Angeles University Foundation Angeles City College of Nursing A.Y.

2012-2013

A CASE STUDY on DIABETES MELLITUS TYPE 2

Presented to: Rhocette M. San Agustin, RN, MN

Presented by: Group 4 BSN III-1 De Guzman, Glazier Ellorin, Lynette Galang, Carmela Iris Halili, John Frederick Lacson, Laiza Fatima

I.

INTRODUCTION Diabetes mellitus is a condition in which the pancreas no longer produces

enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working. The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the bodys defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a role. In Type II diabetes, the pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may not work as effectively. Symptoms of Type II diabetes can begin so gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight loss, slow wound healing, urinary tract infections, gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while

a patient is seeing a doctor about another health concern that is actually being caused by the yet undiagnosed diabetes. Current estimates indicate that 20 million people in the United States have diabetes, 90-95% of who have type 2 diabetes mellitus. The number of Americans with diabetes is projected to increase dramatically in forthcoming years due to increasing rates of obesity, lack of physical activity, and an aging population. Patients with diabetes have an increased risk of developing a wide range of disease-related complications, both macro vascular (e.g., cardiovascular disease [CVD]) and micro vascular (e.g., nephropathy, retinopathy, and neuropathy). According to the research team led by Peninsula College of Medicine and Dentistry (PCMD), University of Exeter, lean type 2 diabetes patients have a larger genetic disposition to the disease than their obese counterparts. The group made a study that identified a new genetic factor associated only with lean diabetes sufferers. Type 2 diabetes is popularly associated with obesity and a sedentary lifestyle. However, just as there are obese people without type 2 diabetes, there are lean people with the disease. Using genetic data from genome-wide association studies, the research team tested genetic markers across the genome in approximately 5,000 lean patients with type 2 diabetes, 13,000 obese patients with the disease, and 75,000 healthy controls. The team found differences in genetic enrichment between lean and obese cases, which support the hypothesis that lean diabetes sufferers have a greater genetic predisposition to the disease. This is in contrast to obese patients with type 2 diabetes, where factors other than type 2 diabetes genes are more likely responsible. Dr. John Perry, one of the lead authors of the study, said: Whenever a new disease gene is found, there is always the potential for it to be used as a drug target for new therapies or as biomarker, but more work is needed to see whether or not this new gene has that potential. According to him, the gene that they found to be present in lean sufferers of diabetes is now called Jack Spratt which needs more studies and

researches

for

it

to

be

used

as

drug

target

and

biomarker

in

the

future(http://www.sciencedaily.com/releases/2012/06/120601103808.htm).

Reason for choosing such case for presentation

Nursing profession is never an easy job. It entails a lot of responsibilities like giving the appropriate care for an individual. Nurses should not only possess the knowledge about a certain disease but also the ability to render nursing care and meet the needs of their patients. Being skillful and knowledgeable, aside from being passionate the two are the most important qualities that nurses should have. Enhancing ones knowledge and skills will serve as foundation. One way to do this is to involve nurses themselves in researches and case studies. This will update their learnings regarding a specific disease condition. The student nurses chose this diagnosis for their case presentation is that they saw that the patients SO is very informative about his daughters condition during the nurse patient interaction. It triggered that with that kind of attitude of an informant, they can do their interview with ease being provided with enough information. Another reason is that the student nurses can appreciate more of what they have learned during their lecture in Nursing Care Management courses. And also, Diabetes Mellitus is a widespread disease condition here in the Philippines so that what they have learned here in this case, they can impart it in the community. Also to show what a single disease condition can lead to a serious condition which can possibly create complications and would prevent the individual from functioning well. Thus, through this case study the student nurses could impart knowledge to their patients. To help them gain enough knowledge on how to avoid the said condition. This can be learned if they receive sufficient time, instruction, and help in overcoming disabilities.

Objectives Nurse-centered: After the completion of this case study, the student nurses should have: Interpreted the current trends and statistics regarding the disease condition and relate the state of the client with her personal and pertinent family history. Analysed and interpreted the different diagnostic and laboratory procedures, its purpose and its essential relationship to clients disease condition, identified treatment modalities and its importance like drugs, diet and exercise. Formulated nursing care plans based on the prioritized health needs of the client and maintained sound communication by making use of self as a therapeutic agent thus, acquiring knowledge and understanding of the development of Diabetes Mellitus Type 2 in relation to risk factors presented by the patient. Discusses management and treatment and provide better nursing care and health teachings through the utilization of the nursing process.

Patient-centered: During the course of the study, the patient and the family shall have: Acquired knowledge on the risk factors that have contributed to the development of Diabetes Mellitus Type 2,. Gained understanding and demonstrated compliance on the treatment management rendered by the health care team to prevent reoccurrence of the disease.

II. NURSING ASSESSMENT

A. PERSONAL HISTORY This is a case of Ms. Candy, a 27 year-old female, single, who was born on November 28, 1985 via Normal spontaneous delivery. She is a natural born Filipino citizen. She used to live somewhere in Bataan since she was a child and transferred to Florida Blanca, Pampanga for five years now with her parents, her moms own hometown. She is the youngest daughter among a brood of seven children. Her mother was 48 years old and her father was 57 years old when she became the breadwinner of the family at the age of 20. Her siblings still support and visit them every now and then. As stated by her Mom she received complete vaccination when she was still a baby. Ms. Candy does not drink alcohol nor smoke cigarette ever since, when she was still a student she goes to school at nine oclock in the morning and comes back at home at six pm, she does not skip meals and she usually sleeps for about seven hours a day; when she was still at work, she wakes up at six am because her work starts at eight in the morning, she take her meals at the right time of the day and finished work at five in the afternoon, she usually sleeps and take her rest at nine oclock in the evening; and after her hospitalization last 2011 she now stays at the house, she wakes up 7am for breakfast, Ms. Candy eats lunch between the hours of 12-1pm, she now takes her dinner at 7pm, watch Television and sleeps for the rest of the hours, and usually sleeps at 9pm. She took Diamicron (oral hypoglycaemic drug) and metformin (antidiabetic drug) as a maintenance drug. Ms. Candy was admitted on January 31, 2013, 1 oclock in the morning in a Government Hospital in Pampanga with an admitting Diagnosis of Diabetes Mellitus type 2 poorly controlled to consider DKA. Her chief complaint was vomiting. Ms. Candy previously worked at Vercons Grocery in a cake department for 3 years, she does the packaging of the cakes, and her job is located also in Bataan. She has an income of two hundred pesos per day and working six days a week that makes her earn approximately five thousand pesos a month. Her

father also works as a jeepney driver, 3 times a week to augment their family income. Her mother is a plain housewife who cooks for them and takes care of household chores. She sometimes picks sampaguita flowers at the backyard and sells them but she only earns twenty pesos a week. Since Ms. Candys blood sugar rises and cannot be controlled fully, she has no other option but to resign from her job and leaves her father to work twice as hard as seven times a week in order to provide for their familys needs. Their electric bill per month usually goes around seven hundred pesos, water bill of two hundred, and three thousand five hundred pesos for food and others. She is a second year college Criminology undergraduate, and stopped school because of having the weakness, headache and dizziness, after experiencing these signs and symptoms it has prompted to seek medical advised at a government hospital in Bataan and was given Diamicron (oral hypoglycaemic drug) and metformin (antidiabetic drug). And being able to work made her decide not to study anymore. The family is Catholics, and they do not believe in any superstitious belief. Whenever someone gets sick they go to hospital and are not utilizing health centers and even herbolarios. The family does not use herbal medicines as a cure when sick, and uses only what the doctor prescribed.

B. FAMILY HEALTH-ILLNESS HISTORY

Grandpa; Died of Respiratory Problem at 68 y/o

Grandma; died of heart attack at 67y/o

Father anemia, hypertensio n and arthritis

Aunty1; living with hypertensio n and DM

Uncle1; living with no known disease

Uncle2; living with DM

Auntie2; living with no known disease

Uncle3; died of Kidney proble m

Auntie3; living with no known disease.

Uncle4; living with no known disease.

Grandpa; died of heart attack at 78y/o

Grandma; died during delivery at 46y/o

AuntieA died of asthma and DM

AuntieB; living with no known disease

Mother; living 55y/o with hypertensi on

AuntieC; living with no known disease

Uncle1; died of liver damage

AuntieD; living with no known disease

Uncle2; living with no known disease

Uncle3; living with no known disease

AuntieE; living with no known disease

AuntieF; stillborn child

Sister1; died of Meningitis at 7mo old

Brother 1; 39y/o, living with DM

Brother 2; 38y/o, living with DM

Sister2; 36y/o, living with DM

Brother 3; died of DM at 28y/o

Brother4; 30y/o, living with no known disease

Ms. Candy

LEGENDS: MALE FEMALE DECEASED

PATIENT

EXPALANATION OF THE GENOGRAM Ms. Candys grandmother died at the age of 46 prior to her tenth delivery of her child. She delivered a stillborn child, while her grandfather died at the age of 78 because of heart attack. AuntieA died because of asthma and Diabetes at the age 50, Mother has hypertension, Uncle1 died because of liver damage, AuntieF died on the day that she was born, and the rest are still alive and has no illnesses. Ms.Candys grandfather died at 68 because of respiratory problem and he is an alcoholic while her grandmother died at 67 because of heart attack. Ms. Candys father has anemia, hypertension and arthritis, Auntie1 has hypertension and Diabetes, Uncle2 also has diabetes and Uncle3 died because of Kidney problem. All of her siblings has Diabetes except for Sister1 and Brother4, Sister1 died at the age of seven months because of Meningitis and Brother3 died because of DM, and now Ms. Candy has DM too because it runs through their genes.

C. HISTORY OF PAST ILLNESS

As verbalized by Ms. Candy, she was not hospitalized nor had illness for reasons other than her present condition which is Diabetes or having high glucose in her blood. She had chicken pox when she was 12 years olds during summer vacation and managed it with unrecalled antivirals.

D. HISTORY OF PRESENT ILLNESS Ms. Candy was 19 years old when she was first hospitalized in one of the hospitals of Bataan because of body weakness, headache and dizziness, from then she found out she has DM type 2. Last 2011 and 2012 she was confined twice at a government hospital in Bataan, because of uncontrolled hyperglycemia she usually stayed in the hospital for one week and was given a maintenance drugs of Diamicron

(oral hypoglycaemic drug) and metformin (antidiabetic drug), and because of this her blood sugar decreases. But her medications were stopped 2 days before admission and now on her fourth time of complain, she was referred to a government hospital in Pampanga and there she was confined again.

E. PHYSICAL EXAMINATION 1st day of Nurse-Patient interaction (Jan 31, 2013, thursday)

General Appearance and Mental Status: Patient is conscious, appears weak and pale. The patient is oriented to person, time and place. She is wearing t-shirt and shorts and has IVF hooked on her left hand. She can only perform simple ADLs.

