METRO COLLEGE OF NURSING

ADVANCED NURSING

PRACTICES

Case study on

DIABETES MELLITUS

SUBMITTED BY: ANURADHA

SUBMITTED TO:

SUBMITTED ON
 HISTORY TAKING AND PHYSICAL EXAMINATION
INTRODUCTION OF THE PATIENT
Patient name: Mr. Rakesh Sharma Age /
sex: 65/ male
UHID: 160211
DOA:21/09/24
Diagnosis: Type II DM.
Address: Sector-65, Noida Marital
status: widow

STUDENT DATA
Name of the student: Ms. Anuradha
Date of care started: 15/ 09/2024
Date of care ended: 20/09/24

HISTORY COLLECTION
Present complaints: Poor Oral intake, High Blood Pressure

Complaints during admission: Drowsiness, High blood Pressure, sweating.

Past complaints:
Before illness the patient was healthy and active and performed of daily living
activities, but sometimes with a little help. There is no H/O any significant disease Past

medical history: No past medical history

Past surgical history: No past surgical history

Family history: Not known case of hypertension in the family or any other co – morbidities.
Genogram of family
Name Age Sex Relational Educatio Occupati Income Remark
ship with n on
patient

Mr. 58 M Father in law 7th passed Shopkeep 5000/ -

Mohanlal yrs er
ji month

Mrs. 54 F Mother in low 5th passed House - -

Reema yrs wife

Mr. 26 M Husband B.A Factory 10000/ -

Ashish ji yrs passed worker month

Mrs. 22 F Self 10thpassed House - -

bimla yrs wife
-
Farhana 2yr F Daughter - - -
M. Mirza s

Socio - economic status:

PHYSICAL ENIVRONMENTAL &LIVING CONDITION:

Area- sector 65, Noida .
Type of House- Own Pakka House
No. Of Rooms- 4 Bed rooms separate kitchen Bathroom/
toilet- Separate bathroom toilet.
Refusal Disposal- Proper refuse Disposal Ventilation – No
proper ventilation in rooms.
Electricity and Water Supply-There is a proper supply of electricity & water
sanitation.

DIETARY &NUTRITIONAL HISTORY

Diet of the family
Vegetarian diet and non-vegetarian packed food items, high salt intake consumed by the
family members.
 PHYSICAL EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR

Posture: Erect Nourishment:
Poor Body built: lean
Health status: malnourished Activity:
Assisted activity done Mental status:
Conscious oriented Look: Tidy appearance
Speech: Normal

VITALS SIGN
Temperature: 101. F
Pulse: 85 bpm
Blood pressure: 160/110 mm hg
Respiration :22/ min
Spo2: 94 % on O2 support 4litres on nasal prongs.
Pain: Patient experience pain 4 score according to patient experience.
Height: 160 cm
Weight: 56 kg

SKIN CONDITIONS
Color: Dark color patches
Texture: Dryness present over the skin Moisture: Loss
of moisture from the skin Temperature: warm, 38.5 c
Lesion: Absent, no lesion present

HEAD TO TOE EXAMINATION

Head and scalp
Scalp: Hair loss due to aging
Face: Facial puffiness due to corticosteroids Lesions:
Absent
Posture: Normal body curves & proper alignment Size:
small
Shape: normal Symmetry:
Normal
EYES
Visual fields: Fundal examination performed raised due to high blood sugar.
Visions: diminished
Conjunctiva: normal Sclera:
normal
Pupils: normal in size, reacted to light (contracted) Ability
to blink: present
EARS
Hearing: Normal hearing tendency
Auricles: Normal
Discharges: No discharge present.
Mouth and pharynx: Oral

hygiene: Maintained Odor of

mouth: Present
Gums: Inflammation present
Swallowing: dysphagia present

CHEST
Observation Shape: barrel
shape
Shape of spine: deviated Palpation:
tenderness present
Auscultation: Breath sound wheezing present Heart
sounds: s1 s2 present
Description of peripheral pulses

ABDOMEN And INGUINAL AREAS

Inspection: Normal in appearance.
Auscultation: Bowel sound present
Palpation: no palpable mass seen.
Percussion: Tympany sound present, no sign of ascites fluid.
Bladder: not distended.
Spleen: not palpable

GENITALIA (MALE)
Rectum and Anus: anal fissure present It is
smooth and not tender.

