outcome.

Dependent
● Administer insulin 2
medications as
directed.
R: Insulin is
required to lower
blood glucose
levels in type 1
diabetes, and for
many patients

155
 with type 2
diabetes.
Patients
receiving TPN
may require
insulin to
maintain stable
blood glucose in
response to high
dextrose
concentration in
the solution.

● Refer to a 6
registered
dietitian for
individualized diet
instruction.
R: An individualized
meal plan depends
on the patient’s
body, weight, blood
glucose values,
activity patterns,
and specific clinical
conditions.
Modifications in the
patient’s food intake

156
will contribute to
stabilization of blood
glucose levels.

157
 4. Impaired Physical Mobility
Name of Patient: R.H. Age/Sex: 62 - Male .Room/ Bed No: 433-2
Chief Complaint: Non healing wound on the right foot Attending Physician: Dr. Arao_________________
Diagnosis (if Discharged): Type II Diabetes Mellitus

Time/ Cues Need Nursing Patient Nursing Imple Evaluation

Date Diagnosis Outcome Intervention ment
ation

O Subjective A Impaired physical Within 8 hours of ● Assess the 1 October 23,

C Cues: C mobility related to nursing client for 2022 @
T “Mag lisud T presence of intervention, the mobility, gait, 7:00am
O ko ug lihok I surgical incision as patient will strength and Goal met
B na ako lang” V evidenced by motor skills
display After 8 hours of
E I disarticulation and
improvement in nursing
R Objective T debridement on Rationale: This
physical mobility assessment interventions,th
Cues: Y Right toe
provides data on the e patient was
2
Rationale: extent of any able to display
3 Disarticulati A
Unmanaged
on and N physical problems improvement in
diabetes can lead
2 debridement D and guides therapy. physical activity
to disarticulation or
0 on Right toe as evidenced
amputations ● Take note of 2
2 E by performing
usually of the toes, prescribed

158
 2 Difficulty on X feet, or leg. It is movement activities on its
moving E because of the limitations own such as
@ R reduced blood flow. eating, drinking
Slow C As a result, tissue Rationale:
and getting
11:00 movement I can become Following surgery
into/out of bed.
pm S damaged, and an patients may be

Dependent E infection can prescribed bed rest

to others develop and to prevent injury.

P spread to the Other orders such

Limited A bones. Once this as “non-weight Ma. Danica

range of T happens, bearing” status or
Grace Guba St.
motion T amputation or the use of braces,
N
E disarticulation is slings, and

Reluctant to R often the only immobilizers must

move N option to prevent be considered.

more damage
● Perform TUG
Vital signs: Disarticulation is 3
(timed up and
T - 36.5 separation or
go) test
RR - 19 amputation of a
PR - 82 body part at a joint.
Rationale: To
CR - 84 The main effect of
assess mobility,
BP - 110/80 this procedure is a

159
reduction of a balance, walking
person's mobility, ability, and fall risk
meaning that they in older adults.
will not be able to
walk as they did ● Evaluate 4
pre-injury or need for

surgery. assistive
devices.

Reference:
Rationale: Proper
Pagan, C. N., &
use of wheelchairs,
Dansinger, M.
(2021). Amputation canes, transfer bars,
and Diabetes. Web and other
MD.com. assistance can
https://www.webmd.c promote activity and
om/diabetes/amputat reduce danger of
ion-diabetes falls.

● Encourage
5
and facilitate
early
ambulation

160
 and other
ADLs when
possible.

Rationale: The
longer the patient
remains immobile
the greater the level
of debilitation that
will occur.

● Allow
patients to
6
perform tasks
at his or her
own rate. Do
not rush the
patient.

Rationale:
Healthcare
providers and

161
significant others
are often in a hurry
and do more for
patients than
needed. Thereby
slowing the patient’s
recovery and
reducing his or her
confidence.

● Provide the
patient of rest 7
periods in
between
activities.

Rationale: Rest
periods are
essential to
conserve energy.
The patient must
learn and accept his

162
her limitations.

● Turn and
position
every 2 8
hours, or as
needed

Rationale: To
optimize circulation
to all tissues and to
relieve pressure.

● Maintain
limbs in
functional
9
alignment
(e.g., with
pillows,)

Rationale: To

163
prevent foot drop
and/or excessive
plantar flexion or
tightness.

● Give positive
reinforcement 10
during
activity.

