ca dm type 1.pdf

1
Case Study
On
Diabetes Mellitus Type -1
Submitted To: Submitted By
Ms. Reena Chaudhary Mrs. Swati Sharma
Assistant Professor Msc. Nursing 1st
Year
ACON ACON
Submitted On:

2
IDENTIFICATION DATA OF THE PATIENT
Name Of The Patient -Mr. HOSHIYAR SINGH NARYAL
Age -63yrs
Sex -Male
Marital Status -Married
Ward - SURGICAL WARD
Bed No -26
Date Of Admission -12-07-2022
Discharge Date -18-07-2022
Address - Vill- Batheri P.O Santhal Teh.- Jogindernagar Disstt Mandi
Religion -Hindu
Educational Status - 8th
Occupation -Driver
Diagnosis - Diabetes Mellitus Type 1 With Foot Ulcer
Surgical Procedure - Leg Amputation
Date And Time Of Assessment – 12/07/22
CHIEF COMPLAINTS WITH DURATION:
Patient admitted to Subhash Chander Bose Zonal Hospital Mandi with chief complaints of-
 Swelling in the foot and ankle x 4 days

3
 Pain in leg x 7 days
 Fever x 3days
 Drainage from the sore on foot x 4days
 Extreme Weight loss x 1month
 Increased thurst x 1month
HISTORY OF PRESENT ILLNESS:
Present Medical History:
Mr.hoshiyar singh is 63years old patient was apparently well one week back he developed excessive pain on sore foot which was intermittent
and change in colour, and odour and pus drained from the site. He was also complaining of hot flushed skin and there was severe reduction
in the weight of the patient. Patient has undergone for many investigations CBC, KFT, LFT and imaging tests like chest X-ray. Patient was
admitted in Subhash Chander Bose Zonal Hospital Mandi .where he had undergone for leg amputation .
Present Surgical History:
Patient had undergone for amputation on 14/7/22 with general and epidural anesthesia.
PAST HEALTH HISTORY:
Past Medical History: Patient was having no significant past medical history of hypertension, asthma, tuberculosis and jaundice
 Childhood illnesses: There is no history of any childhood illnesses e.g. Tuberculosis, Measles, Mumps etc.
 Other illnesses: No history of any communicable or hereditary illnesses e.g. Tuberculosis etc.
Past Surgical History:

4
Patient had not undergone for any surgical procedure before.
FAMILY HEALTH HISTORY:
 Type of family: joint
 No. of family members: 9
 Any Illness: No history of any hereditary or communicable diseases in the family e.g. Cancer, T.B. etc.
FAMILY TREE-
Keys-:
Mr.Hoshiyar singh Mrs. Sulekha Devi
( 63 yrs. ) (59yrs.) - male
Mr. suraj Mrs.Rajni Mr. Vishal Mrs. Poonam
(32years) (28yrs.) ( 29yrs.) (27yrs) - female
- patient
Mast.Rishav(7years)
vrinda
(3yrs)

5
Family Composition:
Family Members Age Sex Relationship with
the patient
Occupation Education Health status
Mr. Hoshiyar Singh 63yrs. MA Patient Retired Driver 8th
Unhealthy
Mrs. Sulekha Devi 59
Yrs
FA Wife House Wife 5th
Healthy
Mr. Suraj 32
Yrs
MA Son Driver 10th
Healthy
Mrs. Rajni Devi 28
Yrs
FA Daughter In Law Anganwari Worker +2 Healthy
Master Rishav 7yrs M Grand Son - 2nd
Healthy
Mrs. Vishal 29yrs MA Son Private Job B.A Healthy
Mrs. Poonam 25yrs. FA Daughter In Law Student Anm Healthy
Ms. Vrinda 3 Yrs. F Grand daughter - - Healthy
Socio economic status
Living locality -Rural
Housing facility -Pucca house
Income per month -Rs.40,000 / 4 = 10,000

6
Relationship with other family members -Good
Environmental History
Ventilation -Appropriate
Drainage -Open drainage
Water Supply -Private water supply
Electricity -Present
Sanitation -Well maintained
Nutritional habits
Eating habits -Non vegetarian
Nourishment -Well nourished
No. of meals -3 times per day
Allergies to any food - allergic to egg plant
PERSONAL HISTORY
 Personal Hygiene:
Oral Hygiene -Maintained (0nce a day)
Bath -Daily but delayed due to disease condition
Diet - Non Vegetarian
No. Of meals / day - 3 time per day but reduced due to cancer
Food preferences - sugar free and less carbohydrates diet

7
Sleep & Rest - Patient is having restlessness, pain and nocturia due to which his sleep level had disturbed
Elimination -Elimination is 0n bed pan
Urine frequency -2850 ml/day
Exercise / Activity - Reduced due to surgical procedure
Joints - Pain due to surgical procedure
Substance use -History of smoking since last 10-15 years.
Marital status -Married
PHYSICAL EXAMINATION
 GENERAL APPEARANCE AND BEHAVIOUR:
Level of consciousness -Conscious
Orientation - Oriented to time place and person
Nourishment - Moderately nourished
Body built - Thin
Activity -Dull
Look -Lethargic
Hygiene - Not Maintained
Speech -Slurred
Mood -Sad
Anthropometric Measurements:
Height -172cm
Weight -52kg
BMI -17.9kg/m2

