PHYSICAL ASSESSMENT FOR CLIENT WITH TYPE 1 DIABETES MELLITUS

Patient AB, a 16 year old female, presents to the clinic with an inappropriate 10 lb loss over the
last few weeks, nauseous, has increased urination, dry mouth, and easy fatigability. Upon assessment,
Patient AB says, “Lagi na lang akong nanghihina at ang bilis-bilis kong mapagod.” Further assessment
also showed blurring of vision. A wound on her left lower knee was also noted with Patient AB’s
complain, “Mahigit tatlong lingo na rin yang sugat na ‘yan simula nung nadapa ako sa fields. Ang
tagal ngang gumaling eh.”
Familial medical history revealed that the father of the client has had Type 1 DM for several years
while the mother is hypertensive. After several laboratory exams, the patient was diagnosed Type 1
Juvenile DM.

PHYSICAL ASSESSMENT

Gordon’s Level of Functioning

Pattern Before Present Interpretation

1.Health Perception- Patient rarely goes to Patient is concerned Patient cannot
Health Management the hospital for about her wound and function normally
checkup. All in all, easy fatigability. She anymore like before
she thinks she is in a thinks that her wound because of her
healthy state. maybe a source of physical condition.
infection.
Delayed wound
healing is primarily
due to reduced
sensation in
peripheral nerves.
There is also a lack
of growth factors,
chemicals that
regulate blood vessel
growth, as well as
certain immune cells
that are necessary to
effectively heal a
wound.
2. Nutritional- Few weeks ago, Patient nutritional
Metabolic patient loves eating status before
Management instant foods and signifies imbalanced
junk foods. She also diet with inclination to
loves colas, fruits, high carbohydrate
cakes and pastries. intake.
She eats irregularly
because of her sport. During Nausea and vomiting
She loves eating hospitalization, she is due to delayed
whatever she likes. complains of nausea gastric emptying
and vomiting despite possibly related to
of increased appetite. impending DKA or
 The patient is already vagus nerve damage
restricted for too due to years of high
much intake of blood glucose levels.
carbohydrate and
other foods with high
glucose content.

The patient also Weight loss is

complains of weight possibly due to the
loss of 10 lbs over loss of sugar in the
weeks ago. urine and depletion of
water. Muscle
breakdown during
high levels of blood
glucose levels may
also contribute to
sudden inappropriate
weight loss.

The patient reported Dry mouth and

dry mouth and increased thirst may
increased thirst be an indication of
during the past few slight dehydration
weeks. which may be
attributable to
polyuria and
vomiting.
3.Elimination Pattern Bowel: Bowel: Bowel:
Patient defecates 1-2 Patient defecates There was a change
times a day, usually once a day but not in the frequency and
morning and in the on a regular basis. amount but has no
afternoon. Stool is Stool is soft, minimal significant
brown in color and in amount and brown implication.
well-formed. in color.

Bladder: Bladder:
Patient voids usually Patient voids 12-15 Bladder:
6-8 times a day. times a day. She Polyuria is due to
Urine is yellow in complains of osmotic diuresis
color. No pain when itchiness in her secondary to
voiding. perineal area. hyperglycemia.

4.Activity, Leisure, Patient is a high The onset of fatigue The fatigue and
and Recreation school student and few weeks ago and weakness may be
Pattern an athlete. Her delayed healing of due to muscle
leisure time would her wound made her wasting from the
include playing, unable to follow her catabolic state of
running, reading practice schedules. insulin deficiency,
books and going out During hypovolemia, and
with her peers. hospitalization, the hypokalemia.
patient is also unable
 to attend her classes
in school.

5.Sleep and Rest Patient puts herself Due to her Patient’s sleep and
Pattern to sleep by watching uncomfortable rest pattern changed
television programs. condition and when since she
She usually sleeps at frequent urination experienced some of
around 11pm to even at night pain, the signs and
6am. She feels patient complains of symptoms and was
rested when sleeping difficulty of sleeping further altered when
and thinks that her and short period of she was admitted.
energy is sufficient sleeps. She cannot put
for her activities. herself to sleep
anymore due to
present condition and
frequent urination
plays a big factor for
her sleep
disturbances.
6.Cognitive – Patient is a high She complained of Blurred vision is due
Perceptual Pattern school student She difficulty while to the effect of the
can read and write. reading her books hyperosmolar state
She can speak and and using her on the lens and
be understood by cellphone due to vitreous humor.
others. blurring of her vision. Glucose and its
metabolites cause
dilation of the lens,
altering its normal
focal length.
7. Self-Perception / Patient is a friendly During the times of There is a slight
Self-Concept Pattern person; she loves to her confinement, she change in her self-
socialize with her doesn’t think that she perception due to
friends and is a holistic person present condition.
classmates. She anymore especially
considers herself as that she can’t attend
holistic human being to her practice
as long as she is schedules and
healthy, complete, classes. However,
and her family is she is positive that
always there. she will be ok after
the confinement.

8. Role Relationship Patient can The patient’s family Normal/ No

understand English is supportive to the alterations.
and Filipino. She has patient. She is happy
3 siblings. She is the with their presence
eldest among them. and support.
9. Sexuality/ Patient is single. Patient reserved her Patient reserved her
Reproductive Pattern right to privacy. right to privacy.
10.Coping and When patient is The recent Patient accepts
Stress Tolerance stressed, she sings hospitalization of the present condition
in their videoke and patient was stressful with a positive
eats comfort foods and source of attitude.
like cakes and anxiety. However,
chocolates. When it she is positive that
comes to problems, she will be able to
she lets herself think cope up with current
immediately for a condition even she
solution. knew that it would be
a lifetime difficulty for
her and her family.
11.Values- Belief Patient is a Roman She follows a Due to her
Pattern Catholic. She has a therapeutic regimen confinement, patient
strong faith to God and her strong faith is trusting God that
and goes to mass to God accounts for she will be discharge
every Sunday with her fast recovery. soon and will recover
her family. without any
complications.