2. Objectives of Case study PresentationObjectives of Case study Presentation
• To share experience and knowledge with
friends and supervisors.
• To get feedback from the supervisors and
friends for further improvement.
• To develop confidence in facing the mass
and presenting skills
3. selection of case study
• DM is commonly seen disease condition
in our country.
• I selected this case as to learn in depth
about the disease condition.
• Providing nursing care by applying nursing
process.
4. To provide holistic nursing care to the patient
using the nursing process.
To gain knowledge about the disease
condition.
To identify the major complication of diabetes .
.
contd
5. Methodology
• History taking
• Observation
• Physical examination
• Discussion with teachers, senior staffs and
doctors
• Using various text books and
• Related internet search technology
6. • Name of client: Purna Bahadur BK
• Age: 63 year
• sex: Male
• IPNO: 26308
• Address : Jutpani 2 Chitwan
• Diagnosis :- DM with HTN
• Ward :- Male medicine
• Bed No. :-15
• Date of admission :-
• Date of interview :-
• Date of discharge :-
• Attending physician :-
• Informants :- Patients and his wife
Bio-profile
8. History of present health
• Patient has history of HTN for 6 months, under
medication (Amlodipine 5 mg OD)
• Diabetes under insulin therapy
• Feeling of weakness, difficult to walk for 3 days
9. 1. Patient was a known case of hypertension for 6 month
2. He had CVA before 6 month
He got weakness of right limbs after CVA
3. No history of COPD
4. No history of any surgical illness.
5.No history of food and drugs allergy.
history of Past health
10. ENVIRONMENTAL HISTORY
• Type of family :- Single Family
• No. of family:- 2 members
• Type of house:- Cemented house
• NO. of rooms :- 4
• Kitchen :- Separated
• Fuel used :- Firewood , Gas
• Drinking Water - Tap water
• Toilet - Water seal
• Drainage System :- Closed drainage
11. Contd
Family history
• No history of Hypertension, Diabetes, TB
or asthma in family.
Socio economic history
• Middle class family.
12. Smoking :- NO history
Alcohol : - No
Food habit :- 3 times a day/ non
vegetarian
Bowel and bladder :- Regular bowel and
bladder habit
Sleeping Pattern :- 8 hours at night
PERSONAL HISTORY
13. Family tree
5
58 s 66yrs
28 yrs
Expired male
Expired female
Patient
Male
Female
65yrs
32yrs
14. Developmental task
In book My patient
Adjusting to retirement and
reduced or fixed income
He had been retired, he is
getting pension,so he is
adjusted to that
Adjusting to decreasing
health and physical
strength.
He was adjusted to that,
as he verbalize that he
could not hear properly,
has vision problem due to
aging process
Adjusting to the death of
the spouse
He has two children,no
loss of spouse
15. Finding way to maintaining
quality of life
Not involved in social work
Accepting self as ageing He had accepted the
ageing process, as he
verbalizes it is natural
Maintaining satisfactory
living arrangements
He had maintained the
satisfactory living
arrangements
Redefining the relationship
with the adult children
He had no good
relationship with son,but in
good relationship with his
daughter
16. General Inspection:
Gait : Uncoordinated
Body Build : General
Consciousness : Conscious and alert
Facial expression : Anxious
Vital signs
Temperature : 980
f
Pulse : 80b/minute and regular ,normal
volume and character.
Respiration : 24 /minute, regular
Blood Pressure : 140/90 mm Hg in both arms
(supine)
Weight : 68kg
P HYSICAL EXAMINATION
17. General examination
• Pallor Absent
• Icterus absent
• Lymph node not palpable
• Clubbing, cyanosis absent
• Edema Not present
• Dehydration absent.
• Skin normal
18. Physical examination cont
• Examination of head ,face and neck
1.Head
Hair colors and texture normal, clean hair no
any injury
2.Eyes
No discharge and redness of the eye lid,
Blurred vision
3. Ears
No discharge but difficulty in hearing
19. contd
4. Nose
No discharge , bleeding and smelling problem.
5.Mouth
Missing teeth and dental carries
6. Neck
No enlarged lymph node and thyroid gland .
normal neck mobility is present
20. Respiratory examination
• Inspection
• Normal
• Palpation
Non tender
• Percussion
• Resonant in all side of the chest.
• Auscultation
• Normal vesicular breath sound in both site
22. Inspection-
no distension ,moving symmetrically with respiration, no
dilated superficial veins, no scar marks
Palpation-
Non tender,
liver- normal, spleen- normal
Percussion- Dullness present
Auscultation-
Bowel sounds present (normal)
Abdominal problem
23. CNS examination
• Higher mental function is adequate
• Motor examination eg position of limbs
normal ,no atrophy, no ulcer,
uncoordinated gait
• No abnormal movement.
• Weak muscle power in right limb.
