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I. INTRODUCTION
A. DESCRIPTION OF THE HEALTH CONDITION
Diabetes Mellitus is a disorder of Endocrine Function in which there is a relative
lack of insulin or an absolute absence of insulin. Insulin is required for glucose (found in
serum) to be transported into the cells. If glucose is not available to the cells, it remains
in the circulating volume and fatty acids are used for energy in its place with resulting
hyperglycemia and ketoacidosis. The disease is categorized into Type 1, Type 2,
gestational and other specific types.
Type 1 Diabetes (absolute insulin insufficiency) occurs due to an inability of
the beta cells of the islets of Langerhans to secrete insulin and is thought to have
an autoimmune basis, where beta cells are destroyed by an autoimmune
process. The subsequent insulin deficiency leads to hyperglycemia, enhanced
lipolysis and protein catabolism. Also called Insulin-dependent Diabetes Mellitus
(IDDM) or Juvenile.
Type 2 Diabetes (insulin resistance with varying degrees of insulin
secretory defects) the beta cells produce insufficient insulin and in addition
there appears to be a resistance of the cells to insulin, which is affected by
obesity, medications, and other factors. Also called non-insulin-dependent
Diabetes Mellitus (NIDDM).
1
Gestational Diabetes (diabetes that emerges during pregnancy) typically
develops during the middle of the pregnancy when insulin resistance is more
apparent.
PROGNOSIS
Patients with type 1 and type 2 diabetes mellitus are at risk for complications
such as vision loss (Diabetic retinopathy), damage to blood vessels and nerves
(diabetic neuropathy), and kidney damage (nephropathy). However, complications can
be minimized by maintaining a normal blood glucose level through consistent
monitoring, administering insulin, and dieting. Patient with gestational diabetes mellitus
will recover following pregnancy; however, they are at risk for developing type 2
diabetes mellitus later in life.
CAUSES
Evidence indicates that diabetes mellitus has various causes, including:
Heredity
Environment (Infection, diet, exposure to toxins and stress)
Lifestyle in genetically susceptible persons
Type 2 diabetes is a chronic disease caused by one or more of these factors:
Impaired insulin production
Inappropriate hepatic glucose production
Peripheral insulin receptor insensitivity
2
History of gestational diabetes
Stress
HALLMARK SIGNS AND SYMPTOM
Type 1
Fast onset because no insulin is being produced.
Increased appetite (polyphagia) because cells are starved for energy, signals a
need for more food.
Increased thirst (polydipsia) from the body attempting to rid itself of glucose
Increased urination (polyuria) from the body attempting to rid itself of glucose
Weight loss since glucose is unable to enter cells
Frequent infections as bacteria feed on the excess glucose
Delayed healing because elevated glucose levels in the blood hinders healing
process.
Type 2
Slow onset because some insulin is being produced
Increased thirst (polydipsia) from the body attempting to rid itself of glucose
Increased urination (polyuria) from the body attempting to rid itself of glucose
Candidal infection as bacteria feeds on the excess glucose
Delayed healing because elevated glucose levels in the blood hinders healing
process
3
Gestational
Asymptomatic
Some patients may experience increased thirst (polydipsia) from the body
attempting to rid itself of glucose.
B. STATISTICAL DATA
Prevalence of diabetes worldwide
Philippines is still low on this score compared with other countries, especially
Scandinavian nations like Finland, Sweden, and Norway, but there’s an increase
number every year. Moreover, mathematical modeling on projection yields that 380
million people are expected to develop diabetes by 2025 based on International
Diabetes Federation/World Health Organization data, a good percentage will be coming
from Southeast Asian countries, including the Philippines.
4
YEAR 2000 YEAR 2030
WORLD 171, 000, 000 366,000,000
PHILIPPINES 2,770,000 7, 798, 000
This finding is no longer astonishing considering the latest statistics on Filipinos afflicted
With diabetes and hypertension which continues to increase on the scale of medical
records. This goes to show that statistics on Diabetes Mellitus in the Philippines
continues to be unfavorable to the general population because of the continuous rise in
the number of Filipinos developing diabetes every year which adds to the number of
people who cannot enjoy life and are becoming less productive due to this disease.
Raised blood glucose was estimated to result in 3.4 million deaths in 2004,
equivalent to 5.8% of all deaths. Impaired glucose tolerance and impaired fasting
glycaemia are risk categories for future development of diabetes and cardiovascular
disease. In some age groups, people with diabetes have a twofold increase in the risk of
stroke. Diabetes is the leading cause of renal failure in many populations in both
developed and developing countries. Lower limb amputations are at least 10 times more
common in people with diabetes than in non-diabetic individuals in developed countries;
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more than half of all non-traumatic lower limb amputations are due to diabetes.
Diabetes is one of the leading causes of visual impairment and blindness in developed
countries. People with diabetes require at least 2-3 times the health care resources
compared to people who do not have diabetes, and diabetes care may account for up to
15% of national healthcare budgets.
The prevalence of hyperglycemia depends on the diagnostic criteria used in
epidemiological surveys. Defined as a fasting plasma glucose value ≥ 7.0 mmol/L (126
mg/dl) or on medication for raised blood glucose), the global prevalence of diabetes in
2008 was estimated to be 9%.
There was little variation in prevalence rates across WHO regions. The prevalence
of diabetes was highest in the Eastern Mediterranean Region (11% for both sexes) and
lowest in the WHO European Region (7% for both sexes). The magnitude of diabetes
and other abnormalities of glucose tolerance will be considerably higher than the above
estimates if the categories of "impaired fasting" and "impaired glucose tolerance" are
included.
