Diabetes Mellitus 2 2ur5i
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Holy Angel University College of Nursing Angeles City
In Partial Fulfillment of Requirements in NCM104-RLE
Diabetes Mellitus Type 2 A CASE STUDY
Group 3/ Subgroup 2 N-405
I.
INTRODUCTION 1. Description Diabetes mellitus is a group of metabolic diseases characterized by high blood
sugar (glucose) levels that result from defects in insulin secretion, or action, or both. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime. Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Over time, diabetes can lead to blindness, kidney failure, and nerve damage. These types of damage are the result of damage to small vessels, referred to as microvascular disease. Diabetes is also an important factor in accelerating the hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease, and other large blood vessel diseases. There are an estimated 23.6 million people in the U.S. (7.8% of the population) with diabetes with 17.9 million being diagnosed, 90% of whom are type 2. With prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as an epidemic. World Prevalence of diabetes worldwide
2000 World Philippines
2030
171,000,000 366,000,000 2,770,000
7,798,000
Chan-Cua said the Philippines is still low on this score compared with other countries, especially Scandinavian nations like Finland, Sweden, and Norway, but we are also seeing an increase every year. Moreover, mathematical modeling on projection yields that 380 million people are expected to develop diabetes by 2025 based on International Diabetes Federation/World Health Organization data, a good percentage will be coming from Southeast Asian countries, including the Philippines. This finding is no longer astonishing considering the latest statistics on Filipinos afflicted with diabetes and hypertension which continues to increase on the scale of medical records. This goes to show that statistics on Diabetes Mellitus in the Philippines continues to be unfavorable to the general population because of the continuous rise in the number of Filipinos developing diabetes every year which adds to the number of people who cannot enjoy life and are becoming less productive due to this disease. Objectives The researches have the following objectives in this case study:
Described and explained Diabetes Mellitus together with the risk factors contributing to the occurrence of the condition.
Reviewed the anatomy and physiology of the organs involved.
Interpreted the results in the laboratory and diagnostic procedures done with the patient including their purposes, and specific nursing responsibilities before, during and after the procedure.
Enumerated the different medications istered for the condition, their indications and specific nursing responsibilities.
Formulated significant nursing diagnoses, with their significantly related nursing care plans.
II.
NURSING HISTORY 1. PERSONAL HISTORY a. Demographic data Mr. Sugar, a 52 years old male who is not married and has no children, was born on June 27, 1957 at Porac Pamapanga. He is pure Filipino. Mr. Sugar graduated Business and ancy at the college of Holy Angel University. After graduation, he worked for 16 years at Saver’s Bank Guagua. He presently resides at Baidbid, Porac Pampanga with his younger brother. b. Socio-economic and Cultural factors Mr. Sugar used to work at the bank for 16 years. Due to a confidential incident at work, Mr. Sugar was asked to leave the company. When he did, he decided to stay with his brother and help at the bakery. He never smoked and used to drink. When he was diagnosed, he stopped drinking. He regularly has a walk in the morning as a form of exercise. He is not choosy in eating foods and loves to eat fruits regularly. Mr. Sugar is a Roman Catholic. Last 3 years ago he made a habit of going to Apo to visit the church there but rarely attends mass. Since he grows up at Porac, he usually speaks the dialect Kapampangan and Tagalog. When it comes to health practices, he usually practices self medicate when the sickness isn’t severe and tolerable. Paracetamol is the usual medications they use for treating colds and colds. He doesn’t use herbs or seek herbalarios or albularyo. If his condition gets worse, medical attention is sought. He usually goes to Porac District Hospital for check-ups and emergency cases. Aside from emergencies, he has an annual check up with his private doctor.
2. FAMILY HEALTH ILLNESS HISTORY
Mr. Sugar is eight child of twelve children. Diabetes Mellitus runs in the family. His grandfather and father had Diabetes 2 while his mother was diagnosed with hypertension and died because of a stroke. Among his siblings, one has hypertension and the two has Diabetes Mellitus while the others are almost at pre-hypertension. His brother before him is his twin who experiences almost the same as he does. 3. HISTORY OF PAST ILLNESS Mr. Sugar was a drinker before. When he is working, he noticed that he got really weak and easily fatigue, so he decided to get a check up and was diagnosed to have Diabetes Mellitus type 2 on 1985. Medications were given to control his situation such as Metformin and a device such as Glucoplus to monitor his blood glucose. Hypertension arised last 3 months ago and was prescribed a maintenance of Neoblock one tab every morning and Combizar at night.
