TYPE 2 DIABETES MELLITUS

Presented by:

BSN II- BENEFICENCE

General Objectives: At the end of 4 hours case presentation, the students will be able to acquire and enhance their knowledge regarding patients general health and condition, integrate the skills through several nursing interventions and health management and to enhance the attitude of the students by promoting openmindedness all throughout the presentation.

Specific Objectives: At the end of 4 hours case presentation, the students aim to achieve the following:

1. 2. 3.

discuss clients specific assessments regarding its condition. describe the signs and symptoms of the disease exhibited by the client. define the disease process.

4. familiarize the systems affected by the disease of the client. 5. apply nursing process as framework for care of the patient. 6. formulate nursing care plans base on the complications manifested by the client. 7. practice the use of appropriate nursing intervention according to level of competency. 8. establish interpersonal relationship while the case is going on. 9. value the essence of prevention and treatment towards diabetes mellitus

HEALTH ASSESSMENT I. Biographical Data

Date of Interview: July 26, 2011 Time of Interview: 11:00 am Date of Admission: July 25, 2011 Time of Admission: 6:20 pm

Name: C. A. Age: 86 Sex: M Marital Status: Married Religion: Roman Catholic Address: St. Francis Subdivision, Roxas ,City Birth date: April 25, 1925 Birthplace: Roxas, City Race: Brown Who lives with the client: Wife, 3 Grand sons Significant others: Mrs. J. A. Educational Level: College Undergraduate Occupation: None Nationality: Filipino Physician: Dr. B. Provider of History Primary: Patient Secondary: Mr. A., Patients Chart Vital Signs upon Admission: T = 33.6 C P = 69 beats/min Relationship to Patient: Grandson

R = 20 breaths/min BP = 80/60 mmHg

II. Clients Health History A. Chief Complaint Cold clammy skin B. Admitting Impression Diabetes Mellitus Type II with neuropathy Hypoglycemia possible secondary to OHA (Oral Hypoglycemic Agent)

C. History of Present Illness Night prior to admission the patient missed to take his dinner due to anxiety related to yellowish discharge noted on his colostomy bag. 6:00AM in the morning he took Pritor Plus & vessel due F as his maintenance and took small amounts of food for his breakfast (1 slice of bread and a cup of coffee) and lunch (half slice of fish and 1/3 cup of rice and glass of softdrinks). Four (4) hours prior to admission, patient was noted to have cold clammy skin associated with blurred vision and weakness at home. Sugar diluted in a glass of water was given to him by his grandson to relieve his condition. Three (3) hours prior to admission, patient was somehow relieved from blurred vision but still felt weak and has cold clammy skin. One (1) hour prior to admission, the above chief complaint persisted so he decided to have a consultation at Capiz Emmanuel hospital. Arrived 6:00 P.M brought via wheelchair at AS, seen and examined by Dr. B thus the admission at exactly 6:20 P.M. He was later transferred to PPWEST for continuous care. D. Past Health History During his childhood years, patient had experienced minor illnesses like fever, colds, chicken pox and mumps. He couldnt remember the type of immunization he had during his childhood. He reported about his accident in the year 1963, when he was rushed at Saint Anthony College Hospital because of three (3) gun shots at San Jose Street , Roxas City which affected his spleen, liver and stomach. In the year 2004, he had undergone colostomy at Iloilo Mission Hospital . Two years later, in 2006, he had undergone appendectomy due to the rupture of his appendix. In the same year, he had also undergone a left eye operation because of cataract with that same hospital. Patient was also diagnosed to have Diabetes Mellitus Type 2 at the age of 40 in the year 1985 upon his check-up at St. Anthony College Hospital after experiencing hypertension, weakness and blurred vision. He has no allergies in any foods and drinks. As for his medical expenses, his children support him financially and his grandsons assist him and his wife at home. E. Family Health History