EXTREMITIES / MUSCO-SKELETAL
Range of motion: present Muscle
strength: weak
Joints: pain present while climbing Bowel
and Bladder: Normal
Muscle strength: Grade 2, 25% of normal strength of right upper extremities
Muscle mass: No any mass present
Node: Not present

NERVOUS SYSTEM
Mental status: patient is oriented to time, place and person. He is good at judgement, Patient
has recall memory and recent memory.
He can calculate the normal value like 12+5=17 Cranial
nerves: Present the motor and sensory nerves response. Deep
tendon reflex: Present.
 MEDICATIONS

Drug Dose Route Frequency Action Indications Contra- Nursing

name indication responsibility

1. Tab 50/500 PO BD Inhibit the Extended- Renewal Monitor the

Metform mg hepatic release dysfunction lactic acidosis,
in gluconeoge tablets, Congestive lethargy,
nesis and USP are cardiac failure stupor, shallow
opposing indicated as Hypersensiti rapid breathing
the action adjunct to vity. Notify
of diet and Impaired physician any
glucagon. exercise to hepatic signs of
improve function hypoglyce mia.
glycemic
control with
type
II

2. Tab 40 mg PO OD Reduce the To treat H/O of Monitor for

pantopra gastric GERD, hypersentivi drug
zole secretion and too ty of drug interaction
prevent much acid .
from in the
acidity. stomach.
3. Inj. 14 unit SC HS Insulin To improve During Monitor blood
Toujeo analogues glycemic episodes of sugar before
lower blood control in hypoglycem administer ing.
glucose adults, not ia
uptake, recomme
especially nded for
by skeletal the
muscle. treatment
of diabetic
ketoacido
sis.
 INVESTIGATION

Name of investigation Patient value Normal value (Range)

1. Glycosylated 7.5 % >5.7 -6.4%
hemoglobulin level
(Hba1c)
2. C-peptide level 1.7ng/ml 0.5-2.7ng/ml
3. Urine ketone Ketone present Below 0.6mmol/L to 1.5
mmol/L

THEORY APPLICATION

Application of Orem’s Self-Care Deficit Nursing Theory (SCDNT) in Diabetes Management

(DM)
Orem’s theory is highly applicable to diabetes mellitus (DM) because self-care plays a crucial
role in managing the disease. Since diabetes requires long-term lifestyle modifications, self-
care deficits may arise due to a lack of knowledge, physical limitations, or complications.
1. Identifying Self-Care Deficits in Diabetes Patients
According to Orem’s theory, individuals with diabetes may experience self-care deficits
in:
 Blood Sugar Monitoring – Patients may not know how to check or interpret glucose
levels.
 Dietary Management – Lack of understanding of proper nutrition or difficulty
adhering to a diabetic diet.
 Medication Adherence – Forgetting or improperly administering insulin or oral
medications.
 Exercise and Lifestyle Changes – Difficulty maintaining an active lifestyle.
 Recognizing and Managing Complications – Inability to detect early signs of
hypoglycemia or complications like diabetic neuropathy.
2. Nursing Systems Applied to Diabetes Care
Orem’s nursing systems provide a structured way to assist patients based on their level
of independence in managing diabetes:
1. Wholly Compensatory System – The nurse provides full care for patients who cannot
manage their diabetes, such as:
o Critically ill patients in a diabetic coma.
o Patients with severe neuropathy or blindness due to diabetes.
o Elderly patients or those with cognitive impairments who need full assistance
with insulin administration and blood glucose monitoring.
 2. Partially Compensatory System – The nurse and patient share responsibility for
diabetes management. Examples include:
o Teaching a newly diagnosed patient how to administer insulin but assisting
initially.
o Helping patients with limited mobility plan an exercise routine.
3. Supportive-Educative System – The nurse primarily educates and supports capable
patients who need guidance. Examples include:
o Teaching patients how to monitor blood glucose and recognize abnormal
levels.
o Providing dietary counseling to improve meal planning.
o Encouraging lifestyle modifications like regular exercise and stress
management.
3. Practical Nursing Interventions Based on Orem’s Theory
 Assessment: Identify self-care deficits through interviews, blood sugar logs, and
observation.
 Education: Teach proper insulin administration, diet control, and exercise habits.
 Support: Provide emotional support to prevent burnout in self-care.
 Follow-Up: Monitor adherence and adjust interventions based on progress.