8
 VITAL SIGNS:
Date Temperature Pulse Respiration Blood pressure
12-7-22 101.6F 98bpm 18 120/70mmhg
13-7-22 98.8F 84bpm 20 100/70mmhg
14-7-22 98.6 F 82 18 100/70mmhg
15-7-22 99.1F 80 18 110/78mmhg
16-7-22 98.4F 84 20 120/84mmhg
17-7-22 98.6F 72 18 120/80mmhg
18-7-22 98.6F 76 18 120/76mmhg
 INTEGUMENTARY SYSTEM
SKIN
Colour -Tan brown
Texture -Dry
Skin Turgor -Decreased (< 3)
Hydration -Dehydrated
Discolouration -Acrocyanosis present
Lesions -Not present
NAILS
On observation -Intact
Nail beds -Normal
Nail plate -Flat
Capillary refill time -less than 3 seconds
Other signs/symptoms - None
HEAD
Shape -Normocephalic

9
Scalp -Mild dandruff is present
Face -Normal
Hairs -Texture of hairs is rough and colour is greyish
FACE
Shape -Square
Paipation of temporomandibular joint -Normal
EYES
Eyebrows -Symmetrical
Eyelashes -Equally distributed
Eyelids -Normal
Sclera - Normal
Conjunctiva - Dry
Vision - Glaucoma
Pupils
Pupil -Pupil of patient are at the centre of the iris
Equal -Both the pupils are equal in size
Round -Pupil of patient are round in shape
Reactive to -Pupil of patient are reactive to light
Light -Pupils are dilated when put light on them
Accomodation -Normal
NECK
Movement of neck - normal extension, flexsion,
Cervical vertebrae -Normal
Range of motion -Passive range of motion

10
EARS
Pinna - Normally placed
Cerumen - Present
Ottorhoea -Absent
Hearing -Normal
Subjective Symptoms -No complaints
MOUTH & PHARYNX
Lips -Dry lips
Colour - Dark in colour
Gums - Dark in colour
Tongue -Coated
Position -Midline
Mobility -Normal
Colour - Blackish in colour
Taste - Decreased taste sensation
Teeth -Dentures
Mucous membrane -Ulcers present in mucous membrane
Breath Odour - Present
Pharynx -Sore throat
Gag Reflex -Present
Tonsils -Not enlarged
Voice -Harsh
NECK
Range of Motion - Possible
Lymph Nodes -Not enlarged

11
Trachea - Midline
Thyroid Gland - Not enlarged
Jugular Veins - Distended
Subjective Symptoms - No complaints
SYSTEM WISE EXAMINATION-
 RESPIRATORY SYSTEM
Inspection
Thorax - Normal
Thorax Expansion - Equal and symmetrical
Chest pain - Not present
Palpitation - Not present
Apical pulse - 98 beats/ min
Cough - Cough is present
Hemoptysis - Absent
Blood pressure - 120/70 mmhg
Palpation
Tactile fermitus - Normal
Cardiomegaly -Not present
Thrill -Not present
Auscultation
S1 and S2 sounds -Normal
S3 and S4 sounds -Not present
Murmur sound -Absent
Friction rub -Absent
Breath Sounds -No abnormal breath sounds present

12
Percussion
Hyper resonance -Absent
Dullness -Absent
Diaphragmatic excursion -Normal
 Gastrointestinal system-
On Inspection
Umbilicus - Clean
Abdominal distension - Distended due to burst abdomen
Appetite -Anorexia
Ascitis -Absent
Auscultation
Bowel sounds -Hypoactive ( 4/min )
Palpation - tenderness
Inguinal Lymph Nodes -Not enlarged
Percussion
No abdominal fluid felt while doing percussion of abdomen.
Palpation
Patient do not felt any pain while doing palpation of abdomen
 MUSCULOSKELETAL SYSTEM
Postural Curves - Normal
Muscle tone - Decreased
Muscle Strength -Weaker than normal

13
Upper extremities:
Symmetry -Symmetrical
Finger nails -Capillary refill <3 seconds
Range of motion -Decreased
Peripheral pulses -Normal
Brachial - Normal
Oedema/ swelling -Present
Cyanosis -Acrocyanosis present
Joints -Painful
Deformity -Absent
Lower extremities:
Symmetry - Ulceratin in left foot
Toe nails -Capillary refill <3 seconds assessed in one foot
Colour - blushish discoloration
Odour - bad odour from ulceration
Lesion or scar - present
Range of motion -Patient is not able to walk due to sever pain
Peripheral pulses -Normal
Oedema/ swelling -Present in left foot with purulent discharge
Tenderness - Present and warm to touch due to ulceration
Cyanosis -Acrocyanosis Present in left foot
Joints -Tenderness
Deformity - present
Gait - Not Normal
Varicose veins -Absent
Dependency level -Dependant

14
 GENITO URINARY SYSTEM
Lesions/scar -Absent
Discharge/infection -Absent
Voiding -Through catheter
 RECTUM & ANUS
Skin Integrity - Intact
Bowel Elimination pattern - bed pan
Impression: Patient is having impaired physical mobility, edema is present over the extremities and acrocyanosis is present over the arms. Hairs
of patient are greyish in colour and mild dandruff is present. Amputation of left leg of patient is done and and in bowel sound of pt. is hypoactive
due to poor mobility . For urination catheter is present.capillary refill time is also reduced.
INVESTIGATION:
Sr. No. Investigation Patient value Normal value Remarks
1. Hb 9.2mg/dl 12-18gm/dl Decreased
2. Na+ 140 mmol/L 135-145 mmol/L Normal
3. K 4.40 mmol/L 2.5-3.5 m mol/L Normal
4. Urea 18mg/dl 6-23mg/dl Normal
5. Cl 97 mmol/L 95-110 m mol/L Normal
6. Albumin 3.3gm 3.5-5.3meq/l Decreased
7. WBC 56 cells/cubic mm 4-11cells/cubic mm Increased
8. Lymphocytes 18% 20-40% Decreased