Heredofamilial Diseases Hypertension Heart Disease Diabetes Mellitus

Paternal

Maternal

Patients father died due to hypertension at the age of 86 and his mother died of heart attack at 85. His grandparents died due to old age; grandmother (mother side) died at 110 years old and grandmother (father side) died at 130 years old. F. Socio Cultural History Patient is a natural born Filipino presently living at St. Francis Subdivision, Roxas City together with his second wife and 3 grandsons. He was married twice due to the death of his first wife after their ambush in the year 1963; a retired business man and a Roman Catholic who usually goes to church with his family every Sunday. The patient admits that he has a sedentary life pattern. He doesnt do any house chores rather just watch television in the living room almost of his time. He enjoys bonding with his grandchildren whenever they visit in their home. Oftentimes, he goes to the market after the mass together with his grandson and wife to buy their foods. They also have a poultry farm in Pontevedra, Capiz which he visits once a month. He usually becomes impulsive whenever theres a delay in giving his demands and sometimes, he would throw things when hes mad. They also have a car as a means of transportation usually driven by his grandson who is also with his wife living on that same house. Sometimes, his friends visited him and they tend to play cards as a form of relaxation. Whenever he feels bored, he usually goes to the beach to unwind and to have fun. He finished his secondary education and went to college with an associate arts degree at Colegio dela Purisima Concepcion but stopped after 2 years due to early marriage with his first wife. Patients family maintains a close bonding relationship with their neighbors and friends.

G. Environmental History Patient lives in a 2 storey concrete house that is more or less 800 square meters lot situated at St. Francis subdivision with complete facilities and services like water and electricity from MRWD and CAPELCO respectively. They use mineral water for drinking. They have 3 air conditioned rooms and 2 guest rooms. They have also 3 comfort rooms: one (1) for the masters bedroom, one (1) in the first floor and one (1) in the second floor all with flush type toilets. Patient with his wife and grandsons are comfortable with their place because of its good camaraderie. There are few trees near their house like Calachuchi, Pine tree and flowering plants found in front and back of their house. They throw their garbage in a trash can in front of their house which is collected by the damp truck every Monday. They also use insect repellants (Baygon) for killing mosquitos and other insects. They have 2 maids who maintain the cleanliness inside their house every day. H. Medications and Substance Use Prior to admission, patient was given sugar diluted in water as a relief to his complaints. At home, his medications used as maintenance are as follow: Pritor Plus 40 mg 1 tablet OD for hypertension and Vessel due F 40 mg 1 tablet OD for diabetes. Patient takes supplements like Centrum 3x a week. He usually drinks 1 cup of coffee once a day and 3 bottles (8ounces) of soft drinks every day. III. PATTERNS OF FUNCTIONING

Fluids and Nutrition

Home Patient eats 1 slice of bread and a cup of coffee during breakfast while half slice of fish and 1/3 cup of rice and glass of softdrinks as his lunch.

Hospital In full diabetic diet IVF of D5 NSS 1L x 60cc/hr

Rest and Sleep

Elimination

Activity and Exercise

Consumes 75% from the total meals given. Patient sleeps at long Sleep at short intervals due intervals. Sleeps around 8 in to environmental changes. the evening and wakes Uses 2 pillows in sleeping. around 6 in the morning. Takes short nap for 2-3 hours. Uses 2-3 pillows and usually prays before sleeping. Average time of sleep: 13 hrs. Patient defecated into a Havent defecated since yellowish watery stool as admission seen in the colostomy bag Urinates for at least 500cc. Urinates for about 6 times every day 6-7 times a day changing of colostomy bag. Walks at short distance Rests on bed, changes his around their house and sits position every now and if he feels tired. then, sits at times and while

Personal Hygiene

eating. Patient takes full body bath Havent taken a bath since 3-4 times a week with warm admission. water, soap and shampoo Uses hair color, cologne and deodorant after bath.

IV. PHYSICAL ASSESSMENT A. General Survey Patient awake lying on bed with IVF infusing well at the right hand vein. Can turn to side independently and alert. He can stand erect with help of his cane and have limited movements. He is often assisted by folks most of the time. He is approachable, cooperative, well oriented with time and place and conversant to the people around him. Vital signs upon assessment are as follows: temperature of 36.2 C, respiration rate of 20 breaths/min, pulse rate of 66 beats/min and blood pressure of 110/80 mmHg. Wt. 55 kgs , height of 5 ft. and 8 inch.