Vital Signs: Temp.: 36.7C PR: 96 bpm RR: 45 cpm BP: 110/70 mmHg

Skin: Fair complexion, hair evenly distributed, with good skin turgor, absence of sores, rashes, lesions and bruises. With dry skin. Head: Round head, with thick, no lesions nor dandruff in the scalp, no tenderness, masses, and nodules noted upon palpation. With headache. Eyes:

Eyebrows are aligned, hair evenly distributed, with white sclera and pale conjunctiva, eyelashes evenly distributed, no nodules noted upon palpation of eyelids. Eyeballs are symmetrically aligned in socket without protruding or sinking. Ears: Symmetrical ears, no lesion, no tenderness and masses noted upon palpation, no abnormal discharges, presence of cerumen, pinna recoils after folded. Nose: No deformities noted, no nasal flaring nor abnormal discharges. No septal deviation. Throat: Patent, no tenderness and nodules upon palpation. Mouth: Lips are symmetrical in shape, with dry pale lips, and with white teeth. Neck: No masses and nodules noted upon palpation, no lesions, no jugular vein distention. Chest and Lungs: The patient has normal respiratory rate, experiences non-productive cough, with clear breath sounds upon auscultation. Shoulders and scapulae are in equal horizontal positions. Sternum is positioned at midline and straight. No retraction. Breast No swelling, nodules, or ulceration. Even color, smooth with no edema. Heart: With normal heart rate rhythm auscultated on the 4th intercostals space. Abdomen: Flat, soft and with normal contour, no lesions, no tenderness, masses and nodules noted upon palpation, with normal bowel sounds. With on and off

stabbing pain Musculoskeletal

felt on epigastric region with a pain rate of 7/10. Patient is

complaining of being nauseous. Feet and legs are symmetric in size, shape, and movement. Extremities warm and mobile with adequate capillary refill. Has moderate range of motion with no swelling, redness, or tenderness nor edema on extremities..

2nd day of Nurse-Patient Interaction (Feb 1, 2013, friday) Vital Signs: Temp.: 36.6C PR: 97 bpm RR: 17 cpm BP: 130/90 mmHg

Skin: Fair complexion, hair evenly distributed, with good skin turgor, absence of sores, rashes, lesions and bruises. With dry skin. Head: Round head, with thick, no lesions nor dandruff in the scalp, no tenderness, masses, and nodules noted upon palpation. With headache. Eyes: Eyebrows are aligned, hair evenly distributed, with white sclera and pale conjunctiva, eyelashes evenly distributed, no nodules noted upon palpation of eyelids. Eyeballs are symmetrically aligned in socket without protruding or sinking. Ears:

Symmetrical ears, no lesion, no tenderness and masses noted upon palpation, no abnormal discharges, presence of cerumen, pinna recoils after folded. Nose: No deformities noted, no nasal flaring nor abnormal discharges. No septal deviation. Throat: Patent, no tenderness and nodules upon palpation. Mouth: Lips are symmetrical in shape, with dry pale lips, and with white teeth. Neck: No masses and nodules noted upon palpation, no lesions, no jugular vein distention. Chest and Lungs: The patient has normal respiratory rate, experiences non-productive cough, with clear breath sounds upon auscultation. Shoulders and scapulae are in equal horizontal positions. Sternum is positioned at midline and straight. No retraction. Aching pain felt at the back (thoracic area) with a pain rate of 5/10. Breast No swelling, nodules, or ulceration. Even color, smooth with no edema. Heart: With normal heart rate rhythm auscultated on the 4th intercostals space. Abdomen: Flat, soft and with normal contour, no lesions, no tenderness, masses and nodules noted upon palpation, with a bowel sound of 18/min on the left upper quadrant. With on and off stabbing pain felt on epigastric region with a pain rate of 7/10. Patient is still complaining of being nauseous. Musculoskeletal

Feet and legs are symmetric in size, shape, and movement. Extremities warm and mobile with adequate capillary refill. Has moderate range of motion with no swelling, redness, or tenderness nor edema on extremities..

CRANIAL NERVE ASSESSMENT

Cranial Nerve

Type: Function

Assessment Procedure

Normal Findings

Actual Results

I. Olfactory

Sensory: Smell

With both eyes The client must The closed, asks the identify client to smell scents like perfume. her as

client

was

the able to identify she the scent. are

different scents smells it even if eyes closed. II. Optic Sensory: Vision At a given At of the given The client was

distance

1 distance

the able to read the

meter, ask the client must be newsprint/book client to read able to read the from a distance the newsprint/book. newsprint/book. of 14 inches.

III. Oculomotor

Motor: Movement six

Instruct

the Both eyes must The the able The the the Pupil

client to

was follow

client to open follow and penlight. the pupils of

to four of and close the direction of the the direction of eye eyelid follow penlight. constricts light is extrinsic muscles (inferior oblique; superior,

direction of the eyes are dilated when a test for and constricts in response to

penlight. This is without the light introduced. papillary

medial, and inferior rectus) and upper eyelid

action.

light.

IV. Trochlear

Motor: Upward and downward movement of (superior oblique)

Instruct client to upward downward assess gaze.

the Without look difficulty, to able her of upward downward. to

any The the able

client to

was move eyes and any

and client must be his/her move upward eyes downward and without difficulty.

eyes directions

V. Trigeminal

Motor: Chewing

Instruct and jaw.

the The client must The able

client

was

client to open be

to able to clench chew properly. client when the side of

clench clench jaw and his/her jaw and chew properly.

Sensory: Senses face teeth of and

Gently

touch The client must The

the lateral side be able to elicit blinked of the clients blinking reflex. eyes using a cotton wisp. touched lateral her eyes.

the cotton wisp

Motor: Lateral

VI. Abducens

movement of rectus) (lateral

Ask the client to The client must The eyes be move able to able laterally.

client to

was move eyes

eyes move

his/her his/her laterally. client to

eyes laterally. Instruct

VII. Facial

Motor: Movement of facial expression Sensory: Taste

the The client must The

was smile,

client to smile, be able to smile, able eyebrows easily.

the frown, and raise frown, and raise frown, and raise his/her eyebrows easily when told to do so. Make use of The client must The be able to able and distinguish like distinguish client was to and the

muscles of eyebrows.

different seasonings soy calamansi, taste sensation of the client

sauce, identify what is identified sweet, salty, and taste.

sugar to test the sour.

VIII.

Sensory: and Balance

Ask the client to The client must The repeat whispered words, Hello. be the able repeat words. exactly the

client

was

Vestibulocochlear Hearing

to able to repeat whispered

whispered word, Hello.

IX. Glossopharyngeal

Motor: Movement of muscles

Instruct client swallow a

the The client must The to be able and swallow

client

was

to able to swallow and and chew food

pharyngeal move mouth in chew chewing difficulty. motion.

without without difficulty.

Sensory: Taste touch back tongue

Make to (soy and each.

use

of The client must The able

client

was

and different

taste be

to able to identify

sauce, identify the taste the taste. ask the

of vinegar, sugar) presented. client to identify

X. Vagus

Motor: Movement of pharynx, and larynx Sensory: Senses pharynx, viscera

Ask the client to The client must The say Ahhh to be able swallow. upon

client

was

to able to swallow saying Ahhh.

palate, swallow.

Using a tongue The client must The of depressor, gently press the gag reflex. to elicit gag

client

was

be able to elicit able to elicit gag reflex when the tongue depressor the surface was of pressed against the tongue.

larynx, and tongue enough reflex.

XI. Accessory

Motor: Movement of neck muscles back muscles

Ask the client to The client must The shrug against resistance student nurse. two shoulders shoulders against exerted

client

was

his be able to shrug able to shrug her shoulders the against resistance exerted by the student nurse. the

and upper exerted by the resistance.

XII. Hypoglossal

Motor: Movement of tongue

Instruct or tongue different directions.

the The client must The able to able or and protrude move in

client to

was move

client to move be

protrude tongue told by

in protrude tongue his/her directions. being the nurse.

different on the directions student

F. DIAGNOSTIC AND LABORATORY PROCEDURES

DATE DIAGNOSTIC/L ABORATORY PROCEDURES ORDERED DATE RESULT(S) IN Date Ordered: Jan. 30, 2013 This test measures HEMOGLOBIN. the amount of was done was to hemoglobin This Hemoglobi Ms. n Hemoglobi n 115-155 g/L GENERAL DESCRIPTION INDICATION(S) PURPOSE(S) OR RESULTS NORMAL VALUES

ANALYSIS AND INTERPRETATIO N OF RESULTS

BLOOD CHEMISTRY

The

results

show that the Hemoglobin level Candy decreased; this indicates of decreased production erythropoietin brought about by decreased blood flow to of Ms. is

Candy to determine if 93 possible oxygen The tissue

present in a whole there Date Results blood. in: Jan. 30, 2013 haemoglobin levels closely red and 2010) This is the part of count. with the cell

deprivation related to

correlates her disease condition. blood

(Brunner Suddarth,

blood that carries oxygen. It is used to detect any anemia that the patient may have.

the kidneys as evidenced by pale and conjuctiva. nailbeds

A hematocrit test HEMATOCRIT. It is also Hematocrit measures percentage used to detect any 0.28 by anemia aids that in the the of

Hematocrit 0.38-0.48L/L

The showed

result that is may

hematocrit level DECREASED which indicate anemia, malnutrition, nutritional deficiencies of iron, vitamin and B6, folate, B12 vitamin and

volume of packed patient may have. This red blood cells in test a whole blood calculation

sample. This test erythrocyte indices. evaluates if there are enough blood cells in the blood, or if there is too much or too little water in the body which may lead to tissue oxygen deprivation.

overhydration.

A WBC count is a WBC COUNT. It was WBC Count blood measure blood (WBCs). blood cells test to done to the patient to 9.6 the detect if she has an cells infectious process and White inflammation. help

WBC Count 5-10 x 109/L

The showed there normal count indicates enough

results that are WBC which that WBC

number of white existing or worsening

Ms. Candy has to fight against infection..

fight infections

Platelets smallest They

are PLATELET

COUNT.

To Platelet

150-400 109/L

x The showed there normal

results that are

formed detect hemorrhage or count promote visual estimate from of a

elements in blood. anemia. To confirm a 375 coagulation and platelet number and

PLATELET count which indicates there is adequate

the formation of a morphology a vascular injury.

hemostatic plug in stained blood film.

amount platelets promotes

of that

coagulation.. Neutrophils the blood are NEUTROPHILS most This test is done to Ms. Candy to evaluate cells. her bodys capacity to resist infection. 0.76 0.45-0.65 Since it is to

attracted

numerous white Neutrophils are the soldiers that fight They eat or gobble up the particles (bacteria) in your body. infectious infections.

sites of injury and infection, an may increase indicate such

metabolic disorder as acidosis. diabetic

Lymphocytes help LYMPHOCYTES provide a specific This test is done to Ms. response to attack Candy to detect and the invading identify various types

0.24

0.20-0.35

The showed normal

result

lymphocytes

organisms. Absolute predicts

of

leukemia. severity of

To an

count indicates

which that

determine the stage overall infection.

lymphocyte count and survival in follicular lymphomas.

Ms. Candy has no infection.