15
10 HbA1C (%) >7.5 5.7- 6.4 Increased
11 PG, fasting ( mg /dl ) <100 >136 Increased
12 PG, 2-hours <140 >228 Increased
OTHER TESTS-
MRI Abdomen- Asymmetrical circumferential thickening involving antro pyloric region of stomach causing marked luminal narrowing with
proximal dilation of stomach- s/o Ca stomach with gastric outlet obstruction needs HPE correlation.Multiple tiny T2 hyperintense foci in liver-
hepatic cyst.
TREATMENT CHART
Sr. no. Name of the Drug Dose Route Frequency Mechanism of Action
1. Inj.Vancomycin 500mg Intravenous TDS Vancomycin acts by inhibiting proper cell wall
synthesis in Gram-positive bacteria. The mechanism
inhibited, and various factors related to entering the
outer membrane of Gram-negative organisms mean
that vancomycin is not active against Gram-negative
bacteria
2. Inj.Meropenem 1gm Intravenous BD Meropenem is bactericidal except against Listeria
monocytogenes, where it is bacteriostatic. It inhibits

16
bacterial cell wall synthesis like other β-lactam
antibiotics. In contrast to other beta-lactams, it is
highly resistant to degradation by β-lactamases or
cephalosporinases
3. Inj. Tylenol IV
infusion
15mg/kg BD Acetaminophen injection is used to relieve mild to
moderate pain and to reduce fever. Acetaminophen
injection is also used in combination with opioid
(narcotic) medications to relieve moderate to severe
pain. Acetaminophen is in a class of medications
called analgesics (pain relievers) and antipyretics
(fever reducers). It works by changing the way the
body senses pain and by cooling the body.
4.. Inj.Ondasetron 4mg Intravenous BD It is used in the prevention of the nausea and
vomiting by blocking the action of chemical
messenger serotonin in the brain that may cause
nausea and vomiting.
5. Inj.Pantaprazole 40mg Intravenous BD It is a proton pump inhibitor that decrease the
amount of acid produce in the stomach.
6. Critipro powder 2 tsp PO BD Protein powder

17
DISEASE CONDITION
Anatomy and Physiology:
DEFINITION:-
The endocrine system is a network of glands in your body that make the hormones that help cells talk to each other. They’re responsible for almost
every cell, organ, and function in your body.
If your endocrine system isn't healthy, you might have problems developing during puberty, getting pregnant, or managing stress. You also might gain
weight easily, have weak bones, or lack energy because too much sugar stays in your blood instead of moving into your cells where it's needed for
energy.

18
GLAND:-
A gland is an organ that makes and puts out hormones that do a specific job in your body. Endocrine and exocrine glands release the substances they
make into your bloodstream.
FUNCTIONS OF ENDOCRINE SYSTEM IN HUMAN BODY:-
Endocrine System Functionshe endocrine system is responsible for regulating a range of bodily functions through the release of hormones.
Hormones are secreted by the glands of the endocrine system, traveling through the bloodstream to various organs and tissues in the body. The
hormones then tell these organs and tissues what to do or how to function.
Some examples of bodily functions that are controlled by the endocrine system include:
 metabolism
 growth and development
 sexual function and reproduction
 heart rate
 blood pressure

19
 appetite
 sleeping and waking cycles
 body temperature
gland
A gland is an organ that creates and releases substances that the body needs to function. There are two types of glands:
 endocrine glands, which release hormones directly into the bloodstream
 exocrine glands, like lymph nodes and sweat glands, which are not part of the endocrine system
Endocrine system:
 Makes hormones that control your moods, growth and development, metabolism, organs, and reproduction
 Controls how your hormones are released
 Sends those hormones into your bloodstream so they can travel to other body parts

20
Parts of the Endocrine System
Many glands make up the endocrine system. The hypothalamus, pituitary gland, and pineal gland are in your brain. The thyroid and parathyroid glands
are in your neck. The thymus is between your lungs, the adrenals are on top of your kidneys, and the pancreas is behind your stomach. Your ovaries (if
you're a woman) or testes (if you're a man) are in your pelvic region.
 Hypothalamus. This organ connects your endocrine system with your nervous system. Its main job is to tell your pituitary gland to start or
stop making hormones.
 Pituitary gland. This is your endocrine system’s master gland. It uses information it gets from your brain to tell other glands in your body
what to do. It makes many important hormones, including growth hormone; prolactin, which helps breastfeeding moms make milk; antidiuretic
hormone(ADH) (vasopressin), which controls blood pressure and helps control body water balance through its effect on the kidney,
corticotropin /ACTH: Adrenocorticotrophic hormone. which stimulates the adrenal gland to make certain hormones, thyroid-stimulating
hormone (TSH), which stimulates the production and secretion of thyroid hormones, oxytocin which helps in milk ejection during breast
feeding; and luteinizing hormone, which manages estrogen in women and testosterone in men.
 Pineal gland. It makes a chemical called melatonin that helps your body get ready to go to sleep.
 Thyroid gland. This gland makes thyroid hormone, which controls your growth and metabolism. If this gland doesn't make enough (a
condition called hypothyroidism), everything happens more slowly. Your heart rate might slow down. You could get constipated. And you
might gain weight. If it makes too much (hyperthyroidism), everything speeds up. Your heart might race. You could have diarrhea. And you
might lose weight without trying. The thyroid gland also produces the hormone calcitonin, which may contribute to bone strength by helping
calcium to be incorporated into bone.
 Parathyroid. This is a set of four small glands behind your thyroid. They play a role in bone health. The glands control your levels
of calcium and phosphorus.