B. Physical Examination

Cephalocaudal Skin

Inspection -Brown complexion -presence of brown and white patches -no lesions - age spots noted -Thin, gray and black in color -absence of infestations/ infections -graying of scalp -unevenly distributed hair -body hair in lower extremities -Long concave nails -slightly pink -presence of white marks normocephalic -limited flexes

Hair

Palpation - slightly warm - dry skin -wrinkle and tent when pinched - poor skin turgor - dry -slightly rough scalp

Percussion

Auscultation

N/A

N/A

N/A

N/A

Nails

-capillary refill less than 3 sec.

N/A
-temporal pulses are palpated

N/A

Head

-presence of moles at the parietal part Face -presence of moles, mustache and wrinkles -slightly assymetrical facial features -outer canthus aligns with the tips of pinna -skin around the eyes are thin and wrinkled -arcus senilis are evident -blurring of vision of the right eye -pupils are black -eyebrows are symmetrical and unevenly distributed -eyelashes turn slightly outward -ears aligned with eyes -earlobes are hanging downward -inability to hear low frequency sounds during conversation -Lips are symmetrical and slightly pink -gums and mucosa are pink and moist -uses 2 teeth dentures at the upper part of teeth -teeth are slightly yellowish -midline in face -septum is straight -nose more prominent in face -patent nares -slightly flaring -no discharges & inflammations -no edema or lesions

N/A N/A

N/A N/A

Eyes

-no drainage -no edema and tenderness

N/A

N/A

Ears

-soft, no nodules or lesions

N/A
-Lips are soft and slightly dry -no lesions, no drainage

N/A

Mouth

N/A

N/A

Nose and Sinuses

-no deformities -no edema

N/A

N/A

Thorax & Lungs

-Smooth and symmetric -presence of moles and brown patches -Breasts even with the chest wall -presence of moles and patches -nipples are dark brown in color

Breasts

-no masses -skin intact -uneven vibration during tactile fremitus test. -no masses or lesions noted

-dull sounds heard in the posterior thorax

-wheezing sounds are heard upon auscultation

N/A
-Apical pulses are palpated -cardiac rate of 68 beats/min

N/A
-Extra heart sounds or systolic murmurs are heard -clear bowel sounds

Heart

N/A

Abdomen

Upper Extremities and Lower Extremities

-no discharge of umbilicus -presence of white marks and moles -healed with appendectomy scar -scars from past accidents -surgery scars due to colostomy with colostomy bag attached. -performs limited range of motion exercises -noted swelling at the right hand -muscle atrophy -dark scars noted -able to flex extremities

-soft without masses or tenderness

N/A

-radial pulse of 66 beats/min -numbness of lower extremities -skin intact and dry -dead skin is visible

N/A

N/A

V. Diagnostic Exams A. Laboratory Exams 1. Exam Desired: CBC Date: 7/25/2011

Result Hemoglobin Mass Concentration Erythrocyte Volume Fraction

Normal Values

Indication

122 0.36

120-150 gms/L 0.37-0.45

With in normal range

Below there is increase CO2 content in the blood, O2 shortage and there is ischemia. Below there is increase CO2 content in the blood, O2 shortage and there is ischemia.

Erythrocyte Number Concentration

3.8

4.0-5.0 x10 /L

Leukocyte Number Concentration Segmenters

6.5 0.84

5.0-10.0 x10 /L .60-.70 L

With in normal range Segmenters indicates presence of infection Decrease lymphocytes often times indicates a sign of infection

Lymphocytes

0.16

18-30

2. Exam Desired: Urinalysis

Date: 7/26/2011

Color

Result Pale straw

Normal Values Amber/straw

Clinical Indication Excessive consumption of vitamin capsules, leading to a potential risk of hyper vitaminosis

Transparency

Slightly hazy

Clear

Inability of the kidneys to produce normal urine, presence of protein in urine Urinary tract infection, like inflammation of the urethra (urethritis), bladder infection,kidney stones etc. With in normal range With in normal range Absence of protein in urine Absence of glucose in urine Absence of RBC in urine Absence of pus cells in urine No clinical manifestation of uric acid crystals No Clinical manifestation of urinary tract infection