Random sugar measures

blood RANDOM

BLOOD 20.21

3.859.0mmol/L

The showed an in glucose glucose uptake

results that

(RBS) SUGAR is done to Ms. blood Candy to check and her blood

the patient has increased blood since is of

glucose regardless monitor ate. This test may . be throughout day. taken the

of when you last sugar levels.

decreased because inadequate insulin.

Creatinine chemical molecule generated muscle metabolism.

is

a CREATININE

123.6

58100umol/L

Elevated creatinine level kidney function or kidney disease. signifies impaired

waste Is done to the patient that is to assess glomerular from filtration and to screen for renal damage.

Sodium substance work

is

a SODIUM that To evaluate balance fluid, and renal

138.3

135145mEq/L

The showed level indicates normal and

results a which fluids in

the body needs to electrolyte, and acidproperly. base Your blood sodium related level represents a functions. balance between the and sodium drinks and you water in the food consume and the amount in urine.

normal sodium

electrolytes the body.

This test measures POTASSIUM the amount of To evaluate of clinical potassium in the signs blood. and (K+) helps nerves To communicate. It potassium renal

3.79

3.55.5mEq/L

The showed levels patient normal

results that the is which

the potassium of

Potassium excess or depletion. monitor muscles function.

means that Ms. Candys renal system functions well.

also helps move nutrients into cells and products cells. waste out of

Date Ordered: bothJan. 31, 2013

Blood nitrogen. nitrogen forms protein is

urea BUN Urea

8.4

1.78.3mmol/L

The first results is between range shows in may normal one BUN indicate kidney

what A test can be done to 12.1 when measure the amount breaks of urea nitrogen in the protein

while the 2nd increased

Date Results down. BUN levels blood. in:bothJan. 31, 2013 reflect excretory intake and renal

Date Ordered: bothJan. 31, 2013 Date Results in:bothJan. 31, 2013

capacity.

problem

or

hypovolemia.

Date Ordered: bothJan. 31, 2013

An enzyme that helps carbohydrates.

AMYLASE is done to 665 possible done to other It pancreatic injury. It is 447

30-110 IU/L

An may

increased indicate of

digests evaluate

in both results presence acute pancreatitis, gastroenteritis or intestinal blockage.

is produced in the also

pancreas and the distinguish in:bothJan. 31, 2013 saliva. When the pain. pancreas diseased is or

Date Results glands that make causes of abdominal

inflamed, amylase releases into the blood

Date Ordered: bothJan. 31, 2013

Measures amount

the ALKALINE of PHOSPHATASE diseases by

284.3 309.4

64-306 IU/L

Normal results are found on the but 1st result slightly on may liver

the enzyme ALP in to detect and identify the blood. ALP is skeletal made mostly in primarily in characterized the activity. is by osteoblastic

increased which indicate

Date Results the liver and in:bothJan. 31, 2013 made neys . made the placenta of It in also

the 2nd result,

bone with some marked intestines and kid

affectation or involvement.

a pregnant woma n. Date Ordered: bothJan. 31, 2013 It is an enzyme SGOT that is produced in enzyme is the liver. The SGOT differential also of acute To found in skeletal disease. Date Results muscles, in:bothJan. 31, 2013 muscles, diagnosis hepatic monitor 12.2 10-40 IU/L Normal results are which indicates there diseases involved. is that no shown

To aid detection and 12.9

red patient progress and kidney and hepatic diseases.

acute hepatic

blood cells, heart prognosis in cardiac

tissue and in the brain When suffers as a from well. person an

injury to any of these parts of the body, the level of SGOT tends to rise in bloodstream. Date Ordered: Jan. 31, 2013 This test measures SGPT how much of An SGPT test is done or Although 8.6 0-39 IU/L The results are within range indicates normal which no the

enzyme ALT in the to see if the liver is 9.1 liver, it is necessary diseased

Date Results for tissue energy damaged. in: Jan. 31, 2013 production.

liver damaged or affectation.

there is normally a low level of GPT in the bloodstream, it will greatly increase in the presence of certain diseases, such as cirrhosis and hepatitis.

HbA1c is a lab test HBA1c30 is done to 10% that blood shows the Ms. Candy to average level of determine how well sugar she is controlling her (glucose) over the diabetes for the past 3 previous 3 months. months. It shows how well you are controlling your diabetes.

4.2-6.5%

The shows increase HBA1c may

result an in which indicate

increase levels of blood sugar.

NURSING RESPONSIBILITIES: BEFORE: Explain to the patients SO the purpose of the procedure. Inform the patient this test can assist in evaluating the amount of hemoglobin in the blood to assist in diagnosis and monitor therapy. Tell the patients SO that the test requires a blood sample, who will perform the venipuncture and when. Explain to the patients SO that she may feel some discomfort from the needle puncture and the presence of the tourniquet.

 Obtain a history of the patient's complaints, including a list of known allergens, especially allergies or sensitivities to latex. Obtain a history of the patient's cardiovascular, gastrointestinal, hematopoietic, hepatobiliary, immune, and respiratory systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures. Note any recent procedures that can interfere with test results. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. DURING: Maintain sterile technique Send the sample to the laboratory as soon as possible to avoid stasis and to allow early separation of serum from the clotted blood. Handle the sample gently to prevent hemolysis. Be aware that hemolysis caused by rough handling of the sample may influence test results. Be aware that hemolysis may elevate results. Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.

AFTER: Apply pressure to the puncture site to prevent bleeding Properly dispose of the needle in the sharps container. (do not lay down or recap needles) Immediately label the specimen. Remove your gloves and wash your hands. Record the clients name, the test performed, and disposition of the specimen collection criteria.

DIAGNOSTIC/LABORATORY PROCEDURES

DATE ORDERED DATE RESULT(S) IN

GENERAL DESCRIPTION

INDICATION(S) OR PURPOSE(S)

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION OF RESULTS

URINALYSIS

Date Ordered: Jan. 2013

Urinalysis 31, physical of

Urinalysis Providers

help Care a

Volume mL hours in

The

present results WBC,

evaluates the Health characteristics diagnose

600 to 2500 urinary of RBC,

24 showed presence Proteins, Glucose

urine, urinary tract or

Date Result in: Jan31. 2013

determines specific gravity pH.

metabolic disease. It is

Yellow

Color Pale to amber Appearance Clear to slightly hazy

in the urine which yellow is not normal indicates renal which altered function.

and also essential in the diagnosis of disease kidneys urinary tract. 1.030 or Cloudy or disorders of the

Specific gravity 1.005 normal intake to fluid 1.030 with a

5 Date Ordered: Jan. 2013 Date Result in: positive 30,

pH 4.5 to 8

Glucose Negative

Jan 2013

30. Ketones Negative Blood Negative Protein positive Negative Bilirubin Negative Nitrate bacteria Negative Casts Negative, occasional hyaline casts Red Blood for

.2/hpf 10-15

Cells Negative rare or

Date Ordered: Jan. and 2013 Crystals Date Result in: Jan and 2013 Moderate 30 31. White Cells Negative rare Epithelial Cells Few; hyaline casts: 0-1/lpf or Blood 18-20/hpf Negative none or 30 31,

NURSING RESPONSIBILITIES: BEFORE: Check the physicians order Identify the client Explain the procedure to the patients SO and its importance Offer the child something to drink.

DURING: Collect specimens form infants and young children into a disposable collection apparatus consisting of a plastic bag with an adhesive backing around the opening that can be fastened to the perineal area or around the penis to permit voiding directly to the bag. Depending on hospital policy, the collected urine can be transferred to an appropriate specimen container. Cover all specimens tightly, label properly and send immediately to the laboratory. Observe standard precautions when handling urine specimens. If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an appropriate preservative added.

AFTER:

 Immediately label the specimen. Remove your gloves and wash your hands. Record the clients name, the test performed, and disposition of the specimen collection criteria

III. ANATOMY AND PHYSIOLOGY Anatomy of the Pancreas The pancreas is located to the

retroperitoneal,

posterior

stomach in the inferior part of the left upper quadrant. It has a head near the midline of the body and a tail that extends to the left where it touches the spleen. It is a complex organ composed of both endocrine and exocrine tissues that perform several functions. The endocrine part of the pancreas consists of pancreatic islets (islets of Langerhans). The islet cells produce the hormones insulin and glucagon, which enter the blood. These hormones are very important in controlling blood levels of nutrients such as glucose and amino acids. The exocrine part of the pancreas is a compound acinar gland. The acini produce digestive enzymes. Clusters of acini are connected by small ducts, which join to form larger ducts, and the larger ducts join to from the pancreatic duct. The pancreatic duct joins the common bile duct and empties into the duodenum. Functions of the Pancreas The exocrine secretions of the pancreas include HCO3, which neutralize the acidic chime that enters the small intestine from the stomach. The increase pH resulting from the secretion of HCO3 stops pepsin digestion but provides the proper environment for the function of pancreatic enzymes. Pancreatic enzymes are also present in the exocrine secretions and are important for the digestion of all major classes of food. Without the enzymes produced by the pancreas, lipids, proteins, and carbohydrates are not equally digested.

The major pancreatic enzymes are trypsin, chymotrypsin and carboxypeptidase. These enzymes continue the protein digestion that started in the stomach, and pancreatic amylase continues the polysachharide digestion that began in the oral activity. The pancreatic enzymes called pancreatic lipases. Nucleases are pancreatic enzymes that reduce DNA and ribonucleic acid to their component nucleotides. The exocrine secretory activity of the pancreas is controlled by both hormonal and neural mechanisms. Secretin initiates the relase of watery pancreatic solution that contains a large amount of HCO3. The primary stimulus for secretin release is the presence of acidic chime in the duodenum. Cholecystokinin stimulates the pancreas to release an enzyme-rich solution. The primary stimulus for cholecystokinin release is the presence of fatty acids and amino acids in the duodenum, and the enzymes secreted by the pancreas digest fatty acids and amino acids. Parasympathetic stimulation through the vagus nerves also stimulates the secretion of pancreatic juices rich in pancreatic enzymes. Sympathetic action potentials inhibit pancreatic secretion. The endocrine part of the pancreas consists of pancreatic islets dispersed among the exocrine portion of the pancreas. The islets secrete two hormones: insulin and glucagon--- which function to help regulate blood pancreatic islets secrete insulin. nutrient levels, especially blood glucose. Alpha cells of the pancreatic islets secrete glucagon, and beta cells of the

It is very important to maintain blood glucose levels within a normal range of values. A decline in the blood glucose level below its normal range causes the nervous system to malfunction because glucose is the nervous systems main source of energy. When blood glucose decreases, fats and proteins are broken down rapidly by other tissues to provide an alternative energy source. As fats are broken down, some of the fatty acids are converted by the liver to acidic ketones, which released into the circulatory system. The pancreas is responsible for

controlling and manipulating blood glucose levels. The pancreas houses islets responsible for production and secretion of the hormones, glucagon and insulin. Because of this, the pancreas falls under both the endocrine glandular system as well as the exocrine glandular system. The islets which produce these hormones are semi scattered throughout the pancreas and are known as the islets of Langerhans. These particular endocrine functioning structures are typically able to be located in the body and along the tail of the pancreas. Alpha cells and Beta cells are the cells that are known to secrete the hormones within the islets. Glucagon is administered from the Alpha cells and insulin comes from the Beta cells. Gulcagon has an affect on insulin by providing the appropriate stimulus for the liver to convert glycogen into glucose. The Alpha cells are able to respond appropriately to the feedback provided and thus are able to self monitor. High blood sugar, which is also known as hypoglycemia, can be the result of continuous output of glucagon.