21
 Thymus. This gland makes white blood cells called T-lymphocytes that fight infection and are crucial as a child's immune system develops.
The thymus starts to shrink after puberty.
 Adrenals. Best known for making the "fight or flight" hormone adrenaline (also called epinephrine), these two glands also make hormones
called corticosteroids. They affect your metabolism heart rate, oxygen intake, blood flow, and sexual function, among other things.
 Pancreas. This organ is part of both your digestive and endocrine systems. It makes digestive enzymes that break down food. It also makes the
hormones insulin and glucagon. These ensure you have the right amount of sugar in your bloodstream and your cells.
 If you don't make insulin, which is the case for people with type 1 diabetes, your blood sugar levels can get dangerously high. In type 2
diabetes, the pancreas usually makes some insulin but not enough.
 Ovaries. In women, these organs make estrogen and progesterone. These hormones help develop breasts at puberty, regulate the menstrual
cycle, and support a pregnancy.
 Testes. In men, the testes make testosterone. It helps them grow facial and body hair at puberty. It also tells the penis to grow larger and plays a
role in making sperm.
Health Issues
As you get older, it's natural to notice some things related to your endocrine system. Your metabolism tends to slow down. So you might gain weight
even though you haven't changed how you eat or exercise. Hormonal shifts also explain, at least in part, why you're more likely to have heart disease,
osteoporosis, and type 2 diabetes as you age.
No matter how old you are, stress, infections, and being around certain chemicals can also mess with parts of your endocrine system. And genetics or
lifestyle habits can increase your chances of an endocrine disorder like hypothyroidism, diabetes, or osteoporosis.

22
Endocrine System Disorders
 Acromegaly. Sometimes the pituitary gland makes too much growth hormone and your bones get bigger. It usually affects your hands, feet,
and face. It usually starts in middle age.
 Adrenal insufficiency. When you have this, your adrenal glands don’t make enough of certain hormones, like cortisol, which controls stress.
 Cushing's disease. In this, your body makes too much cortisol. You could gain weight, get stretch marks, bruise easily at first, then get
weakened muscles and bones and possibly develop a hump on your upper back.
 Hyperthyroidism. This is when your thyroid gland makes more hormones than your body needs. You might hear it called overactive thyroid.
It makes your system run fast and you might feel nervous, lose weight, and have a rapid heartbeat or trouble sleeping.
 Hypothyroidism. When your body doesn’t make enough thyroid hormone, your system slows down. You might feel tired, gain weight, have a
slow heartbeat, and get joint and muscle pains.
 Hypopituitarism. Sometimes your pituitary gland doesn’t make enough of certain hormones and your adrenal and thyroid glands can’t work
right.
 Multiple endocrine neoplasia. This is a group of disorders that affect your endocrine system. It causes tumors on at least two endocrine
glands or in other organs and tissues.
 Polycystic ovary syndrome. An imbalance of reproductive hormones can cause your ovaries to either not make an egg or not release it
during ovulation. This can throw off your periods, cause acne, and make hair to grow on your face or chin.
 Precocious puberty. When glands that control reproduction don’t work properly, some kids start puberty abnormally early -- around 8 in girls
and 9 in boys.
DISEASE CONDITION :-

23
INTRODUCTION:-
Diabetes mellitus is a condition defined by persistently high levels of sugar (glucose) in the blood. There are several types of diabetes. The two
most common are called type 1 diabetes and type 2 diabetes.
During digestion, food is broken down into its basic components. Carbohydrates are broken down into simple sugars, primarily glucose. Glucose
is a critically important source of energy for the body’s cells. To provide energy to the cells, glucose needs to leave the bloodstream and get
inside the cells.
An organ in the abdomen called the pancreas produces a hormone called insulin, which is essential to helping glucose get into the body's cells. In
a person without diabetes, the pancreas produces more insulin whenever blood levels of glucose rise (for example, after a meal), and the insulin
signals the body's cells to take in the glucose. In diabetes, either the pancreas's ability to produce insulin or the cells' response to insulin is
altered.

24
Type 1 diabetes is an autoimmune disease. This means it begins when the body's immune system mistakenly attacks other cells in the body. In
type 1 diabetes, the immune system destroys the insulin-producing cells (called beta cells) in the pancreas. This leaves the person with little or
no insulin in his or her body. Without insulin, glucose accumulates in the bloodstream rather than entering the cells. As a result, the body cannot
use this glucose for energy. In addition, the high levels of blood glucose cause excessive urination and dehydration, and damage the body's
tissues.

25
Type 2 diabetes occurs when your body's cells become less responsive to insulin's efforts to drive glucose into the cells, a condition called
insulin resistance. As a result, glucose starts to build up in the blood.
In people with insulin resistance, the pancreas "sees" the blood glucose level rising. The pancreas responds by making extra insulin to try to
usher the glucose into the cells. At first, this works, but over time, the body's insulin resistance gets worse. In response, the pancreas makes more
and more insulin. Finally, the pancreas gets "exhausted." It cannot keep up with the demand for more and more insulin. As a result, blood
glucose levels rise and stay high.
Type 2 diabetes is also called adult-onset diabetes. That’s because it almost always used to start in middle or late adulthood. However, more and
more children and teens are now developing this condition.