Reaction pH Specific gravity Protein Sugar RBC Pus Cells Amorphous Urates Bacteria

5.0 1.010 Negative Negative Negative Negative Occasional Occasional

Slightly acidic 4.6-8 1.010-1.025 Negative Negative Negative Negative Few Few

Date: 07/25/11

Results Creatinine 115 mg/dL

Normal Values
Male:55-113umol/L

SGPT

47 iul/L

10-40 iul/L

Sodium Potassium

134mmol/L 5.0mmol/L

135-148mmol/L 3.5-5.3mmol/L

Clinical Indication Increase Creatinine indicates a kidney disease, muscle degradation, renal insufficiency, chroni c renal disease Elevated SGPT level indicates may mean a liver disease or other injury from diseases . Normal range of sodium content in urine Normal range of potassium content in urine

3. Exam Desired: CBG Monitoring

Date and time July 25, 2011 (7:30 pm) July 26, 2011 (2pm)

Results 77mg/dL 179mg/dL

Normal Values 82-110mg/dL 82-110mg/dL

Clinical Indication Hypoglycemia Hyperglycemia

4. Exam Desired: Chest PA:

Date: 7/26/2011

As compared with previous exam dated 7/13/2011 shows interval regression of the bibasal pneumonic infiltrates. The pulmonary congestion is unchanged. Rest of the findings are fine.

TEXTBOOK DISCUSSION DIABETES MELLITUS TYPE 2 DESCRIPTION Diabetes Mellitus is a group of metabolic disorders characterized by elevated levels of blood glucose (hyperglycemia) resulting from defects in insulin production or secretion, decreased cellular response to insulin or both. Because cells cannot use glucose, fats and even proteins are broken down and used to meet the energy requirements of the body. As a result, body weight begins to decline. Loss of body proteins leads to decreased ability to fight infections, so diabetics must be careful with their hygiene and in caring for even small cuts and bruises. TYPES OF DIABETES MELLITUS TYPE I DIABETES MELLITUS TYPE 1 Diabetes Mellitus also called Insulin Dependent Diabetes Mellitus starts in childhood or adolescence is usually more severe than that beginning in middle or old age. Patients have little or no ability to produce the hormone and are entirely dependent on insulin injections for survival.  TYPE II DIABETES MELLITUS (Adult onset/ Noninsulin dependent DM) 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 mellitus because of its slow onset and can usually be controlled with diet and oral medication. 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 can begin so gradually that a person may not know that he has it. GESTATIONAL DIABETES MELLITUS Gestational Diabetes Mellitus is any degree of glucose intolerance with its onset during pregnancy.

 EPIDEMIOLOGY:
The dramatic worldwide increase in the prevalence of type 2 diabetes is posing a massive health problem in both developed and developing countries.1 Interestingly, in developed countries, lower socioeconomic groups are most affected, while, in developing countries, the reverse applies.2 The magnitude of the healthcare problem of type 2 diabetes results not just from the disease itself but also from its association with obesity and cardiovascular risk factors, particularly dyslipidaemia and hypertension.1Indeed, type 2 diabetes has now been recognized as one manifestation of the metabolic syndrome, a condition characterized by insulin resistance and associated with a range of cardiovascular risk factors. y One (1) out of every five (5) adult Filipinos are diabetic, according to the latest national survey conducted on the prevalence of diabetes in the country. y The survey, conducted in 2007 by the Philippine Cardiovascular Outcome Study on Diabetes Mellitus (PhilCOS-DM), further shows that as many as three (3) out of five (5) adults are already diabetic or on the verge of developing diabetes unless they change their lifestyle.

 ETIOLOGY:
 RISK FACTORS OF TYPE II DM

1. 2. 3. 4.

OBESITY - overweighing IMPAIRED GLUCOSE TOLERANCE GENETICS/HEREDITARY RACE - Diabetes occurs more often in Hispanic/Latino Americans, African-Americans, Native American, Asian Americans, Pacific Islanders, and Alaska Natives. 5. HYPERTENSION 140/90mmHg or higher

6. SEDENTARY LIFESTYLE Being inactive exercising fewer than 3 times a week makes you more likely to develop diabetes. 7. AGE increasing age puts you at higher risk of developing type 11 diabetes mellitus.