Insulins function on the human physiology is opposite of its counterpart, glucagon. Insulin is designed to lower the blood sugar in the body. Insulin is the initiating factor that

allows blood glucose to the necessary movement through the cell membranes. Muscular cells and adipose cells rely on this movement of glucose for their ability to function. The glucose level within the cell drops as the glucose moves throughout the cell membrane. Insulin is also an initiating factor in the conversion of glucose to glycogen by the cells of the muscles and liver. This action actually assists amino acids into the cells and provides the foundation for the creation of fats and proteins. When Beta cells are incapable of producing the appropriate amount of insulin, diseases such as diabetes occur.

The pancreas is rather soft, created from lobes, Measures about 6 inches long and 1 inch thick, and performs the functions of a mixed gland. Serving both endocrine functions and exocrine functions, the pancreas is serving dual systems. The islets of Langerhans, or pancreatic islets, are the cell clusters responsible for the pancreas endocrine functions. Insulin and glucagon are required hormones of the bloodstream to maintain optimal homeostasis. Performing the exocrine functions requires the proper ability to secrete pancreatic juices which aid in digestion. The pancreatic juice is created within the pancreas and immediately released into the pancreatic duct which empties into the duodenum.

The pancreas is positioned snugly up against the greater curvature of the stomach, which runs along the posterior wall of the abdominal cavity. It head is located close to the duodenum, which is expanded over the central body. The tail tapers off near the location of the spleen. The entire organ is in the retroperitoneal cavity with the exception of the expanded head.

THE CIRCULATORY SYSTEM

The complex nature of the human body demands an efficient circulatory system in order to sustain life. The trillions of cells which comprise the human body demand this efficiency in order to maintain the functions of the multitudes of systems within the human body, which represents an ingenious division of labor. The majority of the bodys cells is immobile, and therefore This means cannot a well retrieve the basics of their existence independently. organized and efficient circulatory

system is responsible for deliver life sustaining oxygen and nutrients to the cells which are incapable of fending for them. The blood within the circulatory system is responsible for delivering this life sustaining oxygen and nutrients. The adult human body hosts nearly 60,000 miles of passageway for the blood, also known as the blood vessels, in order to effectively deliver life to the immobile cells. The red blood cells, which are responsible for the delivery of oxygen and nutrients, can also deliver within its frame work, bacteria, fungus, infection, disease, and other life denying (to the cells) toxins that can compromise the integrity of the immobile cells. The human body has a built in defense system to counteract this situation and come to the aid of the compromised cells known as white blood cells. The white blood cells in conjunction with the lymphatic system are often able to target cells which are being attacked by a toxic element and come to their rescue like little warrior cells.

The circulatory system is not a standalone system, and it requires the assistance of systems such as the respiratory, urinary, endocrine, digestive, and integumentary systems in order to maintain its proper function and give the body the life sustenance it requires to live. While the circulatory system has numerous functions, the various capabilities and functions of this intense system can be segregated into two basic responsibilities. Transportation of the substances necessary to maintain cellular metabolism is one of two main functions of the circulatory system. In conjunction with the respiratory system, red blood cells by the name of erythrocytes are responsible for the transportation of oxygen which are systematically delivered to the cells waiting throughout the body. The human body takes a breath, which enters the lungs. In the lungs, the oxygen molecules attach themselves to hemoglobin molecules, which reside within the erythrocytes, and then make their way via transport by these cells to cells in need of oxygen. Once the cells have used the oxygen which has been delivered, the carbon dioxide that they have produced are then transported back to the lungs and expelled in exhaled air. The blood and lymph vessels work in conjunction with the digestive system in order for the circulatory system to perform the delivery of nutrition. When food is eaten it is broken down by the digestive system and the nutrients are absorbed through the wall of the intestines, which is then picked up by the blood vessels and carried off to the cells requiring the nutrition with a pit stop through the liver for nutrient absorption and toxic cleansing. The wastes associated with excess waters, ions, plasma, and metabolic waste produced by the cells which were delivered

their nutrients, are then filtered through capillaries which belong to the kidneys. From there wastes enter the kidney tubes and are excreted in urine.

The circulatory system is also responsible for the transportation of hormones through the blood stream. This contributes to the regulatory process of maintaining health of the endocrine system.

The second basic function associated with the circulatory effectively system protects involves protection. It against both injury and

disease through clotting, white blood cells, and the process of phagocytosis. White blood cells called leukocytes fight off disease and foreign material in the body. The body becomes feverish in this action as it works harder to produce a greater number of leukocytes.

The bodys natural ability to clot prevents excessive bleeding when blood vessels are harmed or damaged. Excessive damage may cause bleeding faster than the body can create clotting agents, but in most cases the clotting agents cease bleeding for long periods of time.

The circulatory system and the cardiovascular system are often interchangeable and interdependent within their specified roles. The circulatory system relies on the cardiovascular system in order to assist it with transporting required cells, nutrients, or other key vitalities in the blood stream. Without the heart to pump the 5 liters of blood per minute through the average adult body, the cells would float aimlessly along in a limp bloodstream. The four chambered heart pumps blood with enough force that blood pressure plays a vital role in forcing the blood through the body in less than a

minute. The blood vessels form a network throughout the body of thin tubes that act as the transporters for the blood and its vital nutrients and blood cells. Arteries and veins form additional pathways much like tributaries to supply blood to every extremity and crevice of the body.

The microscopic arteries are known as arterioles, while microscopic veins are known as venules. Each play a role in either delivering blood to the necessary body parts or returning used blood back for recirculation.

Blood leaves the arteries through a capillary system which contain the thinnest and smallest of all the veins in the body, with the exception of microscopic systems. Capillaries, which are basic functional unit of the circulatory system, are responsible for the exchange of fluids, blood cells, nutrients, and wastes. When tissue cells have utilized the oxygenation or the nutritional value from a blood cell, it is returned to the blood stream via capillaries.

Tissue fluid, also known as interstitial fluid, comes from fluid derived from the plasma and becomes protective liquid for tissues that are not surrounded by blood. A small percentage of this fluid is returned through the capillaries and is likely to enter the lymphatic system via the connective tissues around the blood vessels. Fluid within the lymphatic system, which is known as lymph, is then discharged back into the venous blood. Strategically placed lymph nodes are responsible for the cleansing of the lymph before it is returned for another use. This is the bodys natural form of recycling and the entire circulatory system is based on this notion of natural recycling.

IV. PATHOPHYSIOLOGY SCHEMATIC DIAGRAM (Book-based)

NON-MODIFIABLE FACTORS Familial predisposition Age (non-obese- 45 yrs. Old) & (obese- 30 years old) Gender (Female) Race (Asians, African-Americans, Native Americans, Pacific Islanders) MODIFIABLE FACTORS Diet (High in fats and carbohydrates) Emotional Stress Physical Stress (infections and Diseases) Obesity Sedentary Lifestyle

Prolonged Increase in blood glucose Compensatory mechanism of beta cells to increase insulin production and alpha cells to decrease glucagon secretion

Altered sensitivity of target tissues to insulin/ Resistance of target tissues to insulin

Impaired transport of glucose by insulin to target tissues (Insulin resistance) Inability of fats and muscles to take up glucose B

Beta cells exhaustion Limited beta cell functions Decrease sensitivity of insulin to glucose levels A

A Decrease in Insulin production Impaired functions of liver to store excess glucose as glycogen

Decrease glucose utilization Cell Starvation ATP is not produced

Not enough energy is utilized by the tissues

Stimulation of hypothalamus that controls hunger Polyphagia

Compensatory mechanism of liver by glycogenolysis Continuous elevation of glucose (hyperglycemia)

Weakness/ easy Fatigability

Weight loss

Dizziness

Chronic elevation in blood glucose

Abnormal Glycosylated hemoglobin

Glucose molecules attaches to hemoglobin

Increase viscosity of blood D

D Lens and retina are exposed to hyperosmolar fluid Damages on the blood vessels in the retina Diabetic retinopathy Macular edema Blurring of vision Glycoprotein cell wall deposits Decrease perfusion especially on small blood vessels Small vessel disease Sluggish blood flow due Decrease oxygen and nutrient supply on the blood vessels Nerves rely on nutrients from blood vessels and therefore deprive of nutrients Diabetic neuropathy Numbness and tingling sensation in the affected part E F
Dehydration

Increased systemic vascular resistance Hypertension Decrease Cardiac Output

Increase glucose osmolarity exceeds renal threshold Glucose promotes osmotic diuresis

Polyuria Active Fluid loss

Glucosuria

to increase viscosity of blood Decrease perfusion in the tissues and major organs Decrease plasma volume

a Glucose is a good medium for bacterial growth Increase risk for UTI

E Symmetrical loss of protective sensation Hyperglycemia alters the aggregation of platelets in the injury site Increase risk for sores and ulcers
Decrease

F Decrease blood supply in the kidney Alteration in the glomerular

membrane

Increase BUN levels due G Decrease blood supply in the brain Dizziness and lethargy Decrease in blood volume Osmoreceptors sends impulses to hypothalamus Increase release of vasopressin from the pituitary gland to hemoconcentration Weight loss Poor skin turgor Dry skin and mucous membrane Changes in LOC

blood supply in the coronary arteries

Irregularity in the heart electricity
conduction Dysrhythmias

Diabetic
nephropathy

Loss of water from the body is restricted

Thirst
mechanism

Loss of selective
permeability

Imbalance

Decrease
erythropoietin

Decrease
metabolism

is stimulated Polydipsia

in acidbase and electrolyte

Decrease stimulation of RBC

production

of Vitamin D Decrease calcium absorption

Hypocalcemia

Passage of large molecules Proteinuria Hematuria

Anemia

Synthesis of the Disease b.1. Definition of the Disease (Diabetes Mellitus) Diabetes Mellitus is a chronic health problem affecting more than 20 million persons in the United States and affects all ages from all walks of life. And according to Joyce Black and Jane Hokanson Hawks, it is the most common endocrine disorders characterized by metabolic abnormalities and by long-term complications involving the eyes, kidney, nerves and blood vessels. The diagnosis is not usually difficult to distinguish duet to three classic symptoms like polyuria, polyphagia and polydypsia. Diabetes Mellitus has two types. Diabetes mellitus type 2 formerly non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes is a metabolic disorder that is characterized by high blood glucose in the context often of insulin initially resistance and managed by relative insulin deficiency Diabetes is may be needed. Unlike type 1 diabetes, there is very little tendency toward ketoacidosis though it is not unknown. One effect that can occur is non-ketonic hyperglycemia. Long term complications from high blood sugar include an increased risk of heart attacks, strokes, amputation, and kidney. Insulin resistance means that body cells do not respond appropriately when insulin is present. Unlike type 1 diabetes mellitus, insulin resistance is generally "postreceptor", meaning it is a problem with the cells that respond to insulin rather than a problem with the production of insulin. This is a more complex problem than type 1, but is sometimes easier to treat, especially in the early years when insulin is often still being produced internally. Severe complications can result from improperly managed type 2 diabetes, including renal

increasing exercise and dietary modification. As the condition progresses, medications

failure, erectile dysfunction, blindness, slow healing wounds (including surgical incisions), and arterial disease, including coronary artery disease. The onset of type 2 has been most common in middle age and later life, although it is being more frequently seen in adolescents and young adults due to an increase in child obesity and inactivity. A type of diabetes called MODY is increasingly seen in adolescents, but this is classified as diabetes due to a specific cause and not as type 2 diabetes. Diabetes mellitus with a known etiology, such as secondary to other diseases, known gene defects, trauma or surgery, or the effects of drugs, is more appropriately called secondary diabetes mellitus or diabetes due to a specific cause. Examples include diabetes mellitus such as MODY or those caused by hemochromatosis, pancreatic insufficiencies, or certain types of medications (e.g., long-term steroid use). Diabetic Ketoacidosis Diabetic Ketoacidosis is a complication of Diabetes Mellitus. The inadequate insulin would promote cellular starvation which would stimulate a hypothalamicpituitary-adrenal activity. Cortisol would be prompt carbohydrate, protein and fat metabolism to counteract cellular starvation. The Fat metabolism would lead to the release of free fatty acids or ketones. The accumulation of ketones in the bloodstream would result to metabolic acidosis, vomiting and Kussmauls respiration.