The prevalence of diabetes was relatively consistent across the income groupings of
countries. The high income countries showed the lowest prevalence rate (7% for both
sexes), possibly reflecting better dietary and other nonmedical interventions. The lower
middle income countries showed the highest prevalence rate (10% for both sex).
6
C. SCOPE AND LIMITATIONS
The researchers have conducted a study to identify the remediating risk factors
and Nutritional assessment of our specific client with Diabetes Mellitus and in order to
determine what would be the best and appropriate Therapeutic Diet through a proper
nutritional assessment and planning.
This study was conducted in 385 F. Encarnacion Street, Baranggay Santisima
Cruz, Santa Cruz Laguna and was limited only to the client residing in the area. The
study started last Friday (March 6, 2015) till Sunday (March 8, 2015)
Different Methods and Instruments were used in the data gathering of the said
study as follows:
Home visit & Interview, where in the student nurses has the opportunity to build
rapport towards the client through therapeutic communications and proper
interaction. This allows the students to gather Verbal and Objective cues from the
client and assessed the home environment of the client whether it is appropriate
to the existing condition or conducive to health.
Head-to-toe Assessment, using IPPA (Inspection, Palpation, Percussion,
Auscultation) and IAPP (Inspection, Auscultation, Percussion, Palpation) in order
to identify any Abnormalities in different system of the body and other
preventable complications n the health status of the client by means of thorough
physical assessment.
Direct measurement of nutritional status by calculating the DBW (Desirable
Body Weight), BMI (Body Mass Index), Measuring waist Circumference of the
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client. This enables the researchers to measure the body fat that gives an
indication of the nutritional status of the client.
Calculating Energy intake by computing for TER (total energy requirement).
Energy needs are estimated by considering age, sex, physical activities and state
of health such as pregnancy, pathologic conditions, etc. To simplify construction
of daily food plan.
Methods of assessing dietary intake by 24 hour food-recall, Food frequency
questionnaire, dietary history and observation of food intake. This tools allows
the researchers to identify the patient's food habits, preferences, socioeconomic
status, cultural practices and other environmental factors that bearing on the diet
of the client. People are different and so are the diets they have that may also
contribute to the underlying cause of the client's existing condition.
C. BACKGROUND OF THE STUDY
Our body converts certain foods into glucose, which is the body's primary
energy supply. Insulin from the beta cells of the pancreas is necessary to
transport glucose into cells where it is used for cell metabolism. Diabetes mellitus
occurs when beta cells either are unable to produce insulin (type 1 diabetes
mellitus) or produce n insufficient amount of insulin (type 2 diabetes mellitus). As
a result, glucose does not enter cells but remains in the blood. Increased glucose
levels in the blood signal to the patient to increase intake of fluid in an effort to
flush glucose out of the body in the urine. Patients then experience increased
thirst and increased urination. Cells become starved for energy because of the
8
lack of glucose and signal to the patient to eat, causing patient to experience an
in increase in hunger. There are three types of diabetes mellitus. These are type
1, known as insulin-dependent (IDDM), where beta cells are destroyed by an
autoimmune process; type 2, known as non-insulin-dependent (NIDDM), where
beta cells produce insufficient insulin; and gestational diabetes mellitus (DM that
occurs during pregnancy).
9
II. PATIENT’S PROFILE
Patient Name: Mr. DM
Address: 385 F. Encarnacion St., Brgy. Santisima, Sta. Cruz, Laguna
Gender: Male
Birthday: October 21, 1944
Age: 70 y/o
Birthplace: Sta. Cruz, Laguna
Nationality: Filipino
Civil Status: Married
Religion: Roman Catholic
Educational Attainment: Elementary Graduate
Occupation: Sari-sari store owner, dealer of LPG and Better Clear
Height: 5’5”
Weight: 51 kg.
Wife’s Name: Emerita O. Garcia
Occupation: Sari-sari store owner
Allergies: None
10
III. PATIENT’S HISTORY
A. History of Present Illness
After the time that the client has been diagnosed to have Diabetes Mellitus, the
patient stop seeking any medical consultation. His son and daughter bought him the
medications that had been prescribed by Doctor. At first he took Metformin, but after few
weeks he stop taking these drug and says if it’s his time to die, he’ll die. At first, the
family member where the client belongs tries to control his diet. But he keeps on saying,
“I’ll eat all that I want at least if I die I tasted all delicious foods.” He gets mad if they
control his diet. So his family was left with no choice but to let him eat food as long as
he can tolerate it. His eye vision is worse than before. He says that 10 meters away
from him looks like a cloud for him. The patient and his daughter and son were planning
to let him have an eye surgery. Last February 8, 2014 at 5:34 p.m his blood pressure is
90/70 mmHg. The client drinks 12 – 15 glass of water each day and urination occurs
frequently.
B. Past Health History
It’s been a year and 2 months since the patient is diagnosed Diabetes Mellitus
with poor compliance to medications to treat diabetes. The client stated also that he is
drinking alcoholic beverages and smoker when he is 16 years old and gradually stop
smoking until he reaches 36 years old. The patient is used to take herbal medicines that
help to improve his condition. His BP is always low as 90/70 mmHg.
11
C. Family History
According to the patient, his father and grandmother had been diagnosed of type 2 Diabetes Mellitus.
Legend:
12
IV. FACTORS AFFECTING NUTRITION AND EATING PATTERN
A. Developmental History
EXPERIENCE INDICATORSOF POSITIVERESOLUTION
ANALYSIS
Erik Erikson’s PsychosocialDevelopment
INTEGRITY vs. DESPAIR
(Old Age)
"Makita ko lang na ok yung mga
anak at apo ko, masaya na ako.