 MANAGEMENT OF DIABETES
y y y y TYPE I Diabetes Mellitus Insulin TYPE II Diabetes Mellitus Diet, Exercise, OHA (Oral Hypoglycemic Agent) Gestational Diabetes Mellitus Insulin, Diet, Exercise

 DIET DIABETIC DIET

PURPOSE Maintain blood glucose as near as normal as possible, delay or prevent onset of diabetic complications. FOODS ALLOWED: y Choose foods with low glucose index compose of: a. 45-55% carbohydrates b.30-35% fats c.10-25% protein

Coffee, tea, spices and flavorings can be used as desired

y Exchange groups include milk, vegetables, fruits, bread/starch, meat (divided in lean, medium fat, and high fat), and fat exchanges. y The number of exchanges allowed from each group is dependent on the total number of calories allowed y Non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics. FOODS TO BE AVOIDED: y Concentrated sweets or regular soft drinks

 EXERCISE: y PURPOSE Helps burn fats which in excess may lead to obesity that can cause serious complications. Not allowed during period of stress (illness or surgery).  INSULIN Insulin increases glucose transport into cells and promotes conversion of glucose to glycogen, decreasing serum glucose levels. Primarily acts in the liver, muscle, adipose tissue by attaching to receptors on cellular membranes and facilitating transport of glucose, potassium and magnesium. Hormone secreted by the alpha cells of the islets of langerhans in the pancreas. Increase blood glucose by stimulating glycogenolysis in the liver.

 CLINICAL MANIFESTATIONS: EARLY SYMPTOMS INCLUDE: y y y y y y y y y y y y Thirst or a very dry mouth Frequent urination High blood glucose levels High levels of ketones in the urine (type 1) Polyphagia Constantly feeling tired Dry or flushed skin Nausea, vomiting or abdominal pain Short, deep breaths Fruity odor or breath (type 1) Confusion OTHER SYMPTOMS APPEAR

y y y y y y

Manifested by client: Polyuria Tingling or numbness in feet Polydipsia Blurring of vision Dry skin Dark scars on lower extremities

Signs and Symptoms (from the book) y polyuria y polydipsia y polyphagia y fatigue y weakness y sudden vision changes y tingling or numbness in hands or feet y weight loss
y y

sores that heal slowly dry skin

 HYPOGLYCEMIA Clinical Manifestations: y y y y y y y Shakiness Dizziness Sweating Hunger Pale skin color Clumsy or jerky movements Confusion

 NEUROPATHY

Clinical Manifestations:
y y y y y y y Numbness and tingling of extremities Decreased or loss of sensation to a body part Muscle weakness Difficulty swallowing Speech impairment Vision changes Urinary incontinence

 Cerebrovascular disease y Hypertension y Myocardial infarction (MI) or acute myocardial infarction (AMI), y Ischemia (restriction in blood supply) PERIPHERAL VASCULAR DISEASE In peripheral vascular disease, a diabetic client can develop arterial occlusion and thrombosis that can lead to gangrene but this can be developed years after you have been diagnosed of diabetes mellitus and not properly treating it. Both the types of diabetes mellitus have a risk to develop this type of disease. Clinical Manifestations: y y y Tingling sensation of affected area Numbness / loss of sensation Pale skin color

 PREVENTION Maintain body weight and prevent obesity through proper nutrition and physical activity/exercise. Encourage proper nutrition eat more dietary fiber, reduce salt and fat intake, avoid simple sugars like cakes and pastries; avoid junk foods. Promote regular physical activity and exercise to prevent obesity, hypercholesterolemia, and enhance insulin action in the body. Advise smoking cessation for active smokers and prevent exposure to second hand smoke. Smoke among diabetes increases risk for heart attack and stroke

PATHOPHYSIOLOGY

REVIEW OF SYSTEMS

THE DIGESTIVE SYSTEM

The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat our body has to break the food down into smaller molecules, and it also has to excrete waste. Most of the digestive organs (like the stomach and the intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus few other organs (like the liver and pancreas) that produce or store digestive enzymes.