Etiology (Book-based) Non-modifiable Factors: Familial Predisposition- Type 2 DM has a strong genetic component. It is clear the disease is polygenic and multifactorial still the major genes responsible for the disease are not yet indentified. An individual with parents who has DM is at risk of acquiring it. Also, genetic factors are thought to play a role in insulin resistance and impaired insulin section in Type 2 DM (Black and Hawks, 2009).

Age- Type 2 DM usually occurs at the age 45 years old and above in non- obese people. Type 2 DM occurs most commonly in people who are obese at the age of 30 years old and above (Black and Hawks, 2009). Gender- Around the globe, it affects 62 million in men versus 73 million among women. It is said to be the sixth leading cause of death among women in the United States. More of, Type 2 DM occurs in more women prior to having Gestational Diabetes Mellitus of 25% to 50% compared with those going through pregnancy with normal glucose tolerance (Black and Hawks, 2009). Race- People with ethnic background such as African Americans, Native Americans, Mexican Americans and Asian/ Pacific Islanders are those populations who have high incidence of Type 2 DM (Black and Hawks, 2009). Modifiable Factors: Diet- Foods rich in carbohydrates can easily promote the increasing level of glucose along the bloodstream which can contribute to having DM Type 2 while increase in fat can lead to development of Obesity which is a major risk factor of insulin resistance (Black and Hawks, 2009). Stress- When an individual is stressed, his/her blood sugar levels rise. Stress hormones like epinephrine and cortisol kick in since one of their major functions is to raise blood sugar to help boost energy when it's needed most. Think of the fight-or-flight response. A person can't fight danger when his/her blood sugar is low, so it rises to help meet the challenge. Both physical and emotional stress can prompt an increase in these hormones, resulting in an increase in blood sugars. Any form of stress with the neuroendocrine response increases glucogenesis and glycogenolysis. Infection, life changes and various environmental factors can be stressors that induce or worsen a diabetic state. (Black and Hawks, 2009).

Obesity- About 80% of persons with NIDDM are obese and the frequency of diabetes in

obese people is greater than in the general population. The interrelations occurs because obesity is associated with insulin insensitivity in target tissues (muscles, liver and adipose cells). It is well known that blood levels of insulin are higher in an obese person and take to return to the fasting state. Obesity acts as a diabetogenic factor because the accompanying insulin resistance increases the need for insulin. Because the obese are resistant to the effects of insulin, in practice, the obese diabetic responds poorly to treatment with insulin (Black and Hawks, 2009). Sedentary Lifestyle- This kind of lifestyle had contributed in the occurrence of DM due to the fact that the lack of muscle activities decreases the need for the body to utilize the glucose as a form of energy, resulting to an increase in its availability in the blood and increase in the insulin production. Signs and Symptoms with rationale (Book-based): Hyperglycemia- Due to increase hepatic glucose production secondary to deacreas insulin production associated with impaired Beta cell functions and altered glucose utilization by cells due to tissue insensitivity or an inadequate insulin production by beta cells of the pancreas. Polyuria- Due to excessive blood volume secondary to increase volume of water in the blood. Water not reabsorb from renal tubules secondary to osmotic activity of glucose leads to osmotic activity of glucose leads to loss of water, glucose and electrolytes. Polydypsia- Due to dehydration brought by frequent urination, the thirst center of the brain will be triggered making the patient to urge for thirst. Not only this, but because of the increase osmolality of the blood glucose due to increase glucose. Polyphagia- Starvation secondary to tissue breakdown (catabolism) causing hunger. And because the cells are not able to utilize glucose in the presence of inadequate insulin level or resistance to insulin.

Hypertension- Due to increase blood flow secondary to increase blood viscosity, in return due a decrease blood flow will activate the rennin-agiontensin aldosterone system. Altered tissue perfusion- Due to decrease oxygen transport to the cells secondary to decreased blood flow associated with increased blood viscosity. Weight loss- Due to insulin deficiency, glucose cannot enter into the cells, as a compensatory mechanism, the liver would be stimulated to undergo gluconeogenesis wherein the body will utilize proteins and fats in order to produce energy. Thus rapid muscle wasting will lead to sudden decline in body weight. Extracellular Dehydration- Due to increase excretion of glucose by the kidneys there will also be an increase in water excretion, osmosis diuresis occurs. Intracellular Dehydration- Due to increase serum glucose, there is increase osmolarity, osmosis occurs wherein intracellular fluids go into the interstitial space to the intravascular. Weakness and fatigue, dizziness- Due to the decrease glucose intake by the cells leading to decrease energy production. Decreased plasma volume to postural hypotension, potassium loss and protein catabolism contribute to weakness. Blurring of vision- Due to viscosity of the blood, there would be increase intaoccular pressure which makes the arteries in the retina become weakened and leak, forming, dot-like hemorrhages. These leaking vessels often lead to swelling or edema in the retina and decreased vision. Oliguria- this resulted from impairment in the selective permeability of the glomerulus. The water together with other electrolytes are not excreted properly, these could lead to water retention and therefore decrease in urine output. Another etiology is due

shifting of blood from intravascular to interstitial, decrease in the intravascular fluid decreases the blood supply to the kidney and therefore decrease in the filtration capacity of the kidneys. Headache- this is a complication of cerebral edema. Cerebral edema increases intracranial pressure and therefore there is decrease functioning of the brain due to congestion. Ulcer formation- this is due to problems in the nutrients supply in the nerves leading to altered nerve function which can lead to symmetrical loss of protective sensation that the patient is unable to feel that he/she had already injured his/her body. Abnormal Glycosylated Hemoglobin- when glucose is elevated, it attaches to the hemoglobin. This test is very important to check for the compliance of the patient to treatment since the life span of hemoglobin can last up to 120 days. Glucosuria- this is a manifestation due to chronic elevation of glucose. When there is too much glucose, it exceeds the renal threshold leading to urination in addition to the osmotic diuretic effect of glucose. Hypertension- this is caused by elevated glucose level. Glucose makes the blood more viscous and therefore harder to pump leading to increase effort of the heart to pump blood leading to elevated blood pressure. Dehydration- this is caused by polyuria induced by elevated glucose levels that exceed the renal threshold leading to loss of water in the plasma. This is manifested by dryness of the skin and mucus membrane, altered LOC, weight loss and hemoconcentration. Dysryhthmias- caused by sluggisg blood flow in the coronary arteries leading to decrease blood flow in the SA node leading to altered conduction of the heart.

Proteinuria and Hematuria- When diabetes leads to diabetic nepropathy, it could lead to alteration in the selective permeability of the glomerulus leading to passage of large molecules like protein and RBCs. Anemia- When diabetes leads to diabetic nepropathy, it could lead to loss of erythropoietin production causing decrease stimulation of RBC formation leading to signs and symptoms associated with Anemia. Hypocalcemia- this is due to decrease Vitamin D activation caused by diabetic nephropathy leading to signs and symptoms of Hypocalcemia like Chvosteks sign and Trousseau sign.

PATHOPHYSIOLOGY SCHEMATIC DIAGRAM (Patient-centered) NON-MODIFIABLE FACTORS Familial predisposition Gender (Female) Race (Asians) MODIFIABLE FACTORS Diet (High in carbohydrates) Stress Sedentary Lifestyle

Prolonged Increase in blood glucose Compensatory mechanism of beta cells to increase insulin production and alpha cells to decrease glucagon secretion

Altered sensitivity of target tissues to insulin/ Resistance of target tissues to insulin

Impaired transport of glucose by insulin to target tissues (Insulin resistance) Inability of fats and muscles to take up glucose B

Beta cells exhaustion Limited beta cell functions Decrease sensitivity of insulin to glucose levels A

A Decrease in Insulin production Impaired functions of liver to store excess glucose as glycogen

Metabolic Acidosis

Body compensates to reduce carbon dioxide in the blood

Decrease glucose utilization

Cell Starvation ATP is not produced

Increased fat metabolism

Accumulation of ketones in the bloodstream Kussmauls breathing resulting to increased respiration

Not enough energy is utilized by the tissues

Stimulation of hypothalamus that controls hunger Polyphagia

Compensatory mechanism of liver by glycogenolysis Continuous elevation of glucose (hyperglycemia)

Weakness/ easy Fatigability

Weight loss

Dizziness

Chronic elevation in blood glucose

Abnormal Glycosylated hemoglobin

Glucose molecules attaches to hemoglobin

Increase viscosity of blood D

D Glycoprotein cell wall deposits Decrease perfusion especially on small blood vessels Small vessel disease Sluggish blood flow due Decrease oxygen and nutrient supply on the blood vessels Nerves rely on nutrients from blood vessels and therefore deprive of nutrients Diabetic neuropathy Numbness and tingling sensation in the affected part E F
Dehydration

Increased systemic vascular resistance Hypertension Decrease Cardiac Output

Increase glucose osmolarity exceeds renal threshold Glucose promotes osmotic diuresis

Polyuria Active Fluid loss

Glucosuria

to increase viscosity of blood Decrease perfusion in the tissues and major organs Decrease plasma volume

a Glucose is a good medium for bacterial growth Increase risk for UTI

E Symmetrical loss of protective sensation Hyperglycemia alters the aggregation of platelets in the injury site Increase risk for sores and ulcers
Decrease

F Decrease blood supply in the kidney Alteration in the glomerular

membrane

Increased BUN levels due

G Decrease blood supply in the brain Dizziness and

lethargy

to hemoconcentration

Decrease in blood volume Osmoreceptors sends impulses to hypothalamus Increase release of vasopressin from the pituitary gland