Hindi ko naman hinangad na maging
sobrang mayaman, pero basta
nakakakain kami ng tatlong beses sa
isang araw, ok na. Mahirap ang buhay
pero kayang kaya naman kapag may
ginagawa ka. Sa edad ko ngayon,
siguro, kontento naman na ako. Sa
totoo lang handa na akong mamatay
pero wag muna ngayon. Hahaha.”
Positivity on the
product of one's
life and care for his
family.
The patient is now evaluating
his life and made a
conclusion on it. At his age,
although not that
successful, he still finds it as
a fulfillment. He works to
provide for his family needs
especially for the
educational expenses of her
grandchildren.
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B. Gender
Gender, defined as the socially prescribed and experienced dimensions of femininity
and masculinity in society, is evident in the diverse ways individuals engage in health
behaviors.
Health is affected by macro-level influences including social structures and
institutions which shape the expectations of women and men, and the way their lives
are organized. To understand health practices and illness experiences it is increasingly
recognized that accounting for gender is vital.
Our patient is a male, with an age of 71 years old. According to 2009–2012 National
Health and Nutrition Examination Survey estimates applied to 2012 U.S. Census data,
there are 15.5 million men have been diagnosed to have diabetes, while 13.4 million on
women. This only means that diabetes is more increased in incidence on males.
C. Ethnicity and culture
Ethnicity has a strong influence on community status relations and also on the health
of a person. And the culture of the patient, also known as the consumer of mental health
services, influences many aspects of health, illness, and patterns of health care
utilization. Every society influences health treatment by how it organizes, delivers, and
pays for health services.
Culture relates to how people cope with everyday problems and more extreme types
of adversity. And our patient stated that he can adjust and cope easily to his
14
environment even at his age right now.
D. Beliefs about food
The value individuals place on diet and health is reflected in the food choices
they make. A survey of restaurant person found out that food choices varied according
to the customer’s perceptions of the importance of diet to health. According to Brown
(2008), customers may be classified as unconcerned, committed, or vacillating.
Committed costumers believe that a good diet plays a role in the prevention of
illness. They tend to consume a diet consistent with their commitment to good nutrition.
While Vacillating customers are people who describe themselves as concerned about
diet and health but who do not consistently base from choices on this concerns – tend
to vary their food choices depending on the occasion.
And our patient belongs to the unconcerned group of people wherein he is
unconcerned about the connection between diet and health and who tend to describe
themselves as ‘meat and potato eaters” – select foods for reasons other than health.
The patient stated that, sometimes, he doesn’t care about what kind of diseases
he may get to the kind of food he eats as long as he enjoys it even if it is restricted to
him.
E. Personal preferences
Our patient has his personal preferences especially when it comes to food that he
15
eats. He likes eating oily foods like fried chicken, fish, chicharon, sisig, bulalo. And
sometimes, he likes eating sweets like candies as substitute when he doesn't want to
smoke.
F. Religious practices
Religion plays one of the most influential roles in the choices and subsequent
selection of foods consumed in certain societies. Our patient is a Roman Catholic. He
goes to church, Immaculate Concepcion of Parish, only twice a year when there is a
special occasion like Christmas and his birthday. He has no food restrictions in terms of
his religion.
G. Lifestyle
Lifestyle is the manner of living that reflects the person's values and attitudes.
And many activities and lifestyle habits affect sleep, rest, relaxation energy patterns in
both positive and detrimental ways. Sleep is affected by many bio-psycho—social-
spiritual factor; some of these threaten wellness, but others are neutral or even positive.
The patient has a sedentary lifestyle. He works at home as a store keeper. He
rests all the time on his rocking chair while waiting for some customers. But his sleep
was always disturbed. Most of the time, he sleeps at 10 pm then wakes up at 3pm then
onwards will just become a dull moments for him. And in the afternoon, he sleeps from
1pm to 2pm at his store. But when there is a customer, his sleep will be interrupted. The
client stated also that he is drinking alcoholic beverages and smoker when he is 16
16
years old and gradually stop smoking until he reaches 36 years old.
However, he still believes that making healthy lifestyle choices can prolong a
person's lifespan and helps to avoid many serious forms of illness. Eating several
servings of fresh fruits and vegetables each day along with fibrous legumes can boost
the immune system so that it is able to fight off diseases more efficiently.
H. Medication and therapy
The patient was diagnosed diabetes when he was 69 years old. The medicine that
was prescribed for him was Metformin 500mg, 1 tab thrice a day. But he stated that he
doesn’t want take these medication. He feels like he's okay and he don't need to have
those.
I. Alcohol abuse
The patient started to learn drinking alcohol when he was 16 years old. When he
was just a teenager, he can consume 2bottles of beer twice a week. Then eventually,
when he reached his adult years, he consumes 3 bottles already per day. He used to
drunk every night while eating bulalo, bopis, letchon or sisig. Hence, when he was
diagnosed diabetes 2 years ago, he stopped doing his unhealthy food habit.
J. Advertising
17
The patient was encouraged to drunk and smoke by his friends and also by the
commercial advertisements that he sees on television. In addition, he loves dinning out
with his family at some fast food chains without knowing the ingredients and method of
cooking.
K. Psychological factors
The patient was able to answer all the questions that we gave to him. He is
conscious, alert and coherent.
L. Socio-Economic status
Socioeconomic factors can influence food quality, quantity, selection, and
accessibility in many ways. Our patient manages his own store with an average
monthly income of 2500 per month. And aside from that, he has his gasoline
business that can give him a profit of 200 pesos per day and 150 pesos per day on
his mineral water business. Overall, he has an estimated monthly salary of 12000
per month.