• Sensory normal
29. Informal health teaching
• Diabetic diet
• Foot care
• Exercise
• Regular check up of eye, BP, blood sugar
• Adequate fluid
• Different site of injection
• Physical care
31. Diabetes mellitus
• Diabetes mellitus, often simply referred
to as diabetes—is a group of metabolic
diseases in which a person has high blood
sugar, either because the body does not
produce enough insulin, or because cells
do not respond to the insulin that is
produced.
32. Incidence
• Diabetes mellitus affects about 17 million
people, 5.9 million of whom are
undiagnosed. In the United States,
approximately 800,000 new cases of
diabetes are diagnosed yearly (Mokdad et
al., 2000).
33. Incidence continue
Diabetes is especially prevalent in the elderly,
with up to 50% of people older than 65
suffering some degree of glucose intolerance.
Among adults in the United States, diagnosed
cases of diabetes increased 49% from 1990 to
2000, and similar increases are expected to
continue (Centers for Disease Control and
Prevention [CDC], 2002).
34. Types of diabetes
• Type 1 diabetes: results from the body's failure
to produce insulin, and presently requires the
person to inject insulin. (Also referred to as
insulin-dependent diabetes mellitus, IDDM for
short, and juvenile diabetes.)
• Type 2 diabetes: results from insulin
resistance, a condition in which cells fail to use
insulin properly, sometimes combined with an
absolute insulin deficiency.
35. Gestational diabetes
• Gestational diabetes: is when pregnant
women, who have never had diabetes before,
have a high blood glucose level during
pregnancy. It may precede development of
type 2 DM.
36. Secondary diabetes
• Accompanied by conditions known or
suspected to cause the disease: pancreatic
diseases, hormonal abnormalities, medications
such as corticosteroids and estrogen-
containing preparations.
• Depending on the ability of the pancreas to
produce insulin, the patient may require
treatment with oral antidiabetic agents or
insulin.
37. Etiology
• Hereditary
• Autoimmune
• Viral
• Environmental factor
Predisposing factors
• Diagnosed over the age of 40 years
• Overweight/obesity
• Pancreatic infection
38.
39. Clinical manifestation
• Polyuria (frequent urination),
• Polydipsia (increased thirst) and
• Polyphagia (increased hunger)
• Visual blurring
• Fatigue
• Weight loss
• Coma
43. Contd
Diabetes is diagnosed by examining glucose levels in blood
samples using one or more of the following tests:
• Random glucose test — a glucose level above
11.1mmol/L taken at a random time on two occasions is
a diagnosis of diabetes.
• Fasting glucose test — a glucose level above 7.8mmol/L
measured without anything to eat and on two different
days is a diagnosis of diabetes.
• Glucose tolerance test — a blood glucose test is taken
two hours after a glucose drink is given to the patient. A
level above 11.1mmol/L is a diagnosis of diabetes, while
a level below 7.8 is normal.
49. Management
1)PREVENTION
There is no know way to prevent diabetes except
it resulting from secondary cause following
environmental factors can be modified in
• prevention of obesity
• Prevention of illness
• Reduction of environmental stressor
• Prevention and control of hypertension
• Exercise
50. Management continue
• 2)EMERGENCY CARE
A)Deabetic ketoacidosis
• Goal of the treatment for this acute condition
are rehydration, restoration of electrolyte
balance and reduction of blood glucose level
• Administer regular insulin
• Administer IV fluid
• Blood glucose level should not be lowered
51. • B) hyperglycemic hyperosmolar non ketotic syndrome
• Is characterized by extreme hyperglycaemia, profound
dehydration, mild or undectable urea and the absence
of Acidosis.Hyperosmolarity of plasma and elevated
blood urea nitrogen
• Is treated with vigorous fluid replacement and
administration of insulin and electrolyte
• infusion N/S over 2 hrs period followed by hypotonic
saline solution
• Insulin is given infusion pump, if blood glucose levels
decreases rapidly about 250 mg/dl dextrose saline is
added to prevent hypoglycemia
C)hypoglacemia
52. Nursing care plan
ASSESSMENT
A. Subjective data
• Polyuria
• Polydipsia
• Polyphagia
• Visual blurring
• Fatigue
• Weight loss
• Un-coordinated gait
53. B. Objective data
• Hypertension
• Right hand and right leg weakness
• Unco-ordinate gait
• Color of injected site
• Anxiety
54. Orem’s self-care theory
Theory of self care
Theory of self care deficit
Theory of Nursing system
Wholly compensatory
Partially compensatory
Supportive educative system
Theory apply for my case
55. Goal: to achieve optimal levels of knowledge
regarding diabetes and its consequence
Objectives:
• Patient will state the importance of maintaining a
diabetic diet.
• List the food items less in carbohydrate and fat
• Patients will state the importance of foot care,
regular check up of eye, glucose level blood, blood
pressure,
56. APPLYING THE OREM’S
THEORY
SELF-CARE DEFICIT
1 . Therapeutic self care demand:
Deficient area: fluid volume
Adequacy of self care agency: inadequate
NURSING DIAGNOSIS
• Fluid volume deficit related to inadequate intake
57. Goal: To achieve optimal levels of fluids
Objectives:
• Patient will state the importance of maintaining a
fluid balance.