CASE IN DETAIL (Anatomy & Physiology)

DEFINITION
Diabetes mellitus is sometimes referred to as “High -sugar levels’ ‘by both clients and heath
care providers.
Diabetes is a chronic, progressive disease characterized by the body’s inability to metabolize
the carbohydrates, fats, proteins are leading to hyperglycemia (high blood glucose levels).
Symptoms oh high blood sugar include polydipsia, polyphagia, polyuria (3P’s). If left
untreated, diabetes can cause complications like Diabetic ketoacidosis, Hyperosmolar
coma or death.
INCIDENCE
DM has become an epidemic in the US with 21million people, having this disease.
Approximately 15 million people are diagnosed with diabetes mellitus.
CLASSIFCATION OF DIABETES MELLITUS
Diabetes mellitus is classified as one of the four different clinical states including:

Type I (Auto – immune): It is the result of auto – immune beta cell destruction, leading to the
absolute insulin deficiency.
Type II: It is the result of a progressive insulin secretory defect along with insulin, resistance,
usually associated with obesity.
Gestational Diabetes: It is a type diabetes occurs during the pregnancy.
Other specific types of diabetes.
ETILOGY and RISK FACTORS
Type I also called Insulin dependent DM or Juvenile onset of DM
- The presence of damaging immune system cells that make auto antibodies:
sometimes family members of people type I diabetes are tested for the presence of auto
antibodies.
- Dietary factors: A number of dietary factors have been linked with type I diabetes such
as low vitamin D consumption or exposure of cereals before 4 months of age.
- Race: More common in whites other than.
- Geography: Certain countries such as Finland, Sweden have higher rates of diabetes.

Type II NIDDM (Non- insulin dependent DM)

- Obesity: Greater weigh higher risk of insulin resistance because fat interference with
body’ s ability to use insulin.
- Sedentary lifestyle
- Unhealthy fooding Habits
- Family history or genetics

Gestational Diabetes Mellitus

Age: women older than age of 25 are at increased risk.
Family or personal history
Weight: Being overweight before pregnancy increase your risk.

Clinical manifestation
An elevated blood glucose level, called hyperglycemia leads to common clinical
manifestation associated with diabetes mellitus. In Type I Dm, the onset of clinical
manifestation may be subtle with the possibility of life-threatening condition (Diabetic
ketoacidosis)
Polyuria (frequent urination)
Polydipsia (excessive thirst)
Polyphagia (excessive Hunger)
Weight loss, weakness
Recurrent blurred vision
Ketonuria
Fatigue

PATHOPHYSIOLOGY OF DIABETES MELLITUS

DIAGNOSTIC TEST FOR DIABETES MELLITUS

 Test for Type I and Type II diabetes

 Glycosylated hemoglobulin (Hba1c)
This blood test which doesn’t require fasting, this indicates your average blood sugar
in the past 3 months. It measures the percentage of blood sugar attached to
hemoglobulin, the oxygen carrying protein in red blood cells.

