Care of a Client with Dm Type 2

Cebu Normal University
College of Nursing
Osmeña Boulevard Cebu City 6000
254 – 4837 / [e-mail]

A Case Study of a Patient with Diabetes Mellitus Type 2: Striving to Live Life worth Living

Taboada, Gwen Marie F.

Chapter 1
Introduction
Diabetes mellitus (DM) 2 or type 2 diabetes is more common than diabetes mellitus type 1 and is prevalent in people over 40 years old. The condition and its symptoms develop slowly over a period from weeks to months. In DM type 2, the patient’s body still makes insulin but the amount is not enough for the body’s needs. This condition is called “insulin resistance” where the body cells become resistant to normal levels of insulin or if there is inadequate production of insulin. With DM type 2, the patient needs more insulin to keep the blood glucose level down. The obese and those who have type 1 diabetes are at risk developing type 2 diabetes.
Among all diseases, the number of deaths due to diabetes grew faster than other conditions between 1999 and 2005. From 9, 749 reported diabetes cases in 1999, 18, 411 cases were listed in 2005.
Prevention and early treatment of diabetes are key elements in preventing the spread of this disease. Information on the early prevention of diabetes will help decrease the prevalence of the disease. Thus, this study aims to increase awareness and knowledge of the seriousness of diabetes, its risk factors, and effective strategies for preventing complications associated with diabetes and preventing DM Type 2 and to help people to live well with diabetes and effectively manage their disease to prevent or delay complications and may improve quality of life.

Physical Assessment
A comprehensive head-to-toe assessment was done with the following baseline data.
Central Nervous System During the time of care, the client’s level of consciousness was alert. She was pleasant and calm upon assessment. She has a congruent affect and displayed appropriate gestures to the situation offered. Her orientation was “x3” meaning she was oriented to place, person and time. She was also able to recall her recent, intermediate and remote memory. There were no unusualities noted with her sensorium. In her sense of sight, she stated that she is using glasses and reported blurring of vision especially when reading. Her pupils on both eyes were both equally round and reactive to light and accommodation. Her taste buds were altered. She feels it when she is touched and has no unusualities on her sense of smell. She can also hear conversation at normal tone of voice. There was no slurring of speech noted. No aphasia noted during the interview.
Cardiovascular System Upon assessment, she had a irregular strong pulse ranging from 110-130 beats per minute. Upon auscultation, there were no extra sounds heard; only S1 and S2 were audible through stethoscope. Her blood pressure was slightly elevated usually at 130/90 mmHg. Her capillary refill time was 2-3 seconds and has pale nail beds.
Respiratory System Client has symmetrical chest and tachypnea noted with respirations at a rate ranging usually to 30 cycles per minute. Regular, shallow, abdominal breathing was observed with no presence of cough. There were no adventitious sounds heard upon auscultation during the time of care. Client has no respiratory assistive devices.

Gastrointestinal System Client was on soft diet with aspiration precaution. Gag reflex is present. When feeding, client must be positioned in moderate high back rest to prevent aspiration. Her appetite was normal, however, she needs an assistant when feeding due to weakness on her left side of her body. Her lips were pink and moist. Client regularly defecates twice a day with semi-solid brown feces. His abdomen is flat and symmetrical with normoactive bowel sounds with 30-35 clicks per minute. No ostomies noted.
Integumentary System The client has a brown complexion and is warm to touch on the upper extremities and cold to touch on the lower extremities. Client has impaired skin integrity with evidence of some cuts and delayed wound healing on her right leg with an estimated size of 2-3 cm. She has poor skin turgor. Non-pitting bipedal edema noted. Presence of small bruises is evident. No lesions and no ulcerations noted.
Urinary System The client urinates 6-8 times a day and reports that she consumes 4-5 diapers a day. She also reported that her urine is clear and yellow in color. No dysuria, urgency, retention, hesitancy, hematuria, nocturia and incontinence reported.
Musculoskeletal System Her grasps on right hand was strong while on her left warm was weak. Her reflexes were graded +2 except on her left side of her body where reflexes were absent and were graded 0. She has weak extremities and in fact, client cannot support one’s own weight. No assistive devices were utilized. She is assisted by her sister in dressing, bed mobility, transferring and ambulating. Limited range of motion on the affected side. No deformities and amputation noted. Negative for homan’s sign and claudication.
Reproductive System Client had never experienced any Pap smear exam and reported no vaginal discharges present. Have no history of sexually transmitted disease and no congenital problems.
Others
No pain felt upon assessment.