Rationale: This is to
boost the patient’s
chances of
recovering and to
increase his or her
self-esteem.

164
 5. Imbalanced Nutrition: Less than body requirements
Name of Patient: R.H Age/Sex: 62-M Room/ Bed No: 433-2
Chief Complaint: Non-healing wound right foot .Attending Physician: Dr. Arao .
Diagnosis (if Discharged): .

Date Cues Need Nursing Patient Nursing Imple Evaluation

& Diagnosis Outcome Interventions menta
Time tion

O N October 23, 2022

Subjective: Imbalanced Within 8 hours Weigh daily or as
C U nutrition: Less @7am
“Nurse of nursing ordered. 2
T T than Body “GOAL
nabalaka Requirement intervention,
O R related to R: Weighing serves as PARTIALLY MET”
pud mi ba the patient will
B I insulin an assessment tool to
kay insufficiency display Within 8 hours of
E T as evidenced determine the
nagbaba ug improvement nursing
R I by weight adequacy of nutritional
tulo ka kilo loss of 4 kg. of nutritional intervention, the
O intake.
akong papa intake as patient has
23, N
na wala Rationale: evidenced by Review the patient’s displayed
A
man na siya 1
2 L If a person eating food diet history. improvement of
naga diet” has that is high in nutritional intake
0 - insufficient
as R: To help identify the
2 M insulin it may protein. as evidenced by
verbalized prevent the patient’s eating habits “Ang akong sud
2 E body from
by the and lifestyle that could an ganina morning
T getting
glucose from be incorporated into

165
@11 patient’s A the blood into the meal plan. kay isda ug boiled
the body’s
PM son. B Consider the patient’s egg tapos sa
cells to use
O as energy, food preferences, afternoon kay nag
thus when
Objective: L eating times, food tinolang manok
this occurs,
Weight I the body values, special needs, ko. Then ako
starts burning
loss: 4kg C ethnic, and cultural panihapon kay
fat and
BMI: 23.4 muscle for backgrounds. nag wheat bread
energy,
Past month P with margarine ko
causing a Document, actual
weight: A reduction in ug avocado as
overall body weight, do not 3
76kg T verbalized by the
weight. estimate. Note total
Current T patient”.
daily intake,
weight: E
Reference: including patterns
72kgs R
and time of eating.
Height: 5’9 N Hardy, K.
(2019).
Unexplained R: Patients may be
Vital signs: Lonququianas,
weight loss. unaware of their actual
T = 36.5 C The global Abegail P., ST. N
diabetes weight or weight loss
(N: community. due to the estimation
36.6-37.2) Retrieved on
October 21, of weight.
RR: 19 bpm 2022 from
(N: 14-22 https://www.di Review the 4
abetes.co.uk/
bpm) carbohydrate
symptoms/un

166
HR: 82 bpm explained-wei counting method
ght-loss.html#
(N: 60-110 with the patient.
:~:text=Diabet
bpm) es%20and%2
0sudden%20 R: Carbohydrate
BP: 110/80
weight%20los counting involves
mmHg s,reduction%
20in%20over counting the number of
(N: 90/60
all%20body% grams of carbohydrate
-120/75 20weight.
in a meal and
mmHg)
matching that to your
dose of insulin.

Observe signs of
hypoglycemia: 5
changes in LOC, cold
and clammy skin,
rapid pulse, hunger,
irritability, anxiety,
headache,
lightheadedness,sha
kiness.

R: Hypoglycemia can
occur once blood

167
glucose level is
reduced, carbohydrate
metabolism resumes,
and insulin is given. If
the patient is
comatose,
hypoglycemia may
occur without a notable
change in LOC.

Promote a pleasant
relieving 9
environment
including
socialization.

R: This promotes
comfort to the patient
and encourages a
good eating habit.

168
Evaluate total daily 6
food intake.

R: Reveals possible
causes of weight loss
changes that could be
made in the patient's
intake.

Encourage me to eat
8
foods that are high in
protein such as fish,
meat, chicken,
legumes, eggs, nuts,
and full cream dairy
food, margarine, and
avocado.

R: Eating high protein

food can help a person
gain weight without

169
causing elevated blood
sugar levels.

Dependent:

Administer
medications as 7
indicated: Ryzodeg
and RI

R: May be useful in
treating symptoms
related to the level of
sugar.