THE DIGESTIVE PROCESS The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules). After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements. Then, food enters the stomach which is a large, sac-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. After being in the stomach, food enters the jejunum, the duodenum and then the ileum of the small intestine. In the small intestine, bile (produced in the liver and stored in the bladder),pancreatic enzymes and other digestive enzymes produced by the inner wall of the small intestine help in the break down of food. After passing through the small intestine, food passes into the large intestines. Here, some of the water and electrolytes are removed from the food. Many microbes (like Bacteroides, Lactobacillus acidophilus, Escherichia coli and Klebsiella) in the large intestines help in the digestion process. The first part of the large intestine is called cecum in which the appendix is connected, food then travels upward in the ascending colon, then travels across the abdomen in the transverse colon to the descending colon then to the sigmoid colon. Solid waste is then stored in the rectum until excreted via the anus.

The illustration above shows two cycles occurring separately to maintain homeostasis in the body. When glucose levels are too high the pancreas secretes insulin to convert excess glucose to glycogen for storage. When glucose levels are too low the pancreas produces glucagon to convert stored glycogen to glucose, resulting in an increase in glucose levels.  Pancreas (pronounced: pan-kree-us) -is a part of the body's hormone-secreting system. The pancreas produces (in addition to others) two important hormones, insulin (pronounced: in-suh-lin) and glucagon (pronounced: gloo-kuh-gawn). They work together to maintain a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce and maintain stores of energy.

FUNCTION The pancreas is a dual-function gland, having features of both endocrine and exocrine (digestive system) glands.

The part of the pancreas with endocrine function is made up of approximately a million cell clusters called islets of Langerhans. Four main cell types exist in the islets. They are relatively difficult to distinguish using standard staining techniques, but they can be classified by their secretion: secrete glucagon (increase glucose in blood), secrete somatostatin (regulates/stops and cells secrete insulin (decrease glucose in blood), cells), and PP cells secrete pancreatic polypeptide. cells cells

The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels. The islets are "busily manufacturing their hormone and generally disregarding the pancreatic cells all around them, as though they were located in some completely different part of the body." The islet of Langerhans plays an imperative role in glucose metabolism and regulation of blood glucose concentration. The pancreas as an exocrine gland helps out the digestive system. It secretes pancreatic juice that contains digestive enzymes that pass to the small intestine. These enzymes help to further break down the carbohydrates, proteins, and lipids (fats) in the chyme.  OHAs: Oral Hypoglycemic Agents Alpha-glucosidase inhibitors are oral anti-diabetic drugs used for diabetes mellitus type 2 that work by preventing the digestion of carbohydrates (such as starch and table sugar). Includes :- ACARBOSE, MIGLITOL, Mogliboze Very important group of drugs and very popular nowadays. The most important point that those drugs mainly reduce the absorption of carbohydrates from the intestine , so the amount of sugar absorbed into bloodstream is reduced and the requirement for insulin will be reduced.

Those drugs play important role particularly in postprandial rise of glucose ( the rise of glucose in the blood after eating ). Why those drugs causes hypoglycemia attack? You know that diabetic patients when they eat,immediately ( or after .5 hour , 1 hour or two hours ) the blood sugar will rise sharply , and this sharp rise means that there is a stressful condition for pancreas particularly in NIDDM , so pancreas will start producing insulin and if the patient taking OHA which stimulates insulin releasing from the pancreas( such as Sulfonylureas class) , the pancreas will work greatly. But the requirement for insulin is high because of the high level of sugar in the blood after eating and the pancreas cant produce enough amount of insulin to lower the blood sugar . So there is a sharp rise in blood sugar level, followed by sustained high level and then gradual decrease in the blood sugar . Sometimes this gradual decrease will reach a level below the normal level that the brain used to be in and the patient goes into hypoglycemia ( hypoglycemic attack).