26
Type 2 diabetes is much more common than type 1 diabetes. It tends to run in families. Obesity also increases your risk of type 2 diabetes. It is
truly a different disease than type 1 diabetes, although both types involve a high blood glucose level and the risk of complications associated
with it.
Another kind of diabetes, called gestational diabetes, happens in women who have higher-than-expected blood sugar levels during pregnancy.
Once it occurs, it lasts throughout the remainder of the pregnancy. Like the other types of diabetes, gestational diabetes happens when the
hormone insulin can't efficiently move sugar (glucose) into the body's cells so it can be used as fuel. In gestational diabetes, the body does not
respond well to insulin, unless insulin can be produced or provided in larger amounts.
In most women, the disorder goes away when the pregnancy ends, but women who have had gestational diabetes are at increased risk of
developing type 2 diabetes later.
Causes-
Book picture Patient picture
Weight. The more fatty tissue you have, the more resistant your cells
become to insulin.
Inactivity. ...
Family history. ...
Race or ethnicity. ...
Age. ...
Gestational diabetes. ...
Polycystic ovary syndrome. ...
High blood pressure.
- Inactive
- Patient father had history of diabetes

27
Symptoms
Diabetes initially might not cause any symptoms. It can sometimes be caught early with a routine blood test before a person develops symptoms.
When diabetes does cause symptoms, they may include:
excessive urination
excessive thirst, leading to drinking a lot of fluid
weight loss.
People with diabetes also have an increased susceptibility to infections,
especially yeast (Candida) infections.
When the amount of insulin in the blood stream is too low, extremely
high blood sugar levels can lead to dangerous complications. The body
can become too acidic, a condition called diabetic ketoacidosis. Or the
blood sugar level gets so high, the person becomes severely
dehydrated. It’s called hyperosmolar syndrome.
The symptoms of these complications include confused thinking,
weakness, nausea, vomiting, and even seizures and coma. In some
cases, diabetic ketoacidosis or hyperosmolar syndrome is the first sign
that a person has diabetes.
The treatment of diabetes also can produce symptoms. Too much
glucose-lowering medicine, relative to dietary intake, can lead to a
blood sugar level that has dropped too low (called hypoglycemia).
- Excessive urination
- Excessive thurst
- Foot ulcers
- Weakness and fatigue
- Confused thinking
- Retinopathy

28
Symptoms of hypoglycemia include:
sweating
trembling
dizziness
hunger
confusion
seizures and loss of consciousness (if hypoglycemia is not recognized
and corrected).
You can correct hypoglycemia by eating or drinking something that
has carbohydrates. This raises your blood sugar level.
Long-term diabetes can have other complications, including:
Atherosclerosis — Atherosclerosis is fat buildup in the artery walls.
This can impair blood flow to all parts of the body. The heart, brain,
and legs are affected most often.
Retinopathy — Tiny blood vessels in the retina (the part of the eye
that sees light) can become damaged by high blood sugar. The damage
can block blood flow to the retina, or can lead to bleeding into the
retina. Both reduce the retina's ability to see light. Caught early,
retinopathy damage can be minimized by tightly controlling blood
sugar and using laser therapy. Untreated retinopathy can lead to
blindness.
Neuropathy — This is another term for nerve damage. The most
common type is peripheral neuropathy, which affects nerves in the feet

29
and hands. The nerves to the legs are damaged first, causing pain and
numbness in the feet. This can advance to cause symptoms in the legs
and hands. Damage to the nerves that control digestion, sexual
function, and urination can also occur.
Foot problems — Any sores, injuries, or blisters on the feet can lead
to the following complications:
If peripheral neuropathy causes numbness, a person may not feel any
irritation or injury that occurs on the foot. The skin can break down
and form an ulcer, and the ulcer can get infected.
Blood circulation can be poor, leading to slow healing of any foot
injuries. Left untreated, a simple sore can become very large and get
infected. If medical treatment cannot heal the sore, an amputation may
be required.
Nephropathy — This refers to damage to the kidneys. This
complication is more likely if blood sugars remain elevated and high
blood pressure is not treated aggressively.
Diagnosis
Diabetes is diagnosed through blood tests that detect the level of glucose in the blood.

30
Fasting plasma glucose (FPG) test. A blood sample is taken in the
morning after you fast overnight. A normal fasting blood sugar level is
between 70 and 100 milligrams per deciliter (mg/dL). Diabetes is
diagnosed if the fasting blood sugar level is 126 mg/dL or higher.
Oral glucose tolerance test (OGTT). Your blood sugar is measured
two hours after you drink a liquid containing 75 grams of glucose.
Diabetes is diagnosed if the blood sugar level is 200 mg/dL or higher.
Random blood glucose test. A blood sugar of 200 mg/dL or greater at
any time of day, combined with symptoms of diabetes, is sufficient to
make the diagnosis.
Hemoglobin A1c (glycohemoglobin). This test measures your average
blood glucose level over the prior two to three months. Diabetes is
diagnosed if the hemoglobin A1c level is 6.5% or higher.
- Fasting sugar is done (136mg/dl )
- Random glucose test is done (228mg/dl )
- HBA1C is done (7.4%)
Expected Duration
Type 1 diabetes is a lifelong illness. Usually, type 2 diabetes is also life-long. However, people with type 2 diabetes can sometimes restore their
blood sugar levels to normal just by eating a healthy diet, exercising regularly, and losing weight.
Gestational diabetes usually goes away after childbirth. However, women with gestational diabetes are at high risk for developing type 2
diabetes later in life.