M. Elimination
The patient defecates every day and voids for almost more than 8 times a day.
N. Hygiene
18
Hygiene has a big factor on our health. And this matters to our patient, as he
said. He always wants to feel fresh. He took a bath every day and brushes his teeth
thrice a day.
V. PHYSICAL ASSESSMENT
Area Methods Findings Analysis
Integumentary System
Skin Inspection/ Palpation
Skin is tan in color with dry and warm skin and absence of masses and lesion on the surface of the skin.
Due to frequent urination and increase thirst and this is an expected manifestation of being hyperglycemia.
Reference:Medical Surgical Nursing Critical Thinking in Client Care Third Edition by Lemone & Burke
Hair Inspection Hair color is white with presence of alopecia.
In relation to the client’s age this is normal
Nails Inspection
Palpation
Pinkish nail beds. Capillary refill within 2-3 seconds upon blanching
Normal
Head
Skull and face Inspection and Palpation
Without traces of facial and periorbital edema. Smooth skull contour; no palpable
Normal
19
nodules and masses
Eyes and vision Inspection Eye are aligned; eyebrow is free of scaling that is normal
With blurring of vision
With pale conjunctiva
Normal
Due to increase blood glucose which affects the eyes for blurring of vision
Retrieve:http://www.webmd.com/diabetes/diabetes-blurred-vision
Pale conjunctiva due to decreased blood flow. There is a decreased concentration of Hgb to supply oxygen.
Reference: Mart Ijnvan Mensvort.Palm Reading Perspectives. Pale Fingernails, Lines & Palms may provide Clues for Lack of Red Blood Cells., January 5, 2011.
Ears and hearing
Inspection Symmetrical ears and equal in size; no presence of tenderness, masses and drainage clogged/cerumen. Pinna recoils immediately.
Normal
20
Nose and sinuses
Inspection and Palpation
Nose is symmetrical in shape and same in color with face; can breathe with one nostril when other is closed; No presence of discharge; No presence of bumps and tenderness; No pain noted; Non tender sinuses
Normal
Mouth and oropharyngx
Inspection
Pale lips and oral mucosa with dry mucous membrane
Complete teeth; No suspected lesions or masses on tongue, gums, hard and soft palate and tonsils.
Pale lips, oral mucosa and gums due to decreased blood flow. There is a decreased concentration of Hgb to supply oxygen.
Reference:
Mart IjnvanMensvort.Palm Reading Perspectives., Pale Fingernails, Lines & Palms may provide Clues for Lack of Red Blood Cells., January 5, 2011
Normal
21
Uvula is in the middle, tonsils are pink without hypertrophy. Tongue easily move in all directions, pinkish with presence of whitish spots,
Moist and with gag reflex.
Neck
Neck muscles Inspection Symmetrical in strength and movement of neck
Normal
Lymph nodes of the neck
Palpation Lymph nodes are non- palpable
Normal
Trachea Palpation and Auscultation
Trachea is in midline position and tracheal sound is heard
Normal
Thyroid gland Palpation Butterfly in shape in midline position, non- palpable lobes, not enlarged and rises as patient swallows
Normal
Thorax and Lungs
Chest shape and size
Inspection Symmetrical chest shape and size; Without chest barrel; Without the use of accessory muscles while breathing; There are no
Normal
22
retractions of intercostal spaces
Breath sounds Palpation, Percussion and Auscultation
Thorax rises and fall with inspiration and expiration. Resonant percussion throughout. Breath sounds is normal without extra sounds
Normal
Cardiovascular and Peripheral Vascular System
Heart Auscultation and Palpation
No extra heart sounds and no murmurs heard. No jugular vein distention at 45 degree. At the 5th intercostals space, MCL left border of sternum point of maximal impulse is heard.
Normal
Central vessels (carotid arteries and jugular veins)
Inspection, palpation and auscultation
With rapid, weak pulse and a PR of 102 bpm;
No bruits upon auscultation of the carotid arteries;
Patient with Type 2 DM usually experinces this especially hyperglycemic one
References:
Medical Surgical Nursing Critical Thinking in Client Care Third Edition by Lemone & Burke
Normal
23
Jugular vein are not distended
PULSES RADIAL POPLITEAL
DORSALIS PEDIS
POSTERIOR TIBALIS
Right 2+ normal 1+ weak and thread pulse
1+ weak and thread pulse
1+ weak and thread pulse
Left 2+ normal 2+ normal 2+ normal 1+ weak and thread pulseIMPLICATION
Pulses at lower extremity are palpable but it is weak and thread; easily obliterated with pressure, because there is insufficient perfusion of tissue / decreased blood flow due to vasospasm.
Reference:R. Dean Hill and Robert B. Smith, III.,Chapter 30 Examination of the Extremities: Pulses, Bruits, and Phlebitis., 2010.
24
Peripheral Vascular System (Peripheral pulses, veins and perfusion)
Palpation Peripheral pulses are equal in pulse rate and rhythm
Normal
Neurologic
Mental status Inspection Able to speak appropriately and easily; Maintains eye contact, can smile and frown appropriately
Normal
Level of consciousness
Inspection Awake, alert and oriented to date, time and place, person and responds to stimuli – Glascow Coma Scale Score: 15
Normal
Cranial Nerves
CN 1 Inspection Identifies odors correctly
Normal
CN 2 Inspection Cannot read a printed writing at 16 inches but can read numbers at least 2 inches away from him with difficulty
Blurring of vision occur in patient who is sufferring from diabetes mellitus
Retrieve:
http://www.webmd.com/diabetes/diabetes-blurred-vision
CN 3, CN 4 Inspection Able to move the eye correctly according to the given side
Normal
25
CN 5 Inspection Able to express face and scalp sensations
Normal
CN 6 Inspection Eyes move smoothly and coordinated motion in all six cardinal directions
Normal
CN 7 Inspection Expression in forehead, eye and mouth is present including taste and salivation
Normal
CN 8 Inspection Able to hear and balance
Normal
CN 9, CN 10 Inspection Salivation and swallowing is present.