Weight loss Poor skin turgor Dry skin and mucous membrane Changes in LOC

blood supply in the coronary arteries

Irregularity in the heart electricity
conduction Dysrhythmias

Diabetic
nephropathy

Loss of water from the body is restricted

Thirst
mechanism

Loss of selective
permeability

Imbalance

Decrease
erythropoietin

is stimulated Polydipsia

in acidbase and electrolyte

Decrease stimulation of RBC

production Decreased Hemoglobin count

Passage of large molecules Proteinuria Hematuria

Synthesis of the Disease Etiology (Patient-centered) Non-modifiable Factors: Familial Predisposition- Type 2 DM has a strong genetic component. It is clear the disease is polygenic and multifactorial still the major genes responsible for the disease are not yet indentified. An individual with parents who has DM is at risk of acquiring it. Also, genetic factors are thought to play a role in insulin resistance and impaired insulin section in Type 2 DM (Black and Hawks, 2009). DM runs through the bloodline of Candy. Gender- Around the globe, it affects 62 million in men versus 73 million among women. It is said to be the sixth leading cause of death among women in the United States. More of, Type 2 DM occurs in more women prior to having Gestational Diabetes Mellitus of 25% to 50% compared with those going through pregnancy with normal glucose tolerance (Black and Hawks, 2009). Candy is a female patient which makes her at greater risk for Diabetes Mellitus. Race- People with ethnic background such as African Americans, Native Americans, Mexican Americans and Asian/ Pacific Islanders are those populations who have high incidence of Type 2 DM (Black and Hawks, 2009). Candy is an Asian population and a full-blooded Filipina. Modifiable Factors: Diet- Foods rich in carbohydrates can easily promote the increasing level of glucose along the bloodstream which can contribute to having DM Type 2 while increase in fat can lead to development of Obesity which is a major risk factor of insulin resistance (Black and Hawks, 2009). Candy loves to eat preserved foods like tocino and longganisa. Rice is also a staple food in their family. Stress- When an individual is stressed, his/her blood sugar levels rise. Stress hormones like epinephrine and cortisol kick in since one of their major functions is to raise blood

sugar to help boost energy when it's needed most. Think of the fight-or-flight response. A person can't fight danger when his/her blood sugar is low, so it rises to help meet the challenge. Both physical and emotional stress can prompt an increase in these hormones, resulting in an increase in blood sugars. Any form of stress with the neuroendocrine response increases glucogenesis and glycogenolysis. Infection, life changes and various environmental factors can be stressors that induce or worsen a diabetic state. (Black and Hawks, 2009). Candy has been the breadwinner of the family so she has gone through a lot of stresses both physically and emotionally. Sedentary Lifestyle A risk factor that had contributed in the occurrence of DM due to the fact that lack of muscle activities decreases the need for the body to utilize glucose as a form of energy. As told by Candys Mom, when she is at home, she spends most of her time watching and sleeping. Signs and Symptoms with rationale (Patient-centered): Hyperglycemia- Due to increase hepatic glucose production secondary to decrease insulin production associated with impaired Beta cell functions and altered glucose utilization by cells due to tissue insensitivity or an inadequate insulin production by beta cells of the pancreas. Candys Random Blood Sugar test was 20.21 mmoL/L. Polyuria- Due to excessive blood volume secondary to increase volume of water in the blood. Water not reabsorb from renal tubules secondary to osmotic activity of glucose leads to osmotic activity of glucose leads to loss of water, glucose and electrolytes. Candy have narrated that before she knew that she had Diabetes Mellitus, she frequently urinates. Polydypsia- Due to dehydration brought by frequent urination, the thirst center of the brain will be triggered making the patient to urge for thirst. Not only this, but because of the increase osmolality of the blood glucose due to increase glucose.

Polyphagia- Starvation secondary to tissue breakdown (catabolism) causing hunger. And because the cells are not able to utilize glucose in the presence of inadequate insulin level or resistance to insulin. Weight loss- Due to insulin deficiency, glucose cannot enter into the cells, as a compensatory mechanism, the liver would be stimulated to undergo gluconeogenesis wherein the body will utilize proteins and fats in order to produce energy. Thus rapid muscle wasting will lead to sudden decline in body weight. Candy have narrated that she is even fatter when she was newly diagnosed with Diabetes Mellitus. Dizziness- Due to the decrease glucose intake by the cells leading to decrease energy production. Decreased plasma volume to postural hypotension, potassium loss and protein catabolism contribute to weakness. Patient reported dizziness especially when moving and standing up. Ulcer formation- This is due to problems in the nutrients supply in the nerves leading to altered nerve function which can lead to symmetrical loss of protective sensation that the patient is unable to feel that she had already injured her body. Abnormal Glycosylated Hemoglobin- when glucose is elevated, it attaches to the hemoglobin. This test is very important to check for the compliance of the patient to treatment since the life span of hemoglobin can last up to 120 days. Candys HbA1C is 10% far from the normal 4.2-6.5%. Glucosuria- this is a manifestation due to chronic elevation of glucose. When there is too much glucose, it exceeds the renal threshold leading to urination in addition to the osmotic diuretic effect of glucose. Patient reported that she always sees ants on the urinary bowl upon urinating.

Health Promotion and Preventive Aspects of the Disease As a health care provider, the nurse should help his/her patients understand their disease condition. As nurses, they should be more of the preventive aspects of the disease not on the curative aspects. Health promotion and health education must be the nurses primary interventions they should prioritize and they should prepare beforehand or before they will encounter their patients. Diabetes Mellitus Type 2 is a preventable disease since the risk factors are more of the modifiable side. Nurses should provide them knowledge of living a healthy lifestyle. Nurses should provide all the essential food constituents, inform the patient to achieve and maintain an ideal body weight, meet energy needs, achieve more normal glucose levels. Also the patients must be educated in doing active range of motions. The nurse should educate their patients to start from simple active ROM until to the patients capacity in doing these activities. Exercise is important in the management of DM since it lowers blood glucose by increasing the uptake of glucose by body muscles and lowers lipids in the blood. Also the patient is advised to maintain an ideal body weight and also the patient should be educated about the medications prescribed to manage her conditions.

V. PATIENT AND HIS CARE A. Medical Management a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc i. Intravenous Fluids Date Ordered Medical Management Treatment Date(s) Performed Date Changed Plain Normal Saline Solution or PNSS (or 0.9% NaCl) is used PNSS 1L x 30-31gtts/min Date Changed: Dated Ordered: after blood transfusion because it is the only compatible diluent or 'cleaner' after transfusion. Its sole content of Sodium and Chloride does not cause blood reactions that may be dangerous to the client. An Isotonic solution that provides Sodium, Potassium, Chloride, and Calcium and Lactate. A solution that exerts the same osmotic pressure found in plasma. This solution is free from water and is used to the patient to The patient maintained hydration status and was able to comply with all of his medication regimens. Clients Response to the treatment

General Description

Indication or Purpose(s)

D5LRS for example is discouraged as it has calcium which is a clotting factor. Introducing D5LRS after blood transfusion may cause massive thrombosis or clotting. NURSING RESPONSIBILITIES IVF PNSS x 30-31 gtts/min BEFORE

correct hyponatremia because this solution contains smaller amount of sodium.

Verify the physicians order indicating the type of solution, the amount to be administered, the rate of flow of the infusion and any allergies. Explain the procedure and prepare the client Assess clients VS for baseline data, skin turgor, bleeding tendencies, disease or injury to the extremities, status of vein to determine the appropriate puncture site.

DURING Wash hands before proceeding with the procedure. Open and prepare infusion set and proceed with the procedures. Select the venipuncture site. Put on clean gloves and clean the venipuncture site before inserting the catheter and initiating infusion. Tape the catheter properly. Ensure appropriate infusion flow.

AFTER Apply a medication label on the solution if a medication is added. Document relevant data.

Monitor clients response. Check infusions at least every 2 hours to ensure that the indicated milliliters per hour have infused and that IV patency is maintained. Medical Management Treatment Date Ordered Date(s) Performed Date Changed General Description Indication or Purpose(s) Clients Response to the treatment

D5LRS 1L x 30-31gtts/min

Date Ordered:

Lactated Ringers Solution in 5% of Dextrose is a hypertonic solution which has an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid,

This is a treatment for persons needing extra calories who cannot tolerate fluid overload. It is also a treatment of shock.

The patient maintained hydration status and was able to comply with all of his medication regimens. In some cases, the patient manifested swelling on IV insertion site.

electrolytes, and calories for energy.

NURSING RESPONSIBILITIES BEFORE Verify the physicians order indicating the type of solution, the amount to be administered, the rate of flow of the infusion and any allergies. Explain the procedure and prepare the client Assess clients VS for baseline data, skin turgor, bleeding tendencies, disease or injury to the extremities, status of vein to determine the appropriate puncture site. DURING Wash hands before proceeding with the procedure. Open and prepare infusion set and proceed with the procedures. Select the venipuncture site. Put on clean gloves and clean the venipuncture site before inserting the catheter and initiating infusion. Tape the catheter properly. Ensure appropriate infusion flow.

AFTER Apply a medication label on the solution if a medication is added. Document relevant data.

Monitor clients response. Check infusions at least every 2 hours to ensure that the indicated milliliters per hour have infused and that IV patency is maintained. b. Drugs Date Ordered Name of Drug Date Generic (Brand) Date Changed metoclopram ide Date Ordered: 1.31.13 IV 1amp taken/given Route of Admin. Dosage Frequency of Admin Metoclopramide inhibits gastric smooth muscle relaxation produced by dopamine, therefore increasing cholinergic response of the q 8 for PRN for nausea and vomiting gastrointestinal smooth muscle. It accelerates intestinal transit and gastric emptying by preventing relaxation of gastric body and increasing the phasic The patient did not manifest any side effects as it eradicates the patients feeling of nauseated. Gen. Action, functional classification, mechanism of action Clients response to the medication with actual side effect

activity of antrum. Simultaneously, this action is accompanied by relaxation of the upper small intestine, resulting in an improved coordination between the body and antrum of the stomach and the upper small intestine. Metoclopramide also decreases reflux into the esophagus by increasing the resting pressure of the lower esophageal sphincter and improves acid clearance from the esophagus by increasing amplitude of esophageal peristaltic contractions. Metoclopramide's dopamine antagonist action raises the threshold of activity in the chemoreceptor trigger zone and decreases the input from afferent visceral nerves. Studies have also shown that high doses of metoclopramide can antagonize 5-hydroxytryptamine (5-HT) receptors in the peripheral nervous

system in animals.

NURSING RESPONSIBILITIES Before -Observe 15 rights in drug administration. - Assess for allergy to metoclopramide . - Assess for other contraindications. - Keep diphenhydramine injection readily available in case extrapyramidal reactions occur (50 mg IM). - Have phentolamine readily available incase of hypertensive crisis. During - Monitor BP carefully during IVadministration. - Monitor for extrapyramidal reactions, and consult physician if they occur. - Monitor diabetic patients. - Give direct IV doses slowly over 1-2minutes. - For IV infusion, give over at least 15minutes. After - Dispose of used materials properly. - Educate patient about side effects. - Instruct to report involuntary movement of the face, eyes, or limbs, severe depression, and severe diarrhea. - Instruct patient to take drug exactly as prescribed.