Statement of the Problem
The study aims to present a case about Diabetes Mellitus (DM) type 2 and its signs and symptoms manifested by the client. It specifically aims to explain the following: 1. What is the pathophysiology of DM type 2 as applied to this particular case in terms of: a. Predisposing factors? b. Precipitating factors? c. Signs and symptoms? d. Complications? e. Prognosis? 2. What are the diagnostic procedures the client has undergone? 3. What are the medical treatment the client experienced to manage the symptoms of DM type 2? 4. What are the nursing managements the client go through to manage the symptoms of DM type 2?

Significance of the Study
The study will pave way for ideas that are relevant to Diabetes Mellitus type 2. The study will be a great benefit to the following:

Patient. Through this paper, she will know more about his condition and its prognosis. Also, she will be aware of the appropriate and recommended treatment to help her achieve back his optimum level of functioning.
Community. Through this research, the people in the community will understand more the information and ideas related to DM type 2. They will have a better knowledge and perception about this disease and will exercise the appropriate action to prevent acquiring the said disease.
Nursing Practice. They can benefit from this study in understanding and empathizing better to clients and significant others and have appropriate interventions regarding the care to these clients.
Nursing Education. They will have expanded knowledge in the nursing care for clients and their families having this disease.
Health-Allied Professional. In relation to their profession, they can benefit from this study in understanding the course of disease. They can also exercise the appropriate prevention management to be exerted to decrease the likelihood of acquiring the disease.
Future Researcher. This research can provide basis and reference for future studies about DM type 2.

Methodology
Research Design The study uses quali-descriptive type of research. This type of research uses different approaches like storytelling, narratology and a lot more. This paper mainly utilizes narrative description from the client’s experience, feeling and actual treatment plan he is taking. It also includes description from secondary sources which includes the chart and supportive others.
Research Locale This study was done at Vicente Sotto Memorial Medical Center, an affiliated hospital of Cebu Normal University, located in V. Rama, Cebu City. It is a General; Tertiary Medical Center; Teaching / Training Medical Facility owned by the Philippine Government (Wikipilipinas, 2012). It has an eight hundred (800) bed capacity as of 1998. It began operation in 1911 as Hospital Del Sur and was soon legally established as Southern Islands Hospital (Wikipedia, 2011). After 84 years of operation, it was renamed to Vicente Sotto Memorial Medical Center to honor Senator Vicente Sotto on May 21, 1992 through Republic Act 7528.
Research Instrument The tools used are the forms which are structured and based from Betty Neuman’s system Model. These forms include RLE 01: Physical assessment form and RLE 02: Nursing Care Plan. Other instruments used are references like books, internet websites and the patient’s chart.
Data Gathering procedure In gathering the data needed for this study, physical assessment and interview was done. The patient’s chart was also utilized to countercheck data and to obtain results that are significant which may help the researcher produce a better paper.

Anatomy and Physiology
This section discusses the anatomical structure and functions of the organ responsible for the production of the hormone causing DM type 2.

Figure 1.0 Human Anatomy of the Pancreas
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.
•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.
Pancreas
Pancreas (Figure 1.0) is 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. Beta cells of the pancreatic islet secrete insulin (Bare and Smeltzer, 2004).
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 malfunction because glucose is the nervous system’s main source of energy. When blood glucose decreases, other tissues to provide an alternative energy source which break fats and proteins rapidly. As fats are broken down, the liver produces acidic ketones, which are released 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.
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. An increase blood level 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. Decreased insulin levels allow blood glucose to be conserved to provide the brain with adequate 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.