Collaborative:

Consult a dietician
and/or physician for 10
further assessment
and recommendation
regarding food
preferences and
nutritional support.
R: To reveal changes
that should be made in

170
the client’s dietary
intake. For greater
understanding and
further assessment of
specific foods.

171
 6. Risk for Surgical Site Infection
Name of Patient: R.H. Age/Sex: 62 - Male .Room/ Bed No: 433-2
Chief Complaint: Non healing wound on the right foot Attending Physician: Dr. Arao_________________
Diagnosis (if Discharged): Type II Diabetes Mellitus

Date/ Time Cues Needs Nursing Diagnosis atient Outcome rsing Intervention mentatio valuation
n

O After 8 hours
C Subjective: H Risk for surgical site After 8 hours of Monitor for the 2
of nursing
T infection related to nursing signs of infection
O E intervention
B invasive procedure in intervention the and inflammation
A the patient
E right toe patient will be able such as flushed
R Objectives: was able to
L to remain free appearance, wound
display
2 T from symptoms of drainage, purulent
3 Rationale: remain from
H surgical site sputum, cloudy
Vital signs: Vulnerable areas symptoms of
2 infections (SSIs) urine.
0 such as fresh surgical surgical site
2 T - 36.5 until discharge as
incisions are R: Early diagnosis as
2 P evidenced by
RR - 19 especially prone to and treatment of evidenced
E absence of pus
infection. Purulent infections can by absence
11 drainage, redness
PR - 82 R
PM drainage may be control their of drainage
in the surgical
CR - 84 C cultured. severity and pus and
redness in

172
 E incision. decrease the surgical
BP - 110/80
P https://www.facs.org/ complications. site.
media/zr5dimjk/woun Patients with
T
d_surgical.pdf diabetes may be
Oct 11: I admitted with
Disarticulation O infection, which
and debridement could have
N
on Right toe Monica
precipitated the
Vivien
ketoacidosis state.
A Ramillano,
They may also
St.N
● Serum uric N develop a
acid nosocomial
D
08/30/22: infection.
0.43 H
M Monitor the
(0.208-0.4 1
temperature of the
28) A
patient.
● aPTT
N
10/11/22: R: Fever is often
A
41.5 sec H the first sign of an
● HDL G
infection. A
08/30/22: E temperature of up
0.75

173
 mmol/L L M to 38º C (100.4º F)
● RBC E 48 hours post-op is
08/30/22: usually related to
N
5.53 x surgical stress after
10^12/L H T 48 hours. A
● WBC temperature of
08/30/22: greater than 37.7º
12.2 H (99.8º F) may
● · indicate infection; a
Lymphocyt very high
es: 0.19 L temperature
● Monocytes accompanied by
: 0.11 H
sweating and chills
may indicate
· septicemia.

Assess and monitor 3

nutritional status,
weight, history of
weight loss, and
serum albumin.

174
 R: Patients with
inadequate nutrition
may be anergic or
unable to muster a
cellular immune
response to
pathogens, making
them susceptible to
4
infection.

Maintain strict
asepsis for
dressing changes
and wound care.

R: Aseptic
technique
decreases the
chances of
transmitting or
spreading
pathogens to or

175
 between patients. 5

Educate clients and

SO (significant
other) about
appropriate
cleaning and
disinfecting things.

R: Knowledge of
ways to reduce or
eliminate germs
reduces the likelihood
of transmission.
6
Administer basal and
prandial insulin.

R: Adherence to the
therapeutic regimen
promotes tissue
perfusion. Keeping
glucose in the normal
range slows the

176
 progression of
microvascular 7
disease.

Teach the patient

follow a low in simple
sugars, low in fat,
and high fiber and
whole grains.

R: A diet low in fat

and high in fiber
helps to control
cholesterol and
triglycerides. Three
daily meals and an
evening snack are
recommended.
Refined and simple
sugars should be
reduced, and
complex
carbohydrates, such 8
as cereals, rice

177
 should be increased.

Teach about the

importance of taking
antibiotics at the right
times and completing
them.

R: The patient needs

to know to complete
the entire course of
antibiotics even after
symptoms subsided
and the patient feels
better. Most
antibiotics need to be
taken at a specific 9
time to maintain a
certain blood level.

Teach the patient to

avoid walking with
bare foot and always
wear shoes and
socks inside or

178
 outside to avoid
minor bumps and
scrapes.

R: Diabetes can
cause nerve damage,
called peripheral
neuropathy, that
makes you lose
feeling in your feet.
This can be a
disaster if you're
walking around
without foot
protection.