Radom Blood sugar test

A blood sample should be taken at random time, Regardless of when you ate last , a random
testing 200mg per deciliter-11.1 millimeter per deciliter, or higher suggest diabetes.
Fasting Blood sugar
A blood sample should be taken empty stomach after an overnight. A fasting blood sugar less
than 100 mg/dl.
Oral glucose tolerance test (OGTT)
For this test you fast overnight and the fasting blood sugar level is measured. Then you drink
a sugary drink or liquid and blood sugar level are tested periodically. For the next two hours.
MANAGEMENT OF TYPE I
Insulin

Insulin is the main treatment for type 1 diabetes. If you have type 1 diabetes, your body
doesn’t make any insulin like it normally would. you manage your blood sugar levels and
prevent serious short or long-term health problems known as diabetes complications. So,
you’ll need daily insulin injections or use an insulin pump a small device that you attach to
your body which releases insulin.

Carb counting
Learning how to carb count helps you manage your blood sugar levels. It means you can
match how much insulin you need for the carbohydrate you eat and drink. The sums can be
made quicker and easier if you use certain apps or an insulin pump or closed loop system as
many of the calculations are done for you. Your diabetes team should be able to suggest free
apps.

Promote Proper nutrition: The essential component of diabetic care and management. The
general goal of dietary management is to help the patients by making changes in habits.
1) Improving blood sugar and lipid levels
2) Providing consistency in day-to-day intake

3) facilitating the body weight management.

4) Limit the alcohol consumption.

Administer Medications

Oral anti diabetic drugs: The major class of OHA include sulphonylureas, Biguanides,
meglitinides, Thiazolidinediones.

INSULIN PUMP THERAPY

Small potable pumps for the continuous administration of the regular insulin sometimes used.
The pump, worn externally injects insulin subcutaneously into the abdomen through an
indwelling needles site changed ever 1-3 days.
Insulin pumps are commonly improved blood glucose control means of continuous
subcutaneous insulin infusion.

COMPLICATIONS :

Educate the patient regarding the complications of diabetes and aware about the check up of
retinal examination, diabetic foot care, educate to avoid may injury which may lead to delay
wound healing.

DISEASE CONDITION:
Book picture Clinical Picture
Definition: Definition:
Diabetes mellitus is sometimes referred Diabetes mellitus is sometimes referred
to as “High -sugar levels’ ‘by both to as “High -sugar levels’ ‘by both
clients and heath care providers. clients and heath care providers.
Diabetes is a chronic, progressive Diabetes is a chronic, progressive disease
disease characterized by the body’s characterized by the body’s inability to
inability to metabolize the metabolize the carbohydrates, fats,
carbohydrates, fats, proteins are leading proteins are leading to hyperglycemia
to hyperglycemia (high blood glucose (high blood glucose levels).
levels).
Etiological and risk factors:
Etiological and risk factors:
Type I also called Insulin dependent Type II Dm patient is diagnosed with
DM or Juvenile onset of DM Type II, the risk factors are promoted the
- The presence of damaging immune diabetes are:
system cells that make auto  Obesity
antibodies: sometimes family  Sedentary lifestyle
members of people type I diabetes are  Alcohol consumption
tested for the presence of auto
antibodies. Clinical manifestation:
- Dietary factors: A number of Polyuria, Polyphagia, Polydipsia
dietary factors have been linked with Weight gain.
type I diabetes such as low vitamin D
consumption or exposure of cereals Diagnostic evaluation:
before 4 months of age. Patient laboratory findings reveal the
- Race: More common in whites Hba1c level is 7.9 %
other than. Urine ketone is present.
- Geography: Certain countries such as
Finland, Sweden have higher rates of
diabetes.
Type II NIDDM (Non- insulin
dependent DM) Management:
- Obesity: Greater weigh Patient After stabilizing the blood sugar
higher risk of insulin level, now patient shifted to the ward
resistance because fat with OHA and inj. Toujeo and Blood
interference with body’ s sugar monitoring TDS before every meal
ability to use insulin. and before giving inj. Toujeo.
- Sedentary lifestyle Client family educated regarding the
- Unhealthy fooding Habits signs of hyperglycemia and its
- Family history or genetics complications of diabetic neuropathy,
diabetic foot care. And monitoring of the
Hba1c level in the intervals of past 3
Clinical manifestation: months to track the record of raised
Polyuria (frequent urination) sugar level.
Polydipsia (excessive thirst)  Educate the client family
Polyphagia (excessive Hunger) members regarding the
Weight loss, weakness dietary habits and
Recurrent blurred vision lifestyle modification,
Ketonuria encourage the client
Fatigue towards the regular
exercise and yoga to
Diagnostic evaluation: maintain the blood sugar
Glycosylated hemoglobulin level.
Random blood sugar, fasting sugar Complications: diabetic neuropathy,
level. Diabetic retinopathy, Diabetic
Oral glucose tolerance test. nephropathy, Delayed wound healing.
Management:
 The essential goal of diabetes to reduce
the glucose level in the blood.
 Promote the lifestyle changes.
 Insulin therapy.
 Oral hypoglycemic drugs
 Exercise and limit the alcohol.