- Instruct not to use alcohol, sleep remedies or sedatives; serious sedation could occur. - Do proper documentation. Name of Drug Generic (Brand) Omeprazole Date Ordered Date taken/given Date Changed Date Ordered: 1.31.13 Route of Admin. Dosage Frequency of Admin Clients response to the medication with actual side effect The patient did not manifest any allergic reactions

Gen. Action, functional classification, mechanism of action Omeprazole suppresses gastric acid

40mg IV/ OD

secretion by specific inhibition of the enzyme system hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) present on the secretory surface of the gastric parietal cell.

NURSING RESPONSIBILITIES BEFORE 1. Assess for any history of allergy pregnancy or lactation 2. Assess skin color and lesions, affect and orientation 3. Orient the patient about the drug to be given 4. Perform an abdominal and respiratory examination

DURING 1. Administer before drug before meals. 2. Provide appropriate comfort and safety measures if CNS effects occur to prevent injury 3. Make sure that the client swallows the tablet whole, not to open, chew or crush 4. Offer support and encouragement to help the patient cope with the disease and drug regimen 5. Provide thorough patient teaching about the drug to enhance patients knowledge about drug therapy and promote compliance AFTER 1. Caution patient to avoid hazardous activities when she is dizzy to avoid injuries. 2. Monitor for adverse effects of the drug 3. Monitor effectiveness of comfort and safety measures and compliance to regimen 4. Evaluate the effectiveness of teachment plan Date Name of Drug Generic (Brand) Isophane Ordered Date taken/given Date Changed 1.31.13

Route of Admin. Dosage Frequency of Admin 10 u AM Insulin is a polypeptide hormone that controls the storage and The patient did not Gen. Action, functional classification, mechanism of action Clients response to the medication with actual side effect

insulin

5 u PM

metabolism of carbohydrates, proteins, and fats. This activity occurs primarily in the liver, in muscle, and in adipose tissues after plasma membranes. Insulin promotes uptake of carbohydrates, proteins, and fats in most tissues. Also, insulin influences carbohydrate, protein, and fat metabolism by stimulating protein and free fatty acid synthesis, and by inhibiting release of free fatty acid from adipose cells. Insulin increases active glucose transport through muscle and adipose cellular membranes, and promotes conversion of intracellular glucose and free fatty acid to the appropriate storage forms (glycogen and triglyceride, respectively). Although the liver does not require active glucose transport, insulin increases hepatic glucose conversion to glycogen and suppresses hepatic glucose output. Even though the actions of exogenous insulin are identical to those of endogenous insulin, the ability to negatively affect hepatic glucose output differs on a unit per unit basis because a smaller quantity of an exogenous insulin dose reaches the portal vein.

manifest any allergic reactions or the administration of the medication.

binding of the insulin molecules to receptor sites on cellular hypoglycemia during

Combination with protamine and low concentrations of zinc in NPH insulin enhances the aggregation of insulin into dimers and hexamers after subcutaneous injection; a depot is formed after injection and the insulin is released slowly.

NURSING RESPONSIBILITIES BEFORE 1. Explain the procedure to the patient and its side effects. 2. Use a tuberculin or insulin syringe for accuracy of measurements. DURING 1. Administer only water and clear solution. Discoloration, turbidity, or unusual viscosity means deterioration or contamination. AFTER 2. Observe closely signs and symptoms of hyper- or hypoglycemia until dosage is established. 3. Be alert for signs of hypoglycemia which may indicate responsiveness has been regained and that a reduction in the dosage is warranted.

c. Diet Date ordered Type of Diet Date Started Date Changed General Description Indications or Purpose(s) Specific foods taken Clients response and for reaction to the diet

NPO (Nothing Per Orem)

No food in any form ( solid and liquid)and will be taken by mouth

None.

The patient complied by not eating or having any food in the mouth or per Orem

NURSING RESPONSIBILITIES BEFORE: 1. Check the doctors order 2. Explain to the patient the importance of placing her on NPO. 3. Ask patients preference that may be included in her diet list 4. Assure the fluid therapy when the patient is NPO

5. Instruct the patients SO not to give anything through the mouth. DURING: 1. Assure that nothing is taken through mouth either liquid or solid 2. Assess the client condition 3. Place NPO sign on the bed where the patient can always see it 4. Remove foods and drinks on the patients side AFTER: 1. Observe patients response to the diet d. Diet Date ordered Type of Diet Date Started Date Changed Diabetes Mellitus (DM) Diet 1.31.13 Diabetes Mellitus diet or low caloric diet is a diet composed of decreased intake in food containing high calories The purpose of a low caloric diet is to achieve a balance between the numbers of calories you consume, the number rice porridge The patient responded well to his diet because he was able to eat the foods he likes and control his blood sugar as well. General Description Indications or Purpose(s) Specific foods taken Clients response and for reaction to the diet

your burn when you exercise, and the energy used for normal functioning such as breathing and digesting your food.

NURSING RESPONSIBILITIES BEFORE: 6. Check the doctors order 7. Explain to the patient the importance of placing her on DM diet. 8. Ask patients preference that may be included in her diet list DURING: 5. Assess the client condition AFTER: 2. Observe patients response to the diet

e. Activity/Exercise Date ordered Type of Exercise Date Started Date Changed High Fowler's position is when the patient's head is raised 80-90 degrees. Fowler's position is a standard patient position. It is used to relax tension of the abdominal muscles, allowing for improved breathing in Semi-Fowler's position is when the patient's head is elevated 30-45 degrees. immobile patients as it alleviates compression of the chest due to gravity, and to increase comfort during eating and other activities. Low Fowler's position is when the head of bed is elevated 15-30 degrees Client was able to sit in bed with in low fowler, semi fowler and high fowlers position but with limited range of motion and difficulty of turning side by side. General Description Indication or Purpose(s) Clients response and/or reaction to the activity/exercise

Low fowlers, Semifowlers or high fowlers position and may sit in bed.

1.31.13

Nursing Responsibilities: 1. Use pressure-reducing bed mattress or additional padding as needed. 2. Momentarily tilt torso slightly away from bed to allow skin to realign with skeletal structures. 3. Slow smooth postural transitions to diminish cardiovascular effects. 4. Assisted in turning side by side. 5. Secured safety of the patient to avoid fall. 6. Secured safety on the injured part to prevent further damage. 7. Checked vital signs after.

C. Nursing Management Problem #1: Fatigue r/t decreased muscular strength NURSING ASSESSMENT DIAGNOSIS S> Fatigue related to decreased O> The patient muscular manifests: >generalized weakness >increased respiratory rate of 22cpm >body weakness >fatigue strength SCIENTIFIC EXPLANATION NURSING OBJECTIVES INTERVENTION 1. Assess response to activity 1.Response to an activity can be evaluated to achieve desired level of tolerance. 2.To determine the level of activity RATIONALE OUTCOME The patient shall have been able to identify measures to conserve and increase body energy The patient shall have been free from signs of fatigue EXPECTED

Diabetes Mellitus is Short Term: a group of After 2-3 of metabolic diseases nursing characterized by interventions, the patient will increased levels of be able to glucose in the identify measures to blood resulting conserve and from defects in increase body insulin secretion, energy. insulin action, or both. In type 2 diabetes, people Long Term:

2.Assess muscle strength of patient and functional level of activity. 3.Discuss with patient the need for activity

After 3-5 days of nursing have decreased interventions, sensitivity to insulin the patient will and impaired beta be free from

3.Education may provide motivation to increase activity level even though patient may

>limited ROM >inability to perform ADL >altered VS >altered sensorium

cell functioning resulting in decreased insulin production. Glucose derived from food cannot be stored in the liver thereby remaining into the bloodstream. The beta cells of the islets of Langerhans release glucagon which stimulates the liver to release the stored glucose. After 8 12 hours, the liver forms glucose from the breakdown of

signs of fatigue

feel too weak initially 4.Prevents excessive fatigue

4.Alternate activity with periods of rest/ uninterrupted sleep.

5.Indicates 5.Monitor pulse, physiological respiration rate levels of tolerance and blood pressure before/after activity 6.Tolerance develops by 6.Perform adjusting activity slowly frequency, with frequent duration and rest periods intensity until desired activity level is achieved.

noncarboghydrate substances, including amino acids resulting to muscle wasting which results to weakness.

7.Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and so on.

7.Interventions should be directed at delaying the onset of fatigue and optimizing muscle efficiency. Symptoms of fatigue are alleviated with rest. Also, patient will be able to accomplish more with a decreased expenditure of energy. 8.For proper oxygenation 9.To be free from injury

8.Provide adequate ventilation 9.Provide comfort and

safety 10.Instruct patient to perform deep breathing exercises 11.Instruct client to increase Vitamins A, C and D and protein in her diet. 12.Instruct also patient to increase iron in diet 13.Administer oxygen as ordered. 10.Promotes relaxation

11.For muscle strength and tissue repair

12.To prevent weakness and paleness 13.To provide proper ventilation

Problem #2: Ineffective tissue perfusion ASSESSMENT S> NURSING DIAGNOSIS Ineffective SCIENTIFIC EXPLANATION Diabetes an OBJECTIVES Short Term: After 2 of NPI, the pt will be able identify ways improve circulation. to and to Monitor record VS and NURSING INTERVENTIONS Assess condition pt.s RATIONALE EXPECTED OUTCOMES

to be able Short Term: to for appropriate interventions to data note changes obtain and prepare The have able identify ways improve circulation. demonstrate to pt shall been to and

tissue perfusion Mellitus Type 2 2 to Diabetes causes O > pt. manifests: - pallor (pale palpebral conjunctiva) - limited range of motion or weakness - altered Sensations Mellitus Type 2 abnormally increased blood glucose level. lead increased blood viscosity that poor circulation because more blood is, causes Chronic to elevations

demonstrate

baseline

Long Term: After 2 days of to Determine presence visual, of assess of degree cerebral perfusion

Long Term: The have demonstrated increased pt shall

the NI, the pt will the increased

viscous demonstrate

-restlessness

slower

is

its perfusion AEB absence cyanosis, VS within of or

sensory/motor changes, dizziness, blurred vision Measure capillary determine presence or quality of pulses refill; to degree peripheral perfusion of

perfusion absence pallor cyanosis,

AEB of or

movement.DM > pt. may manifest: - decreased pulses kidneys reninangiotensin system. Aldosterone is being - capillary refill time of > 3 sec produced which fluid causes retention

also affects the pallor

particularly its dyspnea, and normal range.

dyspnea, and VS within asses normal range.