Normal
CN 11 Inspection Movement of the shoulder and head rotation is done.
Normal
CN 12 Inspection Able to move the tongue
Normal
Breast and Axillae
Inspection and Palpation
Symmetrical in size; No lesions seen; No edema seen; No palpable mass; No breast tenderness
Normal
Bladder Inspection and
Bladder is not distended
Normal
26
palpationFrequent urination in yellowish color in large amount
Polyuria occur in Type 2 DM. Resulting to increase thirst.
Reference::
Medical Surgical Nursing Critical Thinking in Client Care Third Edition by Lemone & Burke
Bowel Movement
Inspection With active flatus; With positive bowel movement; With positive peristaltic movement at RU-5bpm ; RL-8bpm :LU-10 bpm ;LL- 9bpm
Normal
Extremities Inspection There is no edema seen
Normal
Musculoskeletal System
Muscle Inspection Symmetrical and equal muscle mass, tone and strength; Rate of muscle strength is 4 in all four extremities
Normal
References:
Medical Surgical Nursing Critical Thinking in Client Care Third Edition by Lemone & Burke
Health Assessment made incredibly Visual by Lippincott Williams & Wilkins.
VI. ANATOMY AND PHYSIOLOGY
27
ENDOCRINE SYSTEM
Homeostasis depends on the precise regulation of the organ and organ systems
of the body. The nervous and endocrine systems are two major systems responsible for
that regulation. Together they regulate and coordinate the activity of nearly all other
body structures. When these systems fail to function properly, homeostasis is not
maintained. Failure of some component of the endocrine system to function can result
in disease such as Diabetes Mellitus or Addison’s disease. The regulatory function of
the nervous system and endocrine systems are similar in some respects, but they differ
in other important ways. The nervous system controls the activity of tissues by sending
action potentials along axons, which release chemical signals at their ends, near the cell
they control. The endocrine system releases chemical signals into the circulatory
system, which carries to all parts of the body. The cell that can detect those chemical
signal produce responses. The nervous system usually acts quickly and has short term
effects, whereas the endocrine system usually response more slowly and has longer-
lasting effects. In general, each nervous stimulus controls a specific tissue or organ,
whereas each endocrine stimulus controls several tissues or organ
FUNCTIONS:
•It regulates water balance by controlling the solute concentration of the blood.
•It regulates uterine contractions during delivery of the newborn and stimulates
milk release from the breast in lactating females.
28
•It regulates the growth of many tissues, such as bone and muscles, and the rate of the
metabolism of many tissues, which helps maintain a normal body temperature and
normal mental function. Maturation of tissues, which result in the development of adult
features and adult behavior, are also influence by the endocrine system.
•It regulates sodium, potassium and calcium concentrations in the blood.
•It regulates the heart rate and blood pressure and helps prepare the body for physical
activity.
•It regulates blood glucose levels and other nutrient levels in the blood
•It helps control the production and function of immune cells.
•It controls the development and the function of the reproductive systems in males and
females.
Pancreas
an elongated gland extending from the duodenum to the spleen; consist of a
head, body, and the tail. There is an exocrine portion, which secretes digestive
enzymes that are carried by the pancreatic duct to the duodenum, and pancreatic
islet, which secrete insulin and glucagon.
The endocrine part of the pancreas consists of pancreatic islets (small islands;
islet of Langerhans) dispersed among the exocrine portion of the pancreas. The
islets secrete two hormones –insulin and glucagon—which function to help
regulate blood nutrient levels, especially blood glucose.
Alpha cells of the pancreatic islets secrete glucagon.
29
Beta cells of the pancreatic islet secrete insulin.
It is very important to maintain blood glucose levels within a normal range of
values. A decline in the blood glucose levels within a normal range causes the
nervous system to mal function because glucose is the nervous system’s main
source of energy. When blood glucose decreases, other tissues to provide an
alternative energy source break fats and proteins rapidly. As fats are broken
down, the liver to acidic ketones, which are release into the circulatory system,
converts some of the fatty acids. When blood glucose level are very low, the
breakdown of fats can cause the release of enough fatty acid and ketones to
cause the pH of the fluids to decrease below normal, a condition called acidosis.
The amino acids of proteins are broken down and used to synthesize glucose by
the liver.
If blood glucose levels are too high, the kidneys produce large volumes of urine
containing substantial amounts of glucose because of the rapid loss of water in
the form of urine, dehydration result
Insulin is released from the beta cells primarily response to the elevated blood
glucose levels and increased parasympathetic stimulation that is associated with
digestion of a meal. Increase blood levels of certain amino acids also stimulates
insulin secretion. Decreased result from decreasing blood glucose levels and
from stimulation by the sympathetic of the nervous system. Sympathetic
stimulation of the pancreas occurs during physical activity. Decreased insulin
levels allow blood glucose to be conserved to provide the brain with adequate
30
glucose and to allow other tissues to metabolize fatty acids and glycogen stored
in the cell.
The major target tissues for insulin are the liver, adipose tissue, muscles, and the
area of the hypothalamus that controls appetite, called satiety center (fulfillment
of hunger).Insulin binds to membrane-bound receptor and, either directly or
indirectly, increases the rate of glucose and amino acid uptake in these tissues.