CARDIOVASCULAR SYSTEM

RELATIONSHIP OF PANCREAS TO CIRCULATOY SYSTEM: The islets of Langerhans cells within the pancreas are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels.  HCVD- Hypertensive cardiovascular disease refers to heart conditions that develop as a result of uncontrolled high blood pressure (hypertension). Ten percent of individuals with chronic hypertension develop enlarged left ventricles (left ventricular hypertrophy, or LVH). Enlargement of the left ventricle puts the individual at greater risk of illness and death (morbidity and mortality) due to congestive heart failure, heart rhythm irregularities (ventricular arrhythmias,atrial fibrillation), and heart attack (myocardial infarction).

The left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve. FUNCTION: For excellence of health, the left ventricular muscle must:  (a) relax very rapidly after each contraction so as to fill rapidly with oxygenated blood flowing from the lung veins, i.e. diastolicrelaxation and filling.  (b) contract rapidly and forcibly to force the majority of this blood into the aorta, overcoming the much higher aortic pressure and the extra pressure required to stretch the aorta and other major arteries enough to expand and make room for the sudden increase in blood volume, i.e. systolic contraction and ejection.  (c) be able to rapidly increase or decrease its pumping capacity under nervous system control. What is the connection between diabetes, heart disease, and stroke? If you have diabetes, you are at least twice as likely as someone who does not have diabetes to have heart disease or a stroke. People with diabetes also tend to develop heart disease or have strokes at an earlier age than other people. If you are middle-aged and have type 2 diabetes, some studies suggest that your chance of having a heart attack is as high as someone without diabetes who has already had one heart attack. People with diabetes who have already had one heart attack run an even greater risk of having a second one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death. High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).

 Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease characterized by ischaemia (reduced blood supply) of the heart muscle, usually due to coronary artery disease(atherosclerosis of the coronary arteries). Its risk increases diabetes, and hypertension (high blood pressure). with age,smoking, hypercholesterolaemia (high cholesterol levels),

IMMUNE SYSTEM
 COMMUNITY ACQUIRED PNEUMONIA (CAP) Is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses,fungi, and parasites. What is the connection between diabetes and CAP? Obese and persons who suffer from the type 2 diabetes have an altered immune system. If the diabetes goes untreated, the cells become sugar concentrated making them paradise for all microorganisms. It can be better explained like this: The persons immune system is dysregulated (impairment of physiological function), because of the presence of high concentration of sugars.

High sugar implies abundant food reserves making conducive for yeast, bacteria and other parasites to multiply. A person acquires infections very soon as the immune system becomes dwarfed and cannot eliminate them totally. It is for the same reason the diabetics have issues with multiple yeast and bacterial and also fungal infections. These infections also presumably take time longer time to heal when compared to healing in a non-diabetic person. So in order to keep these infections and parasites at bay and to keep immune system function well, you need to take steps to manage type 2 diabetes. Furthermore, physicians and diabetologists believe that the hemoglobin A1C or HbA1C is correlated to immune system; and blood sugars and HbA1C are directly proportional and it gives a picture of blood glucose concentration over 2 months time period. Higher the HbA1C figures reflect higher blood glucose and likelihood for weaker immune system. Therefore, weight loss or addressing the obesity becomes the immediate goal in those type 2 diabetics who are prone to infections and it is from an immunological perspective. This could be achieved with a combination of planned nutritious diet and exercise.

MEDICAL INTERVENTION
Nam e of Drug with Dosa ge Drug Classi fication Mechanism of Action Indication/ Use Special Consideration Side Effects/ Adverse Reaction

Prito Angiotensin II r Antagonists / Di Plus uretics 40 mg, 1 tablet OD

PritorPlus is a Treatment of combination of essentialhyperte an angiotensin nsion II receptor antagonist, telmisartan, and a thiazide diuretic, hydrochlorothi azide. The combination of these ingredients has an additive antihypertensiv e effect, reducing blood pressure to a greater degree

Hepatic impairment. Renovascular HTN, renal impairment & kidney transplant, intravascular vol depletion, other conditions w/ stimulation of the reninangiotensinaldosterone system, primary aldosteronism, aortic & mitral