Pathophysiology
Upon knowing the anatomy and physiology of the organ responsible for the production of hormone (insulin), a pathogenesis is drawn to trace from the cause of the occurrence of the disease to the manifestation of signs and symptoms.
Narrative
The two main problems related to insulin in DM type 2 are insulin resistance and impaired insulin secretion. Insulin resistance refers to decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In DM type 2, these intracellular reactions are diminished, thus rendering insulin less effective at stimulating glucose release by the liver. The exact mechanism that leads to insulin resistance and impaired insulin secretion are unknown, although genetic factors are thought to play a role (Smeltzer & Bare, 2004).
To overcome insulin resistance and prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and DM type 2 develops. Despite the impaired secretion of insulin, there is enough insulin present to prevent the breakdown of fat the accompanying production of ketone bodies. Therefore, DKA does not typically occur in type II diabetes. However, uncontrolled DM type 2 may lead to another acute problem. Because it is associated with a slow, progressive glucose intolerance, its onset may go undetected for many years. If the patient experiences symptoms, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, poor healing skin wounds, vaginal infections or blurred vision if glucose levels are very high.

Diagnostics
This section reveals the diagnostic laboratories the client had undergone to confirm its diagnosis.
Chemistry
Date taken: 12/10/12
Table 1.0 Lipid Profile Results Lipid Profile | Result | Unit | Normal Value | Impression | Cholesterol | 197.1 | mg/dL | 0-200 | WNR | Triglyceride | 93.6 | mg/dL | 0-200 | WNR | HDL | 38.84 | mg/dL | >60 | Low | LDL | 139.5 | mg/dL | <100 | High | Glucose | 401 | mg/dL | 70-115 | High |
Table 1.0 shows the results of client’s lipid profile. Cholesterol and triglyceride are within normal range. High-density lipoprotein (HDL) is low which means that the client will have greater risk of developing heart disease. Low-density lipoprotein (LDL) and glucose are above the normal range. A high LDL result means that there is a greater chance of creating a bump in the artery wall called a plaque. The plaque is made of cholesterol, cells, and debris. The process tends to continue, growing the plaque and slowly blocking the artery. An even greater danger than slow blockage is a sudden rupture of the surface of the plaque. A blood clot can form on the ruptured area, causing a heart attack. And lastly, client has a high glucose result which means that she is experiencing hyperglycemia and is indicative of Diabetes Mellitus.
Clinical Microscopy
Date taken: 12/11/12
Table 2.0 Glycosylated Hgb Result | Result | Unit | Normal Value | Impression | Glycosylated Hgb | 10 | % | 4-6.4 | High |
Table 2.0 illustrates the level of glycosylated hemoglobin in client with poorly controlled diabetes mellitus. Since the glucose stays attached to hemoglobin for the life of the red blood cell (normally about 120 days), the level of glycosylated hemoglobin reflects the average blood glucose level over the past 3 months. The normal level for glycosylated hemoglobin is less than 7%. Diabetics rarely achieve such levels, but tight control aims to come close to it. Levels above 9% show poor control, and levels above 12% show very poor control.
Medical Management
Client had undergone Brain Plain CT Scan at Chong Hua Hospital on December 11, 2012. This was ordered to determine whether inflammation or other changes are present in the paranasal sinuses, to detect hemorrhage and also to evaluate blood flow to the parenchyma of the brain in the setting of suspected ischemia, infarction, and stroke which is a complication of DM. The result of the said test is stated below.
Test result:
There are small poorly defined hypodensities at the paramedian right fronto-parietal lobes, genu of the right corpus callosum, and the right occipital lobe cortex. There are small well defined oblong hypodensities at the right putamen and left caudate head. There is no evidence of hemorrhage. The cortical sulci and gyri are preserved. The ventricles and basal cisterns are within normal limits. The midline structures are not displaced. There are no intra-axial or extra-axial fluid collections seen. There are no abnormal calcifications noted. The orbital structures are unremarkable. The mastoid air cells and the visualized paranasal sinuses are well aerated.
Impression:
1. Small subacute infarcts at the paramedian right fronto-parietal lobes, genu of the right corpus callosum, and the right occipital lobe cortex. 2. Small chronic infarcts at the right putamen and left caudate head.

Surgical Management
No surgical intervention was done.

Drugs and Therapeutics
(for encoding still, ma’am..)