Glucose is converted to glycogen or fat, and the amino acids used to synthesize
protein.
Glucagon is released from the alpha cell when blood glucose level is low.
Glucagon binds to membrane-bound receptors primarily in the liver and caused
the conversion of glycogen storage in the liver to glucose. The glucose is then
released into the blood to increase blood glucose level. After a meal, when
blood glucose levels are elevated a glucagon secretion is reduced.
Insulin and glucagon function together to regulate blood glucose levels. When
blood glucose increase, insulin secretion increases, and glucagon secretion
decreases. When blood glucose levels decrease, the rate of insulin secretion
declines and the rate of glucagon secretion increase. Other hormones, such as
epinephrine, cortisol, and growth hormones, also function to maintain
blood levels of nutrients. When blood glucose level decrease, these hormones
are secreted at a greater rate. Epinephrine and cortisol caused the breakdown of
protein and fat and the synthesis of glucose to help increase blood levels of
nutrients. Growth hormone slows protein breakdown and favors fat breakdown
31
32
VII. PATHOPHYSIOLOGY (Patient-Based)
33
IX. NUTRITIONAL ASSESSMENT AND ANALYSIS
A. Direct measures of nutritional status
DBW
Height (cm) ×12 × 2.54 - 100 - 10%
5'5
=5×12=60+5 = 65
=65×2.54
=165.1 - 100
=65.1 - 10%
=58.59
BMI
Kg/H(cm)2
51kg/(1.65)2
51 kg/ 2.72
=18.75 (healthy weight)
WAIST HIP RATIO
Waist ÷ hip
32÷34 = 0.94 (NORMAL)
34
B. Indirect measures of nutritional status
24-Hour Food Recall
1. What time did you go to bed the night before the last? 9pm in the evening.
Was this the usual time? Yes
2. What time did you get up yesterday? 5am in the morning.
Was this the usual time? Yes.
3. When was the first time you had anything to eat or drink? After having an
excercise.
What did you have and how much? Just 2 glass of water only.
4. When did you eat again? Before having an exercise.
Where? In my house.
What and how much? A cup of fried rice and 1 egg.
5. When did you eat next? lunch
What did you eat and how much? 2 cups of rice and 1 cup of squash and long
beans in coconut milk.
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6. Did you eat or drink anything else?
a. Anything from the 1st to 2nd meal? None
b. Anything from the 2nd to 3rd meal? Porridge and spring roll.
c. Anything from the 3rd meal to bed time? None
7. Was this day’s food intake different from usual? No, I’ts normal.
If so, why? ______
8. Is weekend eating different? No.
If so, why? _______
Food frequency checklist per week
1. Do you drink milk? If so, how much? _________ No ________
What kind? Whole ________ Skim________
2. Do you use fat? If so, what kind? Yes, use ordinary cooking oil
How much? At least 1-2 table spoon
3. How many times you eat meat? 3 times a day.
Eggs __ __ Cheese Beans _______
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4. Do you eat snack foods? If so, which ones? Lumpiang togue, turon.
How often? 2-3 times a week How much? Only one roll
5. What vegetables do you eat? (In each groups)
How often? At least 1 of each in a week.
a. Broccoli ________ Green peppers ______ Cook greens _______
Carrots ______ Sweet potato______
b. Tomato _______ Raw Cabbage ______
c. Asparagus _____ beets ______ Cauliflower _______
Cooked cabbage ______ Celery _______
Peas ________ Lettuce ________
6. What fruits and how often? Sometimes
a. apples or apple sauce _______
banana ________ berries ______apricots ______
grape or grape juice ______ pineapple _______ cherries ______
pears _______ orange juice ______ peaches ______
raisins _______ grape juice fruit _____ plums ________
7. Bread and cereal products
a. How much bread do you usually eat with each meal? three Between
meals? two
b. Do you eat cereal? (daily, weekly)
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Cooked _____ dry______
c. How often do you eat foods such as macaroni, spaghetti, noodles etc.?
three times a week
8. Do you use salt? Yes
Do you “crave” salts or salty foods? Sometimes.
9. How many tsp. of sugar do you use/day?
(1 packet – 1tsp) 1 ½ tsp of white sugar.
10.Do you drink water? Yes
How often during the day? Every hour.
How much each time? 1 glass of water every hour.
How much would you say you drink each day? More than 8 glasses a day.
11.Do you drink alcohol? _________ How often? _________
How much? __________
Beer, wine, Others? _________
Food Diary for 3days (2weekdays/ weekend day)
March 6. 2015
In the morning, Mr. Bayani ate 2 cups of rice, fried egg and drink 1 cup of coffee as his
breakfast. Then in the afternoon he ate 2 cups of rice and squash and long beans in
coconut milk with shrimp as his lunch. Then he ate porridge and spring roll as his mid
afternoon snack and in the evening he ate 2 cups of rice, 1 piece of grilled pork, 1 cup
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of raw tomatoes and onion, pork and vegetable in tamarine broth, grilled chicken wings,
steam mustasa, shrimp sauteed and a glass of dalandan juice for his dinner.
March 7. 2015
In the morning Mr. Bayani ate 1,1/2 cup of fried rice, salted and dried fish (medium
size), 1/2 cup of kare-kare and a cup coffee as his breakfast. In the afternoon he ate 2
cups of rice and blue marlin in coconut milk as his lunch. Then, ate small slice of
yemma cake as his mid afternoon snack. In the evening, he ate 1,1/2 cup of rice and
1/2 of fried chicken legs.