Eye Disorders: Abnormal vision, transient blurred vision. Respiratory, Thoracic and Mediastinal Disorders: Respiratory distress (including pneumonitis and pulmonary edema),

than either component alone. PritorPlus once daily produces effective and smooth reductions in blood pressure across the therapeutic dose range.

valve stenosis, obstructive hypertrophic cadiomyopath y, may impair glucose tolerance & hyperuricemia or frank gout may occur, electrolyte imbalance.

dyspnea. Gastrointesti nal Disorders: Diarrhea, dry mouth, flatulence, abdominal pain, constipation, dyspepsia, vomiting, gastritis. Hepatobiliar y Disorders: Abnormal hepatic function/live r disorder Endocrine Disorders: Loss of diabetic control. Psychiatric Disorders: Restlessness. Nervous System Disorders: Lightheaded ness. Occasional occurrence of the following side effects have been reported: Capsule: Disorders in the

Vess el due F, 1 tablet OD

B01AB11 Sulodexide ; Belongs to the class of heparin group. Used in the treatment of thrombosis.

Vessel Due-F Vascular contains pathologies w/ sulodexide, a thrombotic risk, glycosaminogl transient ycan featuring ischemic attacks a marked & antithrombotic cerebrovascular action either on disease, arterial or peripheral venous vascular

In all cases where anticoagulant treatment is under way, hemocoagulati ve parameters should be monitored periodically.

systems. Sulodexide is also capable of normalizing altered viscosimetry parameters generally present in patients with vascular pathologies with thrombotic risk, this action mainly relies on reduced fibrinogen values.

insufficiency, diabetic retinopathy, MI, retinal vasal thrombosis.

Use in pregnancy: Du e to precautionary reasons, the administration of Vessel Due-F to pregnant women is not recommended.

gastroenteric system with nausea, vomiting and epigastralgia . Ampule: Pain, burn and hematoma at the site of injection. Rarely, there can be sensitization with cutaneous reaction or reaction in other sites.

Isoke t 40 mg, 1 tab OD

C01DA08 Isosorbide dinitrate ; Belongs to the class of organic nitrate vasodilators. Used in the treatment of cardiac disease.

Isosorbide Oral Use: Long- Isoket Retard During dinitrate causes term treatment should be used administratio a relaxation of of coronary only with n of Isoket, vascular particular the artery disease; smooth muscle caution and following severechronic thereby under medical undesirable heart failure in inducing supervision in: effects may combination vasodilatation. Low filling be observed: with cardiac Both peripheral pressure eg, in Cardiac glycosides, arteries and acute Disorders: diuretics,ACE i veins are myocardial Common: nhibitors or relaxed by infarction, Tachycardia. arterial isosorbide vasodilators; pul impaired left Uncommon: monary dinitrate. The ventricular Enhanced hypertension; latter effect function (left angina treatment & promotes ventricular pectoris prevention venous pooling failure); aortic symptoms. of angina of blood and and/or mitral Gastrointesti pectoris (even decreases stenosis; nal venous return after treated disease Disorders: myocardial to the heart, associated Uncommon: infarction). thereby with an Nausea, reducing increased vomiting. ventricular intracranial Very Rare:

end-diastolic pressure and volume (preload).

pressure orthostatic syndrome.

Heartburn. General Disorders and Administrati on Site Conditions: Common: Feeling of weakness. Nervous System Disorders: Very Common: Headache. Common: Lightheaded ness, dizziness, drowsiness. Skin and Subcutaneou s Tissue Disorders: Uncommon: Allergic skin

D50 W Vial now IV push D5050 vial, q4hrs .

References: Doenges, Marilyn E. et. Al, Nursing Care Plan. 7th Edition, 2006. Medical-Surgical Nursing, 10th Edition by:Joyce Young Johnson

Clinical Anatomy and Pathophysiology for the Health Professional by:Joseph Stewart,M.D Nursing Care of the Patient with Medical Surgical Disorder by: Lippincott & Sudharta Nursing Pocket Guide, 10th Edition by: Doenges, Marilyn E. et. Al Fundamentals in Nursing Practice by: Udan ,RN,MAN Mims.com.ph www.nlm.nih.gov www.Free-yd.Net En.Wikipedia.com www.google.com www.yahoo.com