Nursing Management
This section contains the actual focus chartings made from day 1 to day 3 of rendering nursing care to the client within 8 hours of shift.
Day 1
Chief complaint: Client has a difficulty moving her left side of her body.
Focus: Impaired Physical Mobility
D: received lying on bed, afebrile, diaphoretic; with IVF of #2 PNSS 1L @ 30gtts/min infusing well at right hand, with remaining level of 580cc; left-sided weakness noted; skin warm to touch on the upper extremity and cool to touch on the lower extremity; with vital signs of T= 37.0 ˚C, P= 125 bpm, R= 28 cpm, BP= 130/90 mmHg.
A: ensured safety by raising side rails, encouraged SO to remain at bedside; put things on her reach; assisted in feeding; maintained moderate high back rest position; performed isometric exercises to promote muscle strength; asked to raise affected arm and leg; observed movement when unaware of observation; encouraged participation on self-care activities; environmental care done; took vital signs and recorded.
R: Patient is able to turn to sides with minimal assistance needed. With unstable vital signs of T= 37. 4˚C, P=130 bpm, R= 29 cpm, BP= 130/90 mmHg.

Day 2
Chief complaint: Client verbalized, “Pila na ko ka adlaw diri nga walay kaligo. Baho na kayo ko.”
Focus: Hygiene
D: received lying on bed, afebrile; with IVF of #3 PNSS 1L @ 30gtts/min infusing well at left hand, with remaining level of 720cc; unkept hair noted; dirty fingernails observed; seen scratching her skin and head; untidy clothing on; presence of dirt on the skin; with soiled diapers on; with vital signs of T= 36.5 ˚C, P= 127 bpm, R= 30 cpm, BP= 130/80 mmHg.
A: kept hair clean and presentable; cut dirty nails short; performed sponge bath; changed soiled diaper with clean ones; assisted in changing clothing; bed side care done; assisted in changing soiled bed linens; instructed SO to turn sides every 2 hours; emphasized the importance of good personal hygiene; instructed SO to stay at bed side always.
R: Patient is wearing new clothing with nails cut short and hair kept.
Day 3
Chief complaint: Client verbalized, “Ganahan ko mu tindog, unya maglakaw-lakaw. Bahalag lisod. Tabangi ko bi.”

Focus: Safety
D: received lying on bed, non-dyspneic; with IVF of #4 PNSS 1L @ 30 gtts/min infusing well at left hand with remaining level of 840cc; unable to support one’s own weight; left-sided weakness noted; assisted in changing positions; with malfunctioned side rails; lying on unsafe stretcher; with vital signs of T= 36.6 ˚C, P= 116 bpm, R= 25 cpm, BP= 110/80 mmHg.
A: ensured safety by raising side rails; encouraged SO to remain at bed side; put things on her reach; assisted during feeding; elevated head during feeding; changed position every 2 hours; instructed to move slowly; kept in a comfortable position; environmental care done; took vital signs and recorded.
R: Patient is asleep. Seen SO at bedside always.
Nursing Care Plan
Nursing Diagnosis: Impaired physical mobility related to left-sided hemiparesis secondary to cerebrovascular disease infarct
Subjective: “Maglisud ko ug lihok sa akong lawas,” as verbalized.
Objective: received lying on bed, afebrile, non-dyspneic; with IVF #4 PNSS 1L @ 30 gtts/min infusing well at left hand with remaining level of 840 cc; left-sided weakness noted; unable to support one’s own weight; unable to assume sitting position for longer periods without assistance; with vital signs of T= 36.6 ˚C, P= 116 bpm, R=25 cpm, and BP of 110/80 mmHg.
Interventions:
Promotive
I: Asssist in repositioning on regular schedule (every 2 hours)
R: to promote optimal level of functioning
I: Encourage to limit fluid intake to 1.5 L/day
R: to provide hydration and avoid fluid overload
I: Provided safety measures at all times
R: to reduce risk of injury
I: Demonstrated client & SO active and passive ROM exercises
R: to maintain and promote optimal level of functioning
I: Advise to follow strict compliance to low-salt. Low-fat, low-carbohydrates, soft diet
R: to prevent occurrence of complications
Preventive
I: Support affected body parts/joints using pillows
R: to maintain position of function and reduce risk of pressure ulcers
Curative
I: Administer due medications as prescribed
R: to reduce or prevent complications and to enhance level of functioning
I: Stress the importance of drug compliance especially antibiotics
R: to prevent drug resistance
I: Regulate IVF at prescribed rate, 30 gtts/min
R: to provide hydration and prevent fluid overload
Rehabilitative
I: Consult with the physical therapist and speech therapist
R: to develop exercise program
I: Encourage client’s/SO’s e=involvement in decision-making as much as possible
R: enhances commitment to plan, optimizing outcome
Nursing Diagnosis: Self-care deficit; dressing/grooming and toileting related to left-sided weakness
Subjective: “Di ko ka-atiman sa akong kaugalingon kung ako ra, “ as verbalized.
Objective: received lying on bed, afebrile; with #2 PNSS 1L @ 30 gtts/min infusing well at right hand with remaining level of 450 cc; diaphoresis noted; unable to support one’s own weight; unable to maintain appearance at a satisfactory level.