March 8. 2015
In the morning, Mr. Bayani ate 3 pandesal as his breakfast.
Then in the afternoon, he ate 1/2 cup of tokwa-baboy and 3 cups of rice as his lunch.
DIETARY COMPUTATION.
DBW
5'5
HT(cm) ×12 × 2.54 - 100 - 10%
5'5=5×12=60+5 = 65=65×2.54 =165.1 - 100=65.1 - 10%=58.59
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BMI
Kg/H(cm)251kg/(1.65)251 kg/ 2.72=18.75 (healthy weight)
NDAP
112 + 20 = 132 lbs.
TEA59 × 30 = 1770 kcal
A. PERCENTAGE DISTRIBUTION
CARB =1770 × .55 = 974 KcalPRO = 1770 × .15 = 265.5 KcalFAT = 1770 × .30 = 531
B.
CARB = 974 ÷ 4 = 265g.PRO = 266 ÷ 4 = 65g.FAT = 531 ÷ 9 = 50g.
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DIET PRESCRIPTION
Kcal: 1770; CHO: 245g.; CHON: 65g.; FAT: 60g.
Food No. of exchanges CHO PRO FAT ENERGY
(Kcal) (Kj)
Veg. List 1-A 2 3 1 - 16
67
Veg. List 1-B 1 3 1 - 16
67
Fruit. List II 2 20 - - 80
334
Milk. List III 1 12 8 5 125
523
Sugar. List VII 4 20 - - 80
336
Partial requirement = 58
245 (prescribed CHO)
- 58 (partial sum of CHO)
= 187 ÷ 23 = 8 no.of exchanges
Rice. List. VI. 8 184 16 - 800
3344
Partial sum of PRO: = 27
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65 (prescribed PRO)
- 27 (partial sum of PRO)
= 38÷ 8 = 5 no of meat exchanges
Meat List Va 2 - 16 2 82
344
Vb 3 - 24 18 258 1080
Partial sum of Fat = 25
60
- 25
= 35 ÷ 5 = 7 no. of Fat Exchanges
Fat, List V. 7 - - 35 315
1316
= 242 = 67 = 60 = 1772
=7411
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IX. NUTRITIONAL PLAN
Patients meal planning
Meal plan for: Mr. DM
Energy: 1770 kcal Carbohydrates: 245g. Protein: 45g. Fat: 60g.
Total food in one day:
List 1: A vegetables =2
List 1: B vegetables =1
List 2: Fruits =2
List 3: Milk =1
List 4: Rice =8
List 5: Meat and Fish = 5
List 6: Fat = 7
List 7: sugar = 4
BREAKFAST: SCRUMBLE EGGS AND TOAST BREAD
Exchanges
Sample menu
CHO CHON FAT Energy Kcal
Meat and fish
1 60g. 1 piece chicken
egg.
Page 42
- 8 1 41
Rice exchange
2 90g. 4 (11- 1/2 x 8 – ½ x 1 cm each) page. 33
46 4 - 200
Fats 2 2 teaspoon canola oil
- - 10 90
43
Nutrition fact
Fruits 1 40g. 1 (9x3 cm) page. 26
10 - - 40
total 56 12 11 371
MORNING SNACK:
Exchanges Sample Menu
CHO CHON FATS ENERGY Kcal
Rice exchange
2 80g. 6 (5x5 cm each )
pandesal
Page. 33
46 4 - 200
Milk 1 250g. 1 tetra- brick page
30
12 8 5 125
Total: 56 12 11 371
LUNCH: SAUTED TOMATO AND GARLICK, APLE AND CARROT JUICE, MASHED POTATO
Exchanges Sample Menu
CHO CHON FATS ENERGY Kcal
Meat and fish
2 60g. ¼ breast- 6 cm long page
38
- 8 1 41
Vegetable A
2 50g. Tomato raw
page. 22
3 1 - 16
Vegetable 1 40g. ½ cup carrots 3 1 - 16
44
B raw
Page 22
Rice 2 390g. 5 of 7cmlongx
4cm diameter
each potato
Page 34
46 4 - 200
Fruit 1 65g. ½ 8cm diameter or
(6cm diameter)
Apple
Page 25
10 - - 40
Fats 3 3 teaspoon
Page 45
- - 15 135
total 62 14 16 448
DINNER:
Exchanges Sample menu
CHO CHON fats Energy
kcal
Meat and fish
2 20g 6 table spoon
corn beef
Page 43
- 16 12 172
Rice 2 160g. 1cup 1packed
46 - 10 200
45
rice
Page 31
fats 2 2 teaspoon canola oil
(nutrition facts)
- 4 - 90
Total: 46 20 22 463
X. SUMMARY, CONCLUSION AND RECOMMENDATIONS46
Summary
Diabetes mellitus is a disease caused by deficiency or diminished effectiveness
of endogenous insulin. It is characterized by hyperglycemia, deranged metabolism and
squealed predominantly affecting the vasculature.
Diabetes Mellitus is more prevalent in ethnic subgroups. The highest incidence is
seen in Native American and Alaskan Natives, and African Americans having the
second highest rate. Type 1 Diabetes has a peak onset in people younger than 30
years of age. Type 2 Diabetes is responsible for the majority of the cases of diabetes
(approximately 90 percent), has a strong genetic predisposition and occurs in the
middle to later year, peak age of onset between 50-60 years old.
As we visited Mr. Bayani Garcia, a patient from 385 F. Encarnacion St., Brgy.
Santisima, Sta. Cruz, Laguna, He is a 70 year old male who is suffering from Type 2
Diabetes for about 1 year and 2 months from now. He is married to Mrs. Emerita O.