179
B. Nursing Theories

“The Adaptation Model of Nursing” by Sister Callista Roy

As stated by Gonzalo (2019), Sister Callista Roy created The Adaptation Model
of Nursing is a prominent nursing theory aiming to explain or define the provision of
nursing science. Developed by Roy in 1976, the Adaptation Model of Nursing asks three
central questions: Who is the focus of nursing care? What is the target of nursing care?
And When is nursing care indicated? This model views the patient in a holistic
perspective. The three concepts of her model are the human being, adaptation, and
nursing. Under the concept of adaptation are four modes: physiological, self-concept,
role function, and interdependence.
In her theory, Sister Callista Roy‘s model sees the individual as a set of
interrelated systems who strives to maintain a balance between various stimuli. First,
consider the concept of a system as applied to an individual. Roy conceptualizes the
person in a holistic perspective. Individual aspects of parts act together to form a unified
being. Additionally, as living systems, persons are in constant interaction with their
environments. Between the system and the environment occurs an exchange of
information, matter, and energy. Characteristics of a system include inputs, outputs,
controls, and feedback.
According to Roy’s model, the goal of nursing is to promote adaptation of the
patient during illness and health in all four of the modes. Additionally, Roy explained that
adaptation occurs when people respond positively to the occurring environmental

180
changes, and it is the process and outcome of individuals and groups who use
conscious awareness, self-reflection, and choice to create human and environmental
integration. As previously mentioned, diabetes mellitus is a chronic disease, therefore,
patients who are diagnosed with diabetes will have to undergo extensive therapies in
management and control of the disease for the rest of their lives. For most chronic
illnesses, psychosocial and physiologic adaptation were not found to be correlated
according to some studies. With the exception of diabetes mellitus, physiologic and
psychosocial adaptation were found to be positively related.

“Theory of Goal Attainment” by Imogene King

Another statement from Gonzalo (2019), Imogene King‘s Theory of Goal

Attainment focuses on this process to guide and direct nurses in the nurse-patient
relationship, going hand-in-hand with their patients to meet the goals towards good
health. King‘s Theory of Goal Attainment was first introduced in the 1960s. The Theory
of Goal Attainment was developed by Imogene King in the early 1960s. It describes a
dynamic, interpersonal relationship in which a patient grows and develops to attain
certain life goals.
The Theory of Goal Attainment defines nursing as “a process of action, reaction
and interaction by which nurse and client share information about their perception in a
nursing situation” and “a process of human interactions between nurse and client
whereby each perceives the other and the situation, and through communication, they
set goals, explore means, and agree on means to achieve goals.” From the title itself,

181
the model focuses on the attainment of certain life goals. It explains that the nurse and
patient go hand-in-hand in communicating information, set goals together, and then take
actions to achieve those goals. King has interrelated the concepts of interaction,
perception, communication, transaction, self, role, stress, growth and development,
time, and space into a theory of goal attainment. Her theory deals with a nurse-client
dyad, a relationship to which each person brings personal perceptions of self, role, and
personal levels of growth and development. The nurse and client communicate, first in
interaction and then in transaction, to attain mutually set goals. The relationship takes
place in space identified by their behaviors and occurs in forward-moving time.
In chronic illnesses such as diabetes, there is a need for the three interacting
systems in the Theory of Goal Attainment namely: the personal system, the
interpersonal system, and the social system, to be recognized and integrated
throughout the whole process in order to effectively implement the plan of care based
on the recommended treatment regimen. Conditions such as Diabetes Mellitus require
the shared approach between the patient, family, and of the multidisciplinary health
team in setting and achievement of goals.