58. Contd
Implementation
• provided adequate fluid to the patient
• Teach Patient and his wife about liquid and
liquid diet.
Evaluation
• Patient was taken liquid diet
59. APPLYING THE OREM’S THEORY
SELF-CARE DEFICIT
1 . Therapeutic self care demand: Deficient area: diabetic
food adequacy of self care agency: not maintain
NURSING DIAGNOSIS
• Alteration in diet pattern related to knowledge deficit
regarding importance of diabetes diet
60. b. Nursing Goals and objectives
Goal: To achieve optimal level of diabetic diet and
minimize the risk of complication of diabetes.
Objectives:
• Patient will state the importance of diabetic diet.
• Take diabetes diet
61. Contd
Implementation
• Encourage the patient to take low carbohydrate
and fat containing diet
• Teach Patient about amount and timing of the
food.
62. EVALUATION
• Patient and his wife understood the importance of
maintaining diabetic diet.
• in terms of food will be decreased with the
initiation of the nutritional intake.
• The supportive educative system was useful .
63. contd
Design of the nursing system
supportive educative.
Method of helping:
• Guidance
• Support
• Teaching
• Providing developmental environment
64. Knowledge gained through the case study
• I got comprehensive knowledge about the
individualized care
• I got knowledge about diabetic diet.
• I got knowledge to care the diabetic client
• I got knowledge about holistic care of patient
• I got knowledge about possible complication of this
disease
65. Daily Progress reportDaily Progress report
Date :- 2067/5/ 28
Admission day
A patient was came in medical OPD with history of
dizziness and weakness .
On admission patient’s vitals sign were:
B.P=140/90 mm of hg, R.R=32/min,
Pulse=88/min, Temp.=98ºf according to nursing report.
RBS-210mg/dl
Insulin-30.70 u BD Sc
66. Date :- 2067/5/ 29
2nd
day of admission
• Vitals signs:
B.P= 140/80, pulse= 90/min, R.R=24/min,
Temp.=98.6ºf,
• FBS-170mg/dl
67. Date :- 2067/5/ 30
3nd
day of admission
• Vitals signs:
B.P- 140/80, pulse-70b/min, R.R-22/min,
Temp.-98ºf
FBS.
• Sleeping pattern good
• Bowel and bladder normal
68. Date :- 2067/5/31
4th
day of admission
• Vitals signs:
B.P- 130/90, pulse-70b/min, R.R-32/min, Temp.-98ºf,
• Patient condition was normal
• Patient was discharge on request.
69. Complication
• Low blood sugar levels leading to weakness,
confusion and sometimes seizures and loss of
consciousness.
• Susceptibility to infections.
• Ulcers and infections of the feet.
• Arteriosclerosis (hardening of the arteries),
particularly in smokers and those with high blood
pressure.
• Diabetic nephropathy (kidney disease).
• Diabetic retinopathy (diabetes-related eye disease).
• Diabetic neuropathy (nerve damage).
70. • Exercise
• Exercise is very important both type 1 and type 2 diabetes. A
good exercise programme can help to control your blood sugar
level. However, you may need to adjust your insulin dose
according to the amount of exercise you take, as too much
insulin and exercise may lower your blood sugar level.
• Oral medications
• Oral medications lower the blood sugar by increasing the
amount of insulin secreted by the pancreas or by increasing
the action of insulin in the body or by delaying the absorption
of glucose. These drugs are called hypoglycemic tablets. They
will not be effective unless they are combined with dietary
restrictions.
71. Insulin therapy
• Insulin therapy is the main treatment for type 1 diabetes. It may
also be required by some people with type 2 diabetes.,
• The aim of insulin therapy is to control the amount of insulin in
the bloodstream so that glucose levels are normal or near
normal. You will be put on insulin and begin to regulate your
diet as soon as the diagnosis is confirmed.
• As well as self-injections of insulin every day, you should also
check your blood sugar level every day to ensure you get the
right dosage of insulin — if you have too much or too little
sugar in your blood, you will need to change your diet or the
amount of insulin you are taking to keep your blood sugar at a
healthy level.
72. • Diet
• Diet is important in both type 1 and type 2 diabetes, but in type
2 diabetes effective dietary management may be sufficient to
control the disorder. The main aim is to maintain a normal
blood sugar level.
• Your doctor will advise you about which foods you should eat
and how to space your meals to avoid going too long without
food. The number of calories you are allowed is determined by
whether you need to maintain, lose or gain weight.
• Your doctor may refer you to a dietician to help you plan a diet
that includes a lot of carbohydrates and high-fibre food, and
minimises the intake of sugar-rich foods. If you are overweight,
you will be advised to lose weight — losing as little as a few
pounds can reduce your need to take medication.