Garcia and a Sari-sari store owner at the same time a dealer of a Commercial LPG
Gas. The first thing we did is the Home visit & Interview, where we had the opportunity
to build rapport towards our client through therapeutic communications and proper
interaction. This us to gather Verbal and Objective cues from the client and assessed
the home environment of the client whether it is appropriate to the existing condition or
conducive to his health and his family, second we did is the Head-to-toe Assessment,
using IPPA (Inspection, Palpation, Percussion, Auscultation) and IAPP (Inspection,
Auscultation, Percussion, Palpation) in order to identify any Abnormalities in different
system of our patient’s body and other preventable complications on his health status
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by means of thorough physical assessment then we proceed to our nutritional
Assessment, we proceed to Direct measurement of nutritional status by calculating the
DBW (Desirable Body Weight), BMI (Body Mass Index), Measuring waist Circumference
of the client. This enables us to measure the body fat of our patient that gives an
indication of the nutritional status of our client. Next is Calculating Energy intake by
computing for TER (total energy requirement) of our client. Energy needs are estimated
by considering age, sex, physical activities and state of health such as pregnancy,
pathologic conditions, etc. for us to simplify construction of daily food plan.
Then we use different methods of assessing dietary intake by 24 hour food-
recall, Food frequency questionnaire, dietary history and observation of food intake.
This tools allows us to identify the patient's food habits, preferences, socioeconomic
status, cultural practices and other environmental factors that bearing on the diet of our
client. People are different and so are the diets they have that may also contribute to the
underlying cause of the client's existing condition. Lastly we educate our client and his
family on different therapeutic regimens and how to have and maintain a balanced
nutrition that is appropriately to his health condition.
Conclusion
48
In this study, the student nurses’ aim is to understand the disease more,
manifestations, risk factors and complications.
Diabetes mellitus is a condition in which the pancreas no longer produces
enough insulin or cells stop responding to the insulin that is produced, so that glucose in
the blood cannot be absorbed into the cells of the body. Mr. Garcia had diabetes
mellitus was caused mainly by stress , drinking alcohol, smoking, his food preference,
age and due to hereditary factor since his grandmother and his father had diabetes.
The patient has various beliefs that could affect his health condition. As part of the
team we did the, the nurse plans, organizes, and coordinates care among the various
health disciplines involved; provides care and education and promotes the client’s
health and well-being.
Diabetes is a major public health worldwide. Its complications cause many
devastating health problems. Through this case study, we should be able to learn and
understand the disease Diabetes Mellitus type 2 and therefore give us knowledge in
proper management, prevention, treatment and proper diet with patient who had this
disease. As a student nurses, it is very important to know many things including the said
disease condition. After the hardships of completing our case study, a reward of self-
fulfillment and credential to our knowledge and skills has been added to us being
student nurses as well as professionals in the near future.
In the process, we were able to enhance our knowledge about Diabetes, its signs
and symptoms and treatment modalities, as well as on how we, future nurses,
cancare for patients similar to patient. Moreover, we have taken our grand presentation
49
enactment to the next level, owing this to our extensive learning from our experiences
this semester as well as our previous wisdom acquired in the classroomand hospital
settings. Lastly, the group has developed a better working relationship withone another,
especially through this challenging and demanding stretch of our student life.
Recommendation
Recommendations are necessary for Mr. Garcia to be able to improve health and
prevent further complications as possible. This, in turn, will consider having a
better health status – be it physically, emotionally, mentally, and spiritually. For Patient
Mr. Garcia, recommendations would include but not limited to the following:
First, he should be able to develop an optimistic attitude towards the situation in
order to promote a positive inclination of mental and emotional dimension of health.
Second, he should strictly comply with the medication regimen since personaladherenc
e is a determinant of willingness and eagerness to recover. Third, he should also be
able to verbalize feelings to his sons and daughters to take emotional care and actions.
He should also be able to express any discomfort in order for the health care provider to
carry out certain measures. Last, he should be able to strengthen or maintain strong
faith since spiritual health is an important factor to be considered in achieving a healthy
status. As health care providers, we should be able to provide quality health care
services to Mr. Garcia. As nurses and physicians, individualized care should be carried
out. Open and welcome approach should be initiated to the patient, and most especially
by showing empathy and recognizing that there is no enough words to overrule his
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feelings of heaviness and despondency. Sensitivity to the patient has verbalized is also
necessary for us to consider in planning care. Physical, social, spiritual, emotional, and
mental feedbacks and motivations can also be considered in imparting to the client.
51
BIBLIOGRAPHY:
G. Webb.nutrition: A health promotion approach . Diet as a Specific Component of
Therapy.370-375
Mart Ijnvan Mensvort.Palm Reading Perspectives. Pale Fingernails, Lines & Palms may
provide Clues for Lack of Red Blood Cells., January 5, 2011.
Medical Surgical Nursing Critical Thinking in Client Care Third Edition by Lemone & Burke
R. Dean Hill and Robert B. Smith, III.,Chapter 30 Examination of the Extremities:
Pulses, Bruits, and Phlebitis., 2010.
R. Seeley, T. stephens, P. Tate. Assentials of anatomy and physiology. 7th edition.
Endocrine system, 268.
S. Lewis, M. Heitkemper, S. Dirksen. Medical surgical nursing. Patient with Diabetes
Mellitus. Chapter 46, 1367- 1396.
http://www.webmd.com/diabetes/diabetes-blurred-vision, June 15, 2012
http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf,
2009–2012 National Health and Nutrition Examination Survey estimates applied to 2012
U.S. Census data.
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