182
A. Review of Related Literatures

Effect of a Nurse-Led Diabetes Self-Management Education program on

Glycosylated Hemoglobin among Adults with Type 2 Diabetes

A 24-week clinical trial involving 142 adults with type 2 diabetes was conducted
under the title "Effect of a Nurse-Led Diabetes Self-Management Education program on
Glycosylated Hemoglobin among Adults with Type 2 Diabetes." Participants were
randomly assigned to one of two groups and participated in the study. A nurse-led
diabetes self-management education program with conventional diabetes care or
standard diabetic care (Control Group) (Intervention Group). The intervention group
receives the nurse-led DSME intervention for 24 weeks while the control group receives
the usual diabetic care. The Iranian Ministry of Health's T2DM management guidelines,
which include self-care, lifestyle changes, and medication adherence, form the basis of
standard diabetes treatment. Face-to-face consultations and brochures are used to
provide standard diabetic care education. The American Diabetes Educators identified
seven critical self-care practices for long-term and effective diabetes self-management.
These results show that the intervention was well-received by the patient and
that the logistics went smoothly. The clinical investigation found that after 24 weeks, the
nurse-led DSME offered 142 T2DM patients persistent improvements in clinical and
lifestyle outcomes. In persons with chronic illnesses, self-efficacy facilitation has
improved long-term health outcomes. According to the study, people can alter their
behavior by raising their intrinsic motivation and self-efficacy. These results are
consistent with the notion that the focus of healthcare delivery should change from
being doctor-centered to patient-centered. This might put more of an emphasis on
nursing education, patient self-management, and task confidence rather than only
hospital-based management.

183
 Nursing-Intense Health Education Intervention for Persons with Type 2
Diabetes: A Quasi-Experimental Study

Diabetes mellitus (DM), which has become more common over the years, is a
class of metabolic illnesses marked by hyperglycemia brought on by deficiencies in
insulin secretion, action, or both. This article divided DM into three categories
depending on etiology: type 1 diabetes (DM1), type 2 diabetes (DM2), and gestational
diabetes. 90% to 95% of patients in the three clinical classes fall into the DM2 category,
with the majority of these patients being overweight and between the ages of 50 and 60.

The aim of DM2 treatment is to maintain normoglycemia. The glycosylated

hemoglobin (HbA1c) test, which measures this parameter and offers up-to-date
information on blood glucose level changes, is used to measure it. DM2 patients
undergo pharmaceutical and non-pharmacological therapies in order to reach the
necessary HbA1c level. Since the risk of mortality is inversely correlated with the
patient's comprehension of the disease, it is crucial to become knowledgeable about the
condition and be able to provide the recommended treatment. As a result, nurses'
extensive health education programs have a big impact on how DM2 is treated globally.
Even the pre- and post-intervention results indicated a greater reduction in HbA1c in the
intervention group, according to the article's findings.

Considering that DM is a chronic, highly progressive condition, it is crucial to

incorporate health education interventions for DM2 patients since they help patients
maintain healthy lifestyles and improve their quality of life.

184
 Patients with Type 2 Diabetes Mellitus: Obstacle in Coping

A descriptive and cross-sectional study named "Patients with Type 2 Diabetes

Mellitus: Obstacle in Coping" collected data from 186 patients with type 2 diabetes
mellitus who were hospitalized in a Turkish endocrine clinic. Participants in this study
reported difficulties with "living with the disease," "self-monitoring," "disease diagnosis,"
and "lifestyle modifications," with treatment adherence, smoking, educational level, and
anxiety and depression levels indicating the presence of these obstacles. This was
discovered through the use of the Hospital anxiety and depression scale and the
diabetes obstacles questionnaire. Additionally, anxiety and depression were discovered
in this study to have a detrimental effect on lifestyle modifications (such as medication,
exercise, and diet) that are essential for the management of diabetic patients.

Patients' levels of anxiety and sadness as well as lifestyle decisions should be

addressed. As a result, successful diabetes management benefits diabetic therapy, and
successful anxiety and depression management may make it easier for patients to cope
with their illness on a daily basis. In order to promote the best diabetes treatment,
nurses should be knowledgeable about the variables that anticipate obstacles as well as
the difficulties that patients encounter when managing with illness in daily life. The
results of this study also highlight the need of nurses giving diabetic patients additional
attention and the significance of doing research to develop solutions that can help
overcome challenges.

185
IX. DISCHARGE PLANNING

Medications ● Take the prescribed medication as ordered.

R: Post-surgical operations and recovery phase cause mild to
severe pain, medications control and helps speed recovery
and reduced chances of complications. In order to manage
and maintain the health of the patient. Taking medicine as
prescribed by the physician and adhering to medical regimen
is crucial.
● Instruct the patient to take pain medication like tramadol
only when pain occurs and follow the doctor's prescription
exactly as directed.
R: To reduce the effect of pain on the patient function,
maintain a positive effect or mood and quality of life.
● Explain the importance of strict adherence to the
medication regimen as prescribed.
R:Diabetes medications are an important factor in achieving
good diabetes control and preventing mortality and morbidity.
Also, this is done to ensure that the patient fully understands
the need for medication.
● Instruct the patient and the caregiver to take medicines
exactly as directed. Don’t skip doses. If you have missed a
dose, call the healthcare provider right away. The
physician may prescribe the following medications to help
manage the patient’s condition:
R: The importance of 10 medication rights and taking all
medications prescribed is vital in controlling the patient’s
condition in order to prevent certain complications.
● Diabetes medicine or insulin to decrease the amount of
sugar in the blood; diabetes medicines such as Regular