Interventions:
Promotive
I: Identify degree of individual impairment
R: to determine degree of patient’s weakness
I: Determine individual strengths and skills of the patient
R: to promote the functionality of the good side
I: Promote patient’s/ SO’s participation in problem identification and desired goals
R: enhances commitment to plan, optimizing outcomes, and supporting recovery and health promotion
Preventive
I: Allow sufficient time for client to accomplish tasks to fullest extent of ability
R: to prevent dependence to SO/nurse in doing simple task
I: Identify energy-saving behaviors
R: to decrease unnecessary actions that will waste energy
I: Demonstrate on how to do isometric exercises(can be active or passive)
R: to increase muscle strength
Curative
I: Administer due medications as ordered
R: to ensure efficacy of medications
I: Tell the client to change position gradually
R: to avoid orthostatic hypotension
I: Ensure safety by raising side rails up
R: Prevent from falling and decrease the risk of injury
I: Put things on client’s reach
R: To avoid overextending her arms
I: Render sponge bath using tap water and mild soap
R: to maintain proper hygiene and prevent dryness of skin
I: Change clothing when wet
R: to avoid the occurrence of pneumonia
I: Turn to sides every 2 hours
R: to prevent accumulation of sweat, thus preventing pneumonia
Rehabilitative
I: Collaborate with rehabilitation professionals
R: to identify/obtain assistive devices necessary
Nursing diagnosis: Fatigue related to decrease metabolic energy production as evidenced by overwhelming pack of energy, inability to maintain usual routine, decreases performance, accident prone
Subjective: “Kapoy kayo akong paminaw,” as verbalized.
Objective: Received lying on bed, afebrile, conscious and coherent; with IVF #3 PNSS 1L @ 30 gtts/min infusing well at right arm with remaining level of 780 cc; profuse sweating observed; wandering eyes noted; with short attention span; appears to be tired and drowsy;
Interventions:
Promotive
I: Discuss with client the need for activity. Plan schedule with client and identify activities that lead to fatigue
I: Education may provide motivation to increase activity level even though client may feel too weak initially
I: Monitor vital signs before and after activity
I: Encourage client to make decisions related to care
I: Increase client participation in ADLs as tolerated
Preventive
I: Alternate activity with rest periods
I: Ensure safety at all times
I: Encourage SO to turn client every 2 hours
Curative
I: Establish realistic activity goals with client and encourage forward movement
I: Plan interventions to allow individually adequate rest periods
I: Avoid or Limit exposure to temperature and humidity extremes
I: Provide diversional activities. Avoid overstimulation of senses
I: Elevate head of bed during feeding
I: Assist client to identify appropriate coping behaviors
I: Schedule activities for periods when client has the most energy
Rehabilitative
I: Refer to comprehensive rehabilitation program for programmed daily exercises and activities