31
In people with diabetes, aging and episodic illnesses can cause the body's insulin resistance to increase. As a result, additional treatment typically
is required over time.
Prevention
Type 1 diabetes cannot be prevented.
You can decrease your risk of developing type 2 diabetes.
If a close relative—particularly, a parent or sibling—has type 2 diabetes, or if your blood glucose test shows "pre-diabetes" (defined as blood
glucose levels between 100 and 125 mg/dL), you are at increased risk for developing type 2 diabetes. You can help to prevent type 2 diabetes by
 maintaining your ideal body weight.
 exercising regularly—such as a brisk walk of 1-2 miles in 30 minutes—at least five times a week, even if that does not result in you achieving an
ideal weight. That’s because regular exercise reduces insulin resistance even if you don’t lose weight.
 eating a healthy diet.
 taking medication. The medication metformin (Glucophage) offers some additional protection for people with pre-diabetes.
If you already have type 2 diabetes, you can still delay or prevent complications by doing the following.
Keep control of your blood sugar. This helps reduce the risk of most complications.
Lower your risk of heart-related complications. Aggressively manage other risk factors for atherosclerosis, such as:
 high blood pressure
 high cholesterol and triglycerides

32
 cigarette smoking
 obesity
Visit an eye doctor and a foot specialist every year. This can help you reduce the risk of eye and foot complications.
Treatment
Type 1 diabetes is always treated with insulin injections.
In most cases, type 2 diabetes treatment begins with weight reduction through diet and exercise. A healthy diet for a person with diabetes is low
in total calories, free of trans fats and nutritionally balanced, with abundant amounts of whole grains, fruits and vegetables, and monounsaturated
fats.
Most people with type 2 diabetes need drug therapy to control blood sugar. However, it is possible to achieve normal blood sugar levels with
weight loss, a healthy diet and regular exercise.
Even if medications are required, diet and exercise remain important for controlling diabetes.
The medications used for type 2 diabetes include pills and injections. They work in many different ways. They include medications that:
reduce insulin resistance in the muscles and liver
increase the amount of insulin made and released by the pancreas
provide additional insulin
- Insulin( lantus ) injection 28 units is taken after food
-counting fats carbohydrates and proteins

33
cause a burst of insulin release with each meal
delay the absorption of sugars from the intestine
slow your digestion
reduce your appetite for large meals
decrease the conversion of fat to glucose.
Weight loss surgery may be an option for some obese people with type
2 diabetes.
Treatment options
The following list of medications are in some way related to or used in
the treatment of this condition.
Tresiba
insulin degludec
- Eating healthy
Prognosis
The prognosis in people with diabetes varies. It depends on how well an individual modifies his or her risk of complications. If blood sugar is
not well controlled, it can increase a person's risk of heart attack, stroke, and kidney disease, which can result in premature death. Disability due

34
to blindness, amputation, heart disease, stroke, and nerve damage may occur. Some people with diabetes become dependent on dialysis
treatments because of kidney failure.
THEORY APPLICATION:- Roys Adaptation Model
Demographic data-
Name
Age
Sex
IP number
Education
Occupation
Marital status
Religion
Informants
Date of admission
Mr. NR
53 years
Male
-----
Degree
Bank clerk
Married
Hindu
Patient and Wife
21/01/08
FIRST LEVEL ASSESSMENT
PHYSIOLOGIC-PHYSICAL MODE
Oxygenation
 Stable process of ventilation and stable process of gas exchange. RR= 18Bpm.
 Chest normal in shape. Chest expansion normal on either side.
 Apex beat felt on left 5th inter-costal space mid-clavicular line.

35
 Air entry equal bilaterally. No ronchi or crepitus. NVBS. S1& S2 heard.
 No abnormal heart sounds.
 Delayed capillary refill+. JVP0.
 Apex beat felt- normal rhythm, depth and rate.
 Dorsalis pedis pulsation of affected limp is not palpable.
 All other pulsations are normal in rate, depth, tension with regular rhythm.
 Cardiac dullness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line.
 S1& S2 heard.
 No abnormal heart sounds. BP- Normotensive. .
 Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.
Nutrition
 He is on diabetic diet (1500kcal). Non vegetarian.
 Recently his Weight reduced markedly (10 kg/ 6 month).
 He has stable digestive process.
 He has complaints of anorexia and not taking adequate food.

36
 No abdominal distension. Soft on palpation. No tenderness.
 No visible peristaltic movements.
 Bowel sounds heard.
 Percussion revealed dullness over hepatic area.
 Oral mucosa is normal. No difficulty to swallow food
Elimination:
 No signs of infections, no pain during micturation or defecation.
 Normal bladder pattern. Using urinal for micturation.
 Stool is hard and he complaints of constipation.
Activity and rest
 Taking adequate rest.
 Sleep pattern disturbed at night due unfamiliar surrounding.
 Not following any peculiar relaxation measure.
 Like movies and reading. No regular pattern of exercise.
 Walking from home to office during morning and evening.

37
 Now, activity reduced due to amputated wound. Mobility impaired.
 Walking with crutches.
 Pain from joints present. No paralysis.
 ROM is limited in the left leg due to wound.
 No contractures present. No swelling over the joints.
 Patient need assistance for doing the activities.
Protection
 Left lower fore foot is amputated.
 Black discoloration present over the area.
 No redness, discharge or other signs of infection.
 Nomothermic.
 Wound healing better now.
 Walking with the use of left leg is not possible.
 Using crutches.
 Pain form knee and hip joint present while walking.