186
 Insulin (Humulin R) and Insulin Degludec/Insulin Aspart
(Ryzodeg).
R: They reduce hyperglycemia by decreasing hepatic
gluconeogenesis. (primary effect) and increasing peripheral
insulin sensitivity (secondary effect).
● Instruct the patient to take prescribed insulin.
R: Type 2 diabetes causes cells to not respond normally to
insulin; this is called insulin resistance. Taking prescribed
insulin will enable the body to absorb more glucose in the
blood and prevent leading to type 1 and other complications.
● Instruct the patient on how to use insulin correctly.
R:Insulin absorption is more constant when it is administered
at the same anatomical place every time. The abdomen
absorbs the most fluid, followed by the arms, thighs, and
buttocks.
● Educate about home glucose monitoring.
R:To identify and control glucose changes, discuss glucose
monitoring at home with the patient based on specific factors.
● Inform the patient and family about the potential adverse
side effects, adverse reactions, and possible preventable
interventions they can do.
R: Some medication of the patient has mild to severe adverse
reactions. From neurologic, allergic, and gastrointestinal
complications, proper monitoring and taking prescribed
amounts of medication is a must to avoid undesired effects to
happen. Refer immediately to the hospital/physician any
undesired reactions.
● Instruct the patient and family to contact the healthcare
provider if the medicine is not helping. Inform the
physician If allergic to any medication.

187
 R: Reporting a decrease of effectiveness may help adjust
medication therapy.

● Before engaging in different types of exercises, inform the

Exercise
patient and family to consult their physician first.
R:This will promote independence, enhance self-esteem and
facilitate the recovery process. It may help control blood
sugar levels and lower the risk of heart disease and nerve
damage.
● Encourage the client to do a range of motion exercises as
tolerated.
R: Simple movement of limbs and body can improve blood
circulation all throughout the body. This can prevent deep
vein thrombosis and clots from forming, which normally
occurs when a post-operated patient has limited body
movements. Using muscles helps burn glucose and improves
the way insulin works. That’s why blood glucose levels
usually come down during exercise.
● Instruct the patient to maintain a healthy weight according
to the physician’s recommended weight goal.
R: Maintaining a healthy weight through dietary changes and
exercise makes it easier to manage the condition and reach
the target blood sugar levels for the patient.
● Plan daily activities.
R: To save time and energy, get plenty of rest. Plan the
patient’s activities so that he has rest periods. The
post-operated patient can use assistive devices as long as he
can stand and walk, if not do not force the patient, and only
do it near the bed to prevent injury.
● Avoid strenuous activities.

188
 R: Amputated wound: feet need time to heal and strenuous
activities might strain their wound.
● Encourage the patient to do yoga.
R: It can aid type 2 diabetes patients in controlling their blood
sugar, cholesterol, and weight.

● Instruct to continue the prescribed treatment by the doctor

Treatment
such as medications, diet and activities.
R: Doctor’s treatment must be followed for faster healing of
amputated wound and refer to the nurse or physician if
unusualities occur.
● Discuss the risks of not adhering to the treatment plan.
R: To inform the patient and people who are close to them
about the potentially hazardous or undesirable side effects of
not adhering to the treatment schedule.
● Advise patients to be mindful of his daily sugar intake and
glucose monitoring.
R: The patient has type 2 diabetes and taking more sugar or
glucose than necessary can lead to serious complications in
diabetes. Test the glucose level when possible in health
centers, it is free and monitoring the glucose level can make
the patient conscious of his food intake.
● Restrict the patient from smoking, Remind the patient that
e-cigarettes or smokeless tobacco still contain nicotine.
R: Nicotine and other chemicals in cigarettes and cigars can
make diabetes harder to manage.
● Remind patients to abide by the regimen and dressing of
the right foot wound.
R: Promoting clean and dry wounds will promote healing and
avoid infection.
● Confirm follow up check-ups for update.