NURSING DIAGNOSIS
1. Readiness for self- care related to desired to learn about diabetes mellitus and
management.
2. Risk for fluid volume deficit related to polyuria and dehydration secondary to DM.
3. Anxiety related to loss of control, fear of inability to manage diabetes.
4. Knowledge deficit related to complications, Self-care secondary to Dm.
5. Discomfort related to pain in legs due to secondary diabetes related
diabetic neuropathy.
6. Imbalanced nutrition less than body requirements related to insulin, food,
physical activity and obese.

NURSING CARE PLAN

Nursing Nursing Nursing Nursing Nursing Nursin Nursing

assessme Diagnosis Goals plannin Interventi g Evaluatio
nt g on Ration n
ale
1. Discomfort The Assess Assessed To plan The EOC
Subjective related to patient the the for the partially
data: The pain in legs will general general further met as
patient and back reduce conditio condition care. evidenced
says that secondary the pain n of the of the by
he is to evidence patient. patient reduced
having radiculopat d by nature, pain by
pain in hy. facial site, facial
the back expressi severity of expression
pain. on. pain (level To and pain
Give -6). reduce scale=3.
Objective diversio pain
data: n Diversion
Pain facial therapy. therapy
expressio given
n shows
that he is (allow
pain. relative to
Pain scale Give talk with To
rate is 6, position patient). reduce
patient to the the pain
look patient. Supine
restless. and right
L-5 nerve lateral
compressi position To
on Adminis are given reduce
ter alternative the pain
analgesi ly.
cs as
prescrib Administe
ed to the red
patient. analgesics
as
prescribed
Tab.
Pregaba-
75 mg HS.
OD
2. Risk for To Assess Assessed To plan Fuild and
Subjective fluid maintain the the the electrolyte
data: The volume the fluid general general further balance in
patient deficit and conditio condition care of the client
complains related to electroly n of the and the DM and partially.
about the polyuria te patient. dehydratio fluid
frequent and balance n status of balance.
urination dehydratio in the the patient
and n body. by skin
excessive secondary test.
thirst. As to DM Encoura Oral Maintai
evidenced ge the intake n fluid
by the patient enhanced balance.
initial to to promote
signs of enhance the skin
DM. oral status and
intake reduce the
Objective and dehydratio
data: divides n status. To
patient into 3-4 calculat
urine test meal. e the
for the Intake positive
possible Monitor output balance
ketone the monitored. and
boy intake kidney
present or output functio
not. of the n.
patient.