38
 Dorsalis pedis pulsation, not present over the left leg. Right leg is normal in length and size.
 Several papules present over the foot.
 All peripheral pulses are present with normal rate, rhythm and depth over right leg.
Senses
 No pain sensation from the wound site. Relatively, reduced touch and pain sensation in the lower periphery; because of neuropathy. Using
spectacle for reading. Gustatory, olfaction, and auditory senses are normal.
Fluids and electrolytes
 Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte values are with in normal limit. No signs of acidosis or
alkalosis. Blood glucose elevated.
Neurological function
 He is conscious and oriented.
 He is anxious about the disease condition.
 Like to go home as early as possible.
 Showing signs of stress.
 Touch and pain sensation decreased in lower extremity. Thinking and memory is intact.
ENDROCRINE
 He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands.
SELF CONCEPT MODE
Physical self

39
 He is anxious about changes in body image, but accepting treatment and coping with the situation. He deprived of sexual activity after
amputation.
 Belongs to a Nuclear family. 5 members. Stays along with wife and three children. Good relationship with the neighbours. Good interaction with
the friends. Moderately active in local social activities
Personal self
 Self esteem disturbed because of financial burden and hospitalization. He believes in god and worshiping Hindu culture.
ROLE PERFORMANCE MODE
 He was the earning member in the family. His role shift is not compensated. His son doesn't’t have any work. His role clarity is not achieved.
INTERDEPENDENCE MODE
 He has good relationship with the neighbors. Good interaction with the friends relatives. But he believes, no one is capable of helping him at
this moment. He says ”all are under financial constrains”. He was moderately active in local social activities
SECOND LEVEL ASSESSMENT
FOCAL STIMULUS
 Non-healing wound after amputation of great and second toe of left leg- 4 week. A wound first found on the junction between first and second
toe-4 month back. The wound was non-healing and gradually increased in size with pus collected over the area.
 He first consulted in a local (---) hospital. From there, they referred to ---- medical college; where he was admitted for 1 month and 4 days.
During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour. So the physician
suggested for below knee amputation. That made them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.
CONTEXTUAL STIMULI
 Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years, but switched to insulin and using it for 8 years now. Not
wearing foot wear in house and premises.

40
RESIDUAL STIMULI
 He had TB attack 10 year back, and took complete course of treatment. Previously, he admitted in ---Hospital for leg pain about 4 year back. .
Mother’s brother had DM. Mother had history of PTB. He is a graduate in humanities, no special knowledge on health matters.
CONCLUSION
Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer and recent amputation made his life more stressful.
Nursing care of this patient based on Roy's adaptation model provided had a dramatic change in his condition. Wound started healing and he
planned to discharge on 25th april. He studied how to use crutches and mobilized at least twice in a day. Patient’s anxiety reduced to a great
extends by proper explanation and reassurance. He gained good knowledge on various aspect of diabetic foot ulcer for the future self care
activities.
NURSING CARE PLAN
Short term goals:
 Pain will be relieved
 To maintain breathing pattern of patient
 To enhance physical mobility
 To maintain fluid and electrolyte balance
 Nutritional status will be improved
 Activity pattern will be improved.
 Anxiety will be reduced.
 Risk for infection will be reduced.
Long term goals:
 Nutritional status will be maintained at acceptable level
 Knowledge will be improved regarding causes, management and prevention of disease.

41
 Patient will be encouraged for follow up visit
NURSING CARE PLAN-
Assessment Behviour Assessment
stimuli
Nursing
diagnose
Goal Intervention Evaluation
ineffective protection
andsense in physical
physiological mode
(No pain sensation from
the wound site.)
Focal
stimuli:
Non-healing
wound after
amputation
of great and
second toe
of left leg- 4
week
1. Impaired
skin integrity
related to
fragility of the
skin secondary
to vascular
insufficiency
Long-term objective:
1. amputated area will
be completely healed
by 20/5/08
2.Skin will remain
intact with no ongoing
ulcerations.
Short-Term
Objective:
i. Size of wound
decreases to 1x1 cm
within 24/4/08.
ii. No signs of
infection over the
wound within 1-wk
iii. Normal WBC
values within 1-wk
iv. Presence of
healthy granular
tissues in the wound
- Maintain the wound area
clean as contamination affects
the healing process.
- Follow sterile technique
while providing cares to
prevent infection and delay in
healing.
- Perform wound dressing
with Betadine which promote
healing and growth of new
tissue.
- Do not move the affected
area frequently as it affects
the granulation tissue
formation.
- Monitor for signs and
symptoms of infection or
delay in healing.
- Administer the antibiotics
and vitamin C
Short term goal:
Met: size of wound
decreased to less
than 1x1 cms.
WBC values became
normal on 24/4/08
Long term goal:
Partially Met: skin
partially intact with
no ulcerations.
Continue plan
Reassess goal and
interventions
Unmet: not achieved
complete healing of
amputated area.
Continue plan
Reassess goal and
interventions

42
site within 1-wk supplementation which will
promote the healing process.

43
Assessment of
behavior
Assessment
stimuli
Nursing
Diagnosis
Impaired activity in
physical-
physiological mode
Focal stimuli:
During hospital
stay great and
second toe
amputated. But
surgical wound
turned to non-
healing with pus
and black colour.
2.
Impaired
physical
mobility
related to
amputation
of the left
forefoot
and
presence of
unhealed
wound
Long term Objective:
Patient will attain
maximum possible
physical mobility
with in 6 months.
Short term objective:
i. Correct use of
crutches with in
22/4/08
ii. walking with
minimum support-
22/4/08
iii. He will be self
motivated in
activities- 20/4/08.
- Assess the level
of restriction of
movement
- Provide active
and passive
exercises to all the
extremities to
improve the muscle
tone and strength.
- Make the patient
to perform the ROM
exercises to lower
extremities which
will strengthen the
muscle.
- Massage the
upper and lower
extremities which
help to improve the
circulation.
- Provide articles
near to the patient
and encourage
performing activities
within limits which
promote a feeling of
well being.
- Provide positive
Short term goal:
Met: used crutches correctly on
22/4/08.
he is self motivated in doing
minor excesses
Partially Met: walking with
minimum support.
Long term goal:
Unmet: not attained maximum
possible physical mobility-
Continue plan Reassess goal and
interventions

44
reinforcement for
even a small
improvement to
increase the
frequency of the
desired activity.
- Measures for pain
relief should be
taken before the
activities are
initiated as pain can
hinder with the
activity.