189
 R: Check-up and follow-ups or referrals can update the
attending physician on the status of the wound and healing of
the client. Reinforcing answers to questions about diabetes
and wounds. Further assessment of both, and clarifying
misunderstandings can be solved.

● Encourage the patient to wash his hands with soap and

Hygiene
water before and after eating, as well as before and after
using the restroom.
R: Patients with type 2 diabetes should be concerned about
their cleanliness habits. Patients with type 2 diabetes have
weakened immune systems, making them more susceptible
to infections and sepsis.
● Instruct the watcher to assist the client in doing comfort
room privileges.
R: With wound healing on the right foot, standing up may
pose problems to the patient; help is needed.
● Advice to carefully brush and floss their teeth every day.
R: Gum disease can be exacerbated by high blood sugar
levels, resulting in bleeding, sensitive gums, and gums that
tear away from teeth. Gum surgery may be required in the
future to save the patient’s teeth.
● Change clothes when soaked or wet with sweat, change
linens regularly.
R: Skin exposure to sweat may lead to bacterial growth, and
healing of the wound must observe cleanliness and deter
bacterial growth. If the patient does not turn to the sides or
can get up to change linens, there may be sweat
accumulation on his back and the sheets, change clothes and
linen immediately for comfort.
● Avoid places with unclean and polluted air and surfaces.

190
 R: Dirty places may introduce bacterial and viral infections to
the wound, causing further integrity impairment. Keeping the
environment clean will prevent infection as much as possible.

● Instruct the watcher to comply with the doctor’s order on

Out-patient
when to come back for a follow-up and check-up.
R: Follow-up and check-up must be attended to further
assess the dressings and wound of the patient, find the
patient’s current physical findings after the discharge, and
monitor his glucose level.
● Make an appointment for an annual physical assessment
and frequent eye checks.
R: Diabetes can change the blood vessels in the eyes,
resulting in significant complications. Make sure the blood
sugar is under control and schedule an annual eye check with
an eye specialist.
● If unusualities are noted days after discharge, consult a
physician immediately to prevent further complications.
R: As part of the assessment, unusualities after surgery are
common and mean something is not right, and immediate
action must be taken.

● Inform the patient and watcher about the diet of the

Diet
patient, such as whole grains: whole wheat, brown rice,
barley, and oats
R: Whole grains contain a lower glycemic index. They do not
affect blood glucose levels compared to refined carbohydrate
foods which increase sugar in the blood that may complicate
a patient's diabetes and wound healing.
● Promote eating vegetables rich in fiber and regulate eating
fruits rich in sugar like mangoes.

191
R: Fiber can help control blood glucose levels in diabetes
patients. Fiber can make people feel fuller for longer and
improve cholesterol levels, and lower blood pressure.
● Inform to eat more protein-rich food such as lean meats,
chicken, fish, eggs, nuts, beans, and tofu. But less on
processed meats.
R: Protein does not increase blood sugar levels and provides
a source of energy for the muscles instead of using fats that
lead to ketones production.
● The patient might also have non-fat or low-fat dairy milk,
yogurt, and cheese.
R: Non-fat and low-fat dairy products have lower caloric
content to prevent weight gain in diabetic patients.
● Lessen consumption of carbohydrate-rich food such as
candy and sweets, sodas, bread, cakes, ice cream, and
white rice. The more carbs the patient eats, the higher the
blood sugar will be.
R: Carbohydrates are rich in sugar (AKA Glucose) which
mainly increases the glucose levels of the blood, making it
viscous.
● Remember to eat less starchy foods such as white
potatoes, corn and peas.
R: Starch is a complex carbohydrate that takes the body
longer to break down and raises blood glucose levels
significantly.
● Eating about the same amount of carbohydrates each
meal at around the same time, preferably five small meals
a day.
R: Eating the same amount of carbohydrates every meal will
regulate the body and brain and adapt to the new condition of

192
 the body after surgery. Five small meals are enough to
maintain the energy output of the body without compromising
the glucose level of the blood.
● Encourage the patient to drink lots of fluid.
R: It is important to keep hydrated when exercising or doing
something because dehydration can make the glucose in the
bloodstream to be more concentrated which leads to higher
blood glucose levels.
● Instruct the patient to restrict drinking alcoholic beverages.
R: Alcohol can cause the blood sugar levels to be low if using
insulin. In addition, too much alcohol can also cause
hyperglycemia and weight gain.