3. Imbalance The Assess Assessed To plan The EOC

subjective d nutrition patient the the for the patient
data: The less than will activity activity further partially
patient body have pattern pattern, care. met as
says that requiremen normal of the evidenced
he is feel ts related nutrition patient. by the
generalize to insulin, as reduction
d food, evidence Administe To of fatigue
weakness. physical by Adminis red reduce and
activity reductio ter nutritive fatigue. improvem
Objective and obese. n in nutritive diet to ent in
data: body diet to patient as BSL.
Activity weight, the ordered.
resistance Normal patient
due to BSL upto- To
pain, level and 1850Kca Regular improv
weakness. absence l. exercise e
Patient is of advised to insulin
obese. fatigue. the secretio
Uncontrol Advice patient. n and
led hyper the reduce
glycemia. patient periphe
to Administe ral
follow red Tab. resistan
regular Glycomet- t.
exercise Gp-1, BD, To
program Po. control
. hyper
glycemi
Adminis a.
ter OHA
agents to
the
patients.
PATIENT HEALTH EDUCATION
Before the hospital discharge, the patient and the family members must have basic
understanding of diabetes mellitus and its management with blood glucose monitoring,
insulin injections.
 Regular blood sugar monitoring
 Insulin injection.
 Diabetic foot care
Nutrition and exercise.
Diabetes mellitus is a chronic disorder, the client needs time to adapt to as well as to learn
about the many changes that are occurring.
Clients with diabetes mellitus need ongoing monitoring of their self-care ability. Hba1c
levels are usually checked, as the log of daily exercise and glucose levels and insulin, clients
change that result from diabetes mellitus should also be assessed the ongoing basis by
checking vision, kidney function, degree of neuropathy, blood pressure and skin conditions.
A referral to visiting a nurse organization or home health care agency should be initiated
before discharge and regular follow- up.

DISCHARGE PLAN / FOLLOW -UP

Mr. Madho Lal Meena age 65-year-old male known case of Type II Dm, hypertension. Is
admitted with hyperglycemia and currently advise the insulin infusion to monitor the blood
glucose level with in the rang according to the sliding scale of insulin infusion chart.
After stabilizing the blood sugar level, now patient shifted to the ward with OHA and inj.
Toujeo and Blood sugar monitoring TDS before every meal and before giving inj. Toujeo.
Client family educated regarding the signs of hyperglycemia and its complications of diabetic
neuropathy, diabetic foot care. And monitoring of the Hba1c level in the intervals of past 3
months to track the record of raised sugar level.
Educate the client family members regarding the dietary habits and lifestyle modification,
encourage the client towards the regular exercise and yoga to maintain the blood sugar level.
 CONCLUSION

Mr. Madho Lal Meena age 65-year-old male known case of Type II Dm, hypertension. Is
admitted with hyperglycemia and currently advise the insulin infusion to monitor the blood
glucose level with in the rang according to the sliding scale of insulin infusion chart.
After stabilizing the blood sugar level, now patient shifted to the ward with OHA and inj.
Toujeo and Blood sugar monitoring TDS before every meal and before giving inj. Toujeo.
Client family educated regarding the signs of hyperglycemia and its complications of diabetic
neuropathy, diabetic foot care. And monitoring of the Hba1c level in the intervals of past 3
months to track the record of raised sugar level.
Educate the client family members regarding the dietary habits and lifestyle modification,
encourage the client towards the regular exercise and yoga to maintain the blood sugar level.
In the course of hospital patient undergone with the treatment of Tab. Metformin 50/500mg
Bd, Tab. Pantop 40 mg OD and the night time before giving insulin inj. Toujeo S/C 14-unit
HS RBS check if less than 200 mg do not give.

BIBLIOGRAPHY
1. Joyce M. Black, Janes Hokanson Hawks, Medical – Surgical Nursing, 8th edition Vol-
2, Management of client with Diabetes Mellitus
Page No- 1062-1085.
2. Davidson’s Principles &Practice of Medicine -21st edition.
3. Harrison’s Principles of internal medicine- 10th edition &17th edition.
4. Current Medical Diagnosis & Treatment -2014 edition.