45
Assessment of
behavior
Assessment
stimuli
Nursing
diagnose
Alteration in
Physical self in Self-
concept mode
(He is anxious about
changes in body
image)
Change in Role
performance mode.
(He was the earning
member in the
family. His role shift
is not compensate)
Contextual
stimuli:
Known case
DM for past 10
years and on
treatment with
insulin for 8
years.
Residual
stimuli: no
special
knowledge in
health matters
3. Anxiety
related to
hospital
admission and
unknown
Outcome of the
disease and
financial
constrains.
The client will remain
free from anxiety
i. demonstrating
appropriate range
effective coping in
the treatment
ii. Being able to
rest and
iii. Asking fewer
questions
- Allow and
encourage the client
and family to ask
questions. Bring up
common concerns.
- Allow the client and
family to verbalize
anxiety.
- Stress that frequent
assessment are routine
and do not necessarily
imply a deteriorating
condition.
- Repeat information
as necessary because of
the reduced attention
span of the client and
family
Short term goal:
Met: demonstrated
appropriate range effective
coping with treatment
He is able to rest quietly.
Long term goal:
Unmet: client not
completely remained free
from anxiety due to
financial constrains-
Continue plan Reassess
goal and interventions

46
- Provide comfortable
quiet environment for
the client and family
Assessment of
behavior
Assessment
stimuli
Nursing
diagnose
Contextual
stimuli:
Known case
DM for past 10
years and on
treatment with
insulin for 8
years.
Residual
stimuli: no
special
knowledge in
health matters
4. deficient
knowledge
regarding the
foot care,
wound care,
diabetic diet,
and need of
follow up care.
Patient will acquire
adequate knowledge
regarding the t foot
care, wound care,
diabetic diet, and
need of follow up
care and practice in
their day to day life.
i. Verbalization
and demonstration of
foot care.
- Explain the
treatment measures to
the patient and their
benefits in a simple
understandable
language.
- Explain about the
home care. Include the
points like care of
wounds, nutrition,
activity etc.
Clear the doubts of the
patient as the patient
may present with some
matters of importance.
- Repeat the
information whenever
necessary to reinforce
Short term goal:
Met: Verbalization and
demonstration of foot care.
Strictly following diabetic
diet plan
Unmet: Demonstration of
wound care.
Long term goal:
Unmet: not completely
acquired and practiced the
required knowledge.
Continue plan Reassess
goal and interventions

47
HEALTH EDUCATION
Diet- Patient is taught to take high protein diet up to few days of surgery.
Patient is advised to take juices and fiber rich diet .
Provided low carbohydrate and diet to the patient..
Exercise – Patient is taught some active & passive exercise.
Patient is advised to do deep breathing exercises.
Advised patient to sit in a semi-fowler’s position
Hygiene – Patient is advised to keep his surroundings clear & perform hand hygiene properly.
Advised patient to change clothes daily
Patient is adviced to keep hygiene of wound
ii. Strictly following
diabetic diet plan
iii. Demonstration
of wound care
learning.

48
Fluids – Patient is advised to take more fluids & beverages.
Advised patient to take up to 1000ml of water daily
Administer iv fluids as prescribed.
Pain management & Medications - Analgesic and antibiotic medication timing is clearly explained to patient & with that feedback for
medications intake is also taken .
CONCLUSION
I was posted in surgical unit of Subhash Chander Bose Zonal Hospital Mandi . I took a case of diabetes mellitus with ulcerative left foot I took
detailed history of patient & performed physical examination on him. I provided all the need based care to my patient, with that I maintained
good IPR with patient & listened his difficulties & problems. I provided health education to my patient. In future , if I will get the similar case, I
will be able to provide holistic care to my patient .

49
BIBLIOGRAPHY
International Consensus on Diagnosing and Treating the Infected Diabetic Foot (2003) defined diabetic foot infections as “ Any infection
involving the foot in a person with diabetes originating in a chronic or acute injury to the soft tissues of the foot, with evidence of pre-existing
neuropathy and/or ischemia” Ref: Berendt T. Diabetic foot infection: what remains to be discovered?. FDA Anti-Infective Drugs Advisory
Committee, October 2003. http://www.fda.gov/OHRMS/DOCKETS/ac/03/slides/3997S1_01_Berendt.ppt. Accessed on 24-7-06.
 A classification of diabetic ulcers is shown on the slide. Ref: Calhoun JH, Cantrell J. Foot Ankle. 1988 Dec;9(3):101-6.
 Foot ulcers or infections cannot heal without adequate circulation. Vascular disease in diabetes is certainly common, but it often becomes a
limb-threatening problem only after a skin injury. Vascular problems complicate a neuropathic foot ulcer rather than being a primary event. Ref:
Watkins PJ. BMJ. 2003 May 3;326(7396):977-9.
 Patients with diabetes mellitus (DM) have infections more often than those without DM. The course of the infections is also more complicated
in this patient group. One of the possible causes of this increased prevalence of infections is defects in immunity. Furthermore, some
microorganisms become more virulent in a high glucose environment. Many studies show decreased functions (chemotaxis, phagocytosis,
killing) of diabetic polymorphonuclear cells and diabetic monocytes/macrophages compared to cells of controls. Ref: Geerlings SE, Hoepelman
AI. FEMS Immunol Med Microbiol 1999; 26(3-4):259-65

ca dm type 1.pdf

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to ca dm type 1.pdf

Similar to ca dm type 1.pdf (20)

Recently uploaded

Recently uploaded (20)

ca dm type 1.pdf