X. PROGNOSIS
Type 2 Diabetes Mellitus (T2DM) is a lifelong disease, and there is no cure.
Although it varies widely, the overall excess mortality risk for people with T2DM is about
15% higher. In the United States, the prevalence of vision-threatening diabetic
retinopathy is around 4.4% among persons with diabetes, while it is 1% for end-stage
renal disease. However, vascular problems can now be effectively managed with
pharmacotherapy for hyperglycemia, as well as decreasing LDL cholesterol, controlling
blood pressure with ACE/ARB therapy, other antihypertensive drugs, and aspirin in
secondary prevention. This reduces morbidity and death (Goyal & Jialal, 2021).
The level of glucose control has a big impact on the prognosis of T2DM. The risk
of complications from T2DM is considerably increased with chronic hyperglycemia
(Sapra & Bhandari, 2021). Premature mortality can be brought on by complications
such kidney disease, heart attack, and stroke. Moreover, blindness, amputation, heart
disease, stroke, and nerve injury caused by T2DM can all lead to disability. Some
people with type II diabetes get renal failure, which makes them dependent on dialysis
or even worse, necessitates a kidney transplant (Harvard Medical School, 2022).
Patients with a favorable prognosis who can return to normal glucose levels during the

193
transition from pre-diabetes to frank T2DM may be able to slow the course of the
disease. If they reduce weight and become more active, some type 2 diabetics could no
longer require medication. Their body's insulin and a good diet can control their blood
sugar level once they achieve their optimum weight. In conclusion, the prognosis for
persons with type 2 diabetes varies depending on how successfully a person reduces
their risk of complications. A person's life expectancy is lower if they smoke, can't
control their blood sugar levels, and don't exercise compared to that if they live a
healthy, active lifestyle, don't smoke, and keep their blood sugar levels stable (Huizen,
2019).
In review of our patient's case, our group decided that the patient’s final
prognosis is good. In R.H. case’s, he is a newly diagnosed T2DM patient. He manages
his glucose level by strictly adhering to his medication regimens; he stopped smoking
and drinking alcohol. Moreover, he tries to be active most of the time by helping in their
business, cleaning, and doing leisure times. However, If he were to ignore the wound he
sustained on his right foot from cleaning, it would have led him into having a diabetic
foot and may undergo amputation; but, he was immediately brought to the hospital after
noticing that his wound was not healing properly. With this, a disarticulation and
debridement was done to him. Lastly, he does not have any further complications
brought about TD2M

194
XI. References

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2-diabetes-mellitus-peer-reviewed-fulltext-article-DMSO
Americans Diabetes Association. (2022). COVID-19 and Diabetes. Retrieved October
20, 2022, from
https://diabetes.org/coronavirus-covid-19/how-coronavirus-impacts-people-with-d
iabetes
Azami, R. (2018). Effect of a Nurse-Led Diabetes Self-Management Education program
on Glycosylated Hemoglobin among Adults with Type 2 Diabetes. Retrieved
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Basina, M. (2022). Diabetes and headaches: What’s the connection?. Retrieved
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Basina, M. (2021). Diabetes and Metallic Taste in the Mouth. Retrieved October 22,
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Bass Medical Group. (2022). Article: Fatigue and Other Signs You May Have Type 2
Diabetes. Retrieved October 22, 2022,
https://www.bassmedicalgroup.com/blog-post/fatigue-and-other-signs-you-may-h
ave-type-2-diabetes
Brooks, A. (2018, September 4). Emergency nursing: Everything you need to know
about being an ER nurse. Emergency Nursing: Everything You Need to Know
About Being an ER Nurse | Rasmussen University. Retrieved October 16, 2022,
from https://www.rasmussen.edu/degrees/nursing/blog/emergency-nursing/
Cabrera, M. (2021). Nursing-Intense Health Education Intervention for Persons with
Type 2 Diabetes: A Quasi-Experimental Study. Retrieved October 22, 2022, from
https://pubmed.ncbi.nlm.nih.gov/34356210/
Centers for Disease Control and Prevention. (2022). Smoking and Diabetes. Retrieved
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Cleveland Clinic. (2020). Diabesity: How Obesity Is Related to Diabetes. Retrieved
October 20, 2022, from
https://health.clevelandclinic.org/diabesity-the-connection-between-obesity-and-d
iabetes/
Cleveland Clinic. (2021). Diabetes Rash: Causes, Appearance and Prevention.
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