Discharge Instructions
This section provides home care instructions upon discharge to reduce recurrence of condition and to prevent further complications associated with the case of J.T.J., 41 years old, female, eldest in the family, a Filipino citizen, from a Roman Catholic family, born on August 14, 1971, and is currently living in Matab-ang, Cordova, Cebu; admitted last December 10, 2012 at 1:51 in the afternoon, with an admitting diagnosis of CVD Infarct Right Mid-cerebral Artery secondary to DM Type 2.
Take home medications consisting of Irbesartan 150 mg/tab, Amlodipine 5 mg/tab, and Human Insulin 40 units Subq. It was explained well to the client on what each medication is for and when to take it. Emphasis on the importance of taking the medication and not skipping a dose were instilled on the client. In addition, the client was instructed to report any side effects and adverse reactions as indicated by the health care provider.
A peaceful and well-ventilated environment conducive for fast recovery and healthy living must also be provided. The SO was advised to reduce environmental distractions as much as possible to promote undisturbed sleep and rest. The SO was also advised to provide passive range of motion exercises on the affected side. Encouraged to move extremities slowly to promote muscle strength.
Client was informed for follow up checkup 1 week after discharge. Client’s hygiene must also be observed by advising her to take a bath daily, change diapers every four hours or when soiled and brush teeth at least twice a day. Emphasizing the importance of taking care of the foot/feet must be understood to avoid cuts or wounds on the area. Proper insulin injection was also taught to provide knowledge independence on the client’s part.
The client was taught how to take axillary temperature properly and the importance of reporting temperature elevation and other signs and symptoms of infection such as redness, swelling, foul odor discharges and fever to the health care provider.
Diet must also be followed strictly and fluid intake must be at least 1000 ml a day. Instructed client to consume foods low in carbohydrates and fats to avoid hyperglycemic episodes and also encourage foods high in fiber to prevent client from straining when defecating. Encouraged to eat foods rich in vitamin C to aid in increasing immunity. Supported the family with prayers for the promotion of wellness of the client and acknowledged the family for spiritual guidance.

Chapter 3

Summary
The incidence of diabetes is also rising in the Philippines. The Bohol Standard reported in November, 2008 that one out of every five Filipinos living in the Philippines had diabetes. Furthermore, a survey conducted by the Philippine Cardiovascular Outcome Study on Diabetes Mellitus in 2007 found that “20.6 percent of adults aged 30 and above were found to be diabetic”. In 1998 only 3.9 percent of Filipinos living in the Philippines had diabetes.
One problem for the increase in diabetes among Filipino people has been the low level of diabetes awareness among Filipinos. Some individuals theorize this low level of diabetic awareness is influenced by a couple misconceptions. One misconception reported by Dr. Ferrer from Davao Medical Center, is the belief among many Filipino people that an overweight child is a healthy child, which he says is “simply not true”. Another misconception reported among the Filipino people is the lack of knowledge many individuals have on the devastating consequences of diabetes. Among Filipino people diabetes is often called the “silent killer” because people are often unaware of the complications of the disease-resulting from an unhealthy lifestyle.
Furthermore, this disease became the ninth leading cause of death in the Philippines from 1999 to 2002. In 2005 however, diabetes became the eighth leading cause of death with 1 in 25 Filipinos having the condition. More women than men have diabetes.
Conclusion
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can be associated with serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications. Diabetes can affect many parts of the body and can lead to serious complications such as blindness, kidney damage, and lower-limb amputations. Working together, people with diabetes and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, and blood lipids and by receiving other preventive care practices in a timely manner.

Recommendation
Diabetes Mellitus type 2 can often be controlled through a carefully planned diet that keeps your blood glucose levels under control, while also reducing your risk of developing heart disease and other complications of diabetes.

One of the most important aspects of a diet for diabetes is balancing the amount of calories one can get from carbohydrates, proteins and fats. As a general rule, the client should get between 50 and 60 percent of your calories each day from carbohydrates if you have type 2 diabetes, the Patient Education Institute explains. In addition, less than 30 percent of your calories should come from fat, with the rest coming from protein. To do this, monitor the carbohydrate, fat and protein content of the different foods you eat.
The Mayo Clinic recommends that if you have type 2 diabetes that you get most of your carbohydrate intake from sources such as lentils, low-fat dairy, whole grains, vegetables, fruits and legumes. Increasing your fiber intake is also beneficial because fiber lowers blood glucose and cholesterol levels. Consume two servings of fatty fish, such as mackerel, herring or salmon each week because the omega-3 fatty acids in them helps lower your risk of heart disease.