Elevate and head neutral in

HOB maintain a or to or promote venous circulation drainage

and eventually - increased respiration and pulse rate hypertension. Due impaired circulation, less oxygen being delivered to is to

midline position

Encourage quiet and restful atmosphere to promote

- delayed wound healing

the

different to Teach breathing exercises relaxation techniques and deep

relaxation and rest

systems especially Oxygen delivery is also specifically decreased the level. decrease also difficulty breathing. in capillary A in the periphery.

to and

promote

-fatigue

oxygenation relaxation

Instruct to avoid strenuous activities to prevent

oxygen supply causes of Provide client, backchange weakness and rubs or massage position every 2

increase cardiac workload to promote

circulation

Provide for diet

restrictions such as too salty or fatty while foods, provide to prevent in

further increase vascular resistance that causes decreased tissue perfusion as

adequate calories to meet the need bodys

Assist or teach pt in using safety devices

the pt has DM and HPN to prevent occurrence of accidents

Provide adequate periods Administer medications as rest

or falls to conserve pts energy

ordered to promote

pharmacolo gical relief or treatment

Problem #3: Altered nutrition; less than body requirements r/t insulin deficiency ASSESSMENT S> O > pt manifests: - altered Sensations - weakness -increased CBG results - fatigue - poor muscle tone NURSING DIAGNOSIS Altered nutrition; than r/t SCIENTIFIC EXPLANATION Due less decrease in the OBJECTIVES NURSING INTERVENTIONS daily RATIONALE EXPECTED OUTCOMES Short Term: of The have identified measure Ascertain pts identifies and dietary program and usual pattern deficits promote and nutrition of levels. be Long Term: of The of have demonstrated behaviors lifestyle to prevent or pt shall onset and to pt shall

to Short Term: or After 2 of NI, pt will to

Weigh the pt assesses adequacy nutritional intake

body lack of insulin the insulin the level continuously rises glucose cannot the of Glucose required facilitate cellular utilized without

requirements deficiency

body, identify glucose measures promote nutrition of be levels.

because normalization glucose

deviation from normalization therapeutic needs may glucose

presence Long Term: insulin. After 5 days Observe is of NI, the pt to will demonstrate behaviors or signs for of

indicative the

hypoglycemia such as cold clammy skin

carbohydrate metabolism

> pt may manifest:

metabolism,

lifestyle to Auscultate bowel sounds

nutrition imbalance

changes regain appropriate weight.

to

while insulin is changes the vehicle to regain the body appropriate storage. of

- weight loss poor skin

tissues for use weight. or hyperglycemia Advice pt to comply to the dietary regimen nutrition but with adequate and electrolyte disturbances can decrease gastric motility or function promotes Include SO in meal planning as indicated sense involvement, provides information for SO identified needs of pt for of fluid Because decreased insulin level in the blood the starve to of body

turgor

- halitosis

stream, cells leading alteration

metabolism. The for metabolism; there will be a breakdown of needs glucose

energy reserved muscles liver (glucagons). This will result to weight loss. But when the energy breaks down, glucose increases because there is less amount of insulin. body need fed, to The be tissues because the level Perform finger stick testing ordered glucose as bedside analysis is of more serum glucose accurate then monitoring urine which sensitive enough detect fluctuations in to is sugar not from Monitor serum glucose, ABG and electrolytes lab and studies such as blood glucose will decrease with slowly adipose tissue,

continued fluid replacement and therapy insulin

continuously

the tissues are

not being fed and glucose metabolism. (muscle wasting) need for

serum and affected

levels can be by

pts individual renal threshold or presence renal failure Administer glucose solutions ordered as glucose solutions added insulin fluids brought to approximately 250 mg/dl are after and have to the of

blood glucose

Problem #4: Fluid volume deficit/t excessive fluid losses: vomiting AEB dry skim/ mucous membranes ASSESSMEN T S> O > pt manifests: mucous membranes NURSING DIAGNOSIS Fluid volume deficit/t excessive vomiting AEB dry skim/ - weakness mucous and mild membrane s headache -thirst and nausea SCIENTIFIC EXPLANATION Entry of Microorganism NURSING OBJECTIVES Short Term: Independent: Established rapport to the client and significant others Monitored and recorded v/s Provide proper ventilation and cool environment Health Teachings done to the S.O.: Instructed to Inc. Oral Fluid To gain trust and confidence INTERVENTION S Short Term Goal: GOALSUCCESSFULLYME T After 2hrs of continuous nursing care and proper health teachings the patient manifested: Decreased risk for complications of Fluid volume deficit Significant others acquired proper knowledge regarding the disease. Significant others understand the intervention of the problem. To maintain hydration Long Term: RATIONALE EXPECTED OUTCOMES

- dry skin/ fluid losses:

After 2hrs of continuous s on the GI tract nursing care leads to and proper health Inflammation teachings the process that patient will manifest: affects Digestive and Absorptive Decrease risk for malfunction complication which causes s of Fluid volume Excessive gas deficit formation GI Significant distention others will Increase have the proper Peristaltic knowledge Movement regarding the disease.

To obtain baseline data To avoid other fluid loses through excessive sweating.

vomiting

nausea

and

Significant vomiting, others will Imbalance Fluid know the proper Volume Deficit intervention of the problem. Long Term: After 2 days of continuous nursing care and proper health teachings the client will maintain fluid volume at functional level as evidenced by: Moist mucous membrane and good skin turgor

intake of the client Advised proper hygiene of the client Adequate rest and sleep should be provided Collaborative: IVF administered as ordered. Maintained at proper regulation Medications given as prescribed

status, thus, avoiding dehydration To avoid reoccurrenc e of the disease To avoid exhausting the patient, this may lead more on fluid loss. To deliver fluids accurately at desired rates.

Still on further Evaluation

Problem #5: Altered Comfort: Pain NURSIN ASSESSM ENT S> O > pt manifests : - dry skin/ mucous membra nes weaknes s mild headach e unmyelinat ed Cfibers and End terminals Afferent Nerves .Nocicept ors Long term: After the series of nursing interventions, the patient will be able to: 1 . V e r b a l i z e relief of pain. 2. Have n o r m a l RespiratoryRate. 3. recite t h e nonpharmacologic ways to lessen pain 4. d e m o n s t r a t e thenonphar macologic ways to lessen pain G DIAGNO SIS Altered Comfort : pain , SCIENTIFIC EXPLANATI ON Mechanical Short term: thermal or chemic al stimuli After 4 hours of nursing interventions, the patient will be able to experience gradual reduction/relief of pain. Independent :-Provide comfort measures such providing enough ventilation and fixing of linens - Encourage and assist client to do deep breathing exercises . - Teach client and significant other about the nonpharmacologic ways to lessen the pain. - Instruct client to report any improvement/exacer bation in pain experience To promote relief and wellness. OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

Short term: After 4 hours of nursing interventions, the patient shall have experience gradual reduction/relief of pain. Long term: After the series of nursing interventions, the patient shall have been able to: 1. Verbalize relief of pain. 2. have n o r m a l Respira

Deep breathing exercises contribute to relief of pain To maximize opportunitie s for selfcontrol over pain manifestati ons. Only the client

and -thirst - nausea and vomiting -irritability -curled up bed -pain scale 6/10 Alteration in comfort of Pain in brain cortex spinal cord Dependent : - Administer medications, particularly analgesics, as prescribed. myelinatedA deltafibers - Encourage verbalization of feelings about the pain. Physical Examination:

can judge the level and distress of pain; pain managemen t should be a team approach that includes the client.

tory Rate. 3. recite t h e nonpharmac ologic ways to lessen pain 4. demonstrat e the nonpharmacologic ways to lessen pain

Necessary for manage ment of underlying and possible complicatio ns

VI. PATIENTS DAILY PROGRESS IN THE HOSPITAL

Clients Daily Progress Chart DAYS 1. Fatigue r/t decreases muscle strength 2. Ineffective Tissue Perfusion 3. Altered nutrition; Less than Body Requirements r/t insulin deficiency 4. Fluid Volume Deficit r/t excessive fluid losses: vomiting AEB dry skin/ mucous membranes 5. Altered Comfort: Pain VITAL SIGNS 1. Temperature 2. Respiratory Rate 3. Pulse Rate 4. Blood Pressure 36.7 C 18 cpm 96 bpm 110/70 mmhg DIAGNOSTIC AND LABORATORY PROCEDURE 36.6 C 17 cpm 97 bpm 130/90 mmhg January 30, 2013 January 31, 2013 February 01, 2013

NURSING PROBLEMS:

1. Random Blood Sugar Test (RBS) 2. Creatinine 3. HBAIc 4. Hematology a. Hemoglobin b. Hematocrit c. Amylase d. BUN e. ALP H f. Neutrophils g. SGPT

20.21mmol/L 123.6 umol/L 10.0

93 g/l .28 665.0 IU/L 8.4 mmol/L 309.4 .76 9.1 MEDICAL MANAGEMENT

1. PNSS 1L x 12 DRUGS 1. Metoclopromide 1 amp/IV q8 PRN for nausea & vomiting 2. Omeprazole 40mg/IV/OD 3. Isophane Insulin (IAI) 10 u AM, 5 u in PM

4. Metoclopromide 10/amp/IV q8 5. Metoclopromide 1gm IV q8 DIET NPO for 4hours EXCERCISE Low fowlers, Semi- fowlers or high fowlers position and may sit in bed.

VIII. CONCLUSION AND RECOMMENDATIONS CONCLUSION Diabetes Mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood (Hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Normally, a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food substances. Diabetes has been classified in several ways. The different types of diabetes mellitus vary in cause, clinical course and treatment. It is classified as Type 1 (insulin dependent diabetes) and Type 2 (non-insulin dependent diabetes). Treatment varies because of changes in lifestyle and physical and emotional status as well as advances in treatment methods. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy by the patient. Although the health care team directs the treatment, it is individual patient who must manage the complex therapeutic regimen. For this reason, we nurses, as member of the health care team, must perform patient and family education because it is an essential component of diabetes treatment and is as important as all other components of regimen to attain our goal of maintaining our patients optimum level of functioning and health.

RECOMMENDATIONS To other student nurses, that they may learn more what Diabetes Mellitus is, its signs and symptoms, risk factors, laboratory and diagnostic procedures that can be done to detect this disease, its origin and how it can be acquired and the nursing management that we have to consider regarding this disease condition. To the DOH, that they may conduct seminars and other programs in order for the public to be aware of what Diabetes Mellitus is and its cause and effect, and on how to reduce the risk of acquiring it.

To the government, that they may provide adequate financial budget for health and allotting free or low priced medicines for the treatment of this disease and to give people proper information regarding Diabetes Mellitus. To the different members of the Health Care Team, that they may perform adequate skills in taking care of the patients afflicted with this illness and that they may know the nursing considerations and managements prior, during and after conducting procedures that the patients will undergo and to prevent further complications. To the patients afflicted with this illness and to the public, that they may understand the factors that will predispose them to acquire such illness, the reason for performing such diagnostic procedures to determine the progress of their condition, the importance of medications that they are taking, the ways on how to prevent this illness and that they may demonstrate techniques and procedures on how to promote maximum health and participate in the process of preventing complications in their health.

VIII. BIBLIOGRAPHY http://biology.clc.uc.edu/courses/bio105/endocrin.htm http://www.diabetes.org/type-1-diabetes/pancreas-transplants.jsp http://www.doh.gov.ph/programs/diabetes http://www.drugs.com/cdi/humulin-r.html http://www.medscape.com/viewarticle/444348 http://www.sciencedaily.com/releases/2012/06/120601103808.htm