Mr. Sugar thought his medications would maintain his health but one month ago, his eyes started to swell and the doctor said that it was diabetic retinopathy. Thus, he had undergone laser therapy to prevent further damage. 4. HISTORY OF PRESENT ILLNESS On November 13, 2009, Mr. Sugar started to have the feeling of fullness but didn’t affect his appetite. He also noticed that his bowel pattern started to change because the urge to defecate is gone. After 2 days, he started to vomit a lot of times. He mentioned that “parang hindi nadigest ang mga kinakain ko.” Mr. Sugar was afraid to go to the hospital but his brother noticed him getting weak and pale. He went to Porac District Hospital on November 17, 2009 at 7:30pm with a chief complaint of body weakness and abdominal pain. Diagnostics exams were done and his tentative diagnoses were constipation, Diabetes Mellitus type 2 and Pre-renal disease. He was then itted for observation and treatment. A stool softener, Senokot 2 tabs was prescribed so that he can eliminate and to lessen the abdominal pain. On November 18, 2009 when the student nurses had their nurse-patient interaction, the patient stated he defecated twice and the pain eased. 5. PHYSICAL EXAMINATION November 17, 2009 (ission) Vital Signs: Bp- 160/110 mmHg; PR- 90bpm; RR- 19bpm; T- 36.4 ºC\ Chief complaint: Constipation and body weakness General Appearance: SKIN: • Pale • No lesions observed • Dry skin HEENT: Head • Hair is thin and quite moist, black with minimal white hair strands • Even distribution of hair
• No dandruff observed Eyes • Pale palpebral conjunctiva • Anicteric sclera • Patient has blurred vision Ears • External canal is clean • No discharge noted Nose • No discharge seen Tongue and mouth • Incomplete set teeth • Pale lips • Dry lips • No breath odor LUNGS: • Chest expands during inhalation ABDOMEN: • Rigid upon palpation MUSCULOSKELETAL: • No edema November 18, 2009 Vital Signs: Bp- 170/90 mmHg; PR- 80bpm; RR- 20bpm; T- 36 ºC General Appearance: Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left hand. Assessment: SKIN: • No lesions observed •
Skin is moist and warm
HEENT: Head •
Hair is black with minimal white hair strands
•
Even distribution of hair
•
No dandruff observed
Eyes •
Pale palpebral conjunctiva
•
Anicteric sclera
•
Patient has a blurred vision
•
Pupils are constrict when in light and dilates when the light is removed
Ears •
External canal is clean
•
No discharge noted
•
Pinna recoils after it is folded (<2secs)
Nose •
No discharge seen
•
Can breath with one nostril occluded
Tongue and mouth •
Dry lips
•
Incomplete set of teeth
•
No breath odor
NECK: •
Lymph nodes are palpable
LUNGS: •
chest expands during inhalation
ABDOMEN: •
Non-tender upon palpation
•
Flabby
•
With bowel movement (twice in one day as stated by patient)
GENITO-URINARY: •
With urinary frequency
UPPER AND LOWER EXTREMITIES •
With dry cracking fissures on the soles of the feet.
•
With non-pitting edema on both lower extremities
•
Capillary refill: 1-2 secs.
6. DIAGNOSTICS AND LABORATORY PROCEDURES Diagnostic/ Laboratory Procedures Complete Blood Count (CBC) WBC count
Lymphocytes
Eosinophils
Hemoglobin
Date Ordered Date results IN 11/17/09
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
-Measures the number of WBCs in a cubic mm of blood. -It is used to detect infection or inflammation and to monitor client’s response to or adverse effects of chemotherapy or radiation therapy. -To determine immune function, provides a gross measure in nutritional status. -To fight infection and control mechanism associated with allergies and asthma. -To evaluate the hemoglobin content (iron status and O2 carrying
11.7 x 10g/L
5-10 x 10 g/L
The result is slightly above the normal range which may signify infection.
0.21
0.20 - 0.40
The result is within the normal range.
0.01
0.01 - 0.06 The result is within the normal range.
107g/L
140 - 180 g/L
The result is below the normal range which indicates
Hematocrit
capacity) of erythrocytes by measuring the no. of grams of hemoglobin /dl of blood. - Measures the volume of RBCs in whole blood expressed as a percentage. - It is also a useful in the diagnosis of anemia, polycythemia, and abnormal hydration states. -Value is roughly three times the hemoglobin concentration.
anemia.
0.32
0.40 – 0.54
The result is below the normal range which indicates anemia.
Nursing Responsibilities: Prior to the procedure: •
Explain the procedure to the pt. and why it is indicated
•
Inform the patient that fluid and food restriction is not required
•
Inform the patient that a blood sample will be taken.
•
Tell the patient that he may experience transient discomfort from the needle pincture
•
Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.
During the procedure: •
Inform the patient that pain may be felt through prick in the needle
•
Instruct the patient to calm down to avoid uneasiness.
After the procedure: •
Apply brief pressure to prevent bleeding
•
Apply warm compress if Hematoma will develop at the venipuncture site.
Diagnostic/ Laboratory Procedures Random Blood Sugar
Date Ordered Date results IN 11/17/09
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
To measure blood glucose regardless of when you last ate.
145.3 mg/dl
< 140 mg/dl
The result is above the normal range which indicates too little insulin/ diabetes mellitus.
Nursing Responsibilities: Prior to the procedure: •
Inform patient that there are no food restrictions.
•
Wash your hands thoroughly before beginning procedure.
•
Ready your meter according to on-screen instructions or owner's manual (every meter is slightly different).
During the procedure: •
Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry or dry with gauze.
•
Wipe away the first drop of blood
•
Squeeze slowly and rhythmically, gripping the digit firmly between the base of thumb and first finger.
After the procedure: •
Check for sample acceptance and allow time for the machine to work. Apply firm pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
•
Record your glucose level and follow your physician's guidelines pertaining to necessary actions for low or high glucose levels.
Diagnostic/ Laboratory Procedures Kidney Function Test
Date Ordered Date results IN 11/17/09
Createnine
Indication or Purpose
Results
To monitor renal 3.7 function, mg/dl specifically the ability of the kidney to excrete waste products
Normal Values
Analysis and Interpretation of results
0.4-1.4 mg/dl
Creatinine level is above the normal range which indicates kidney impairment.
Nursing Responsibilities: Prior to the procedure: •
Explain to the patient the purpose of the procedure.
•
Inform the patient that he need not restrict food or fluids before the test, NPO post midnight
•
Check the patient’s history for use of drugs that may influence test results.
•
Inform the patient that the test requires blood sample. Explain whom will perform the venipuncture and when it will be done
During the procedure: •
Explain to the patient that may experience slight discomfort from the needle puncture and the tourniquet but that collecting the sample usually takes less than 3 minutes
•
Instruct the patient to calm down to avoid uneasiness.
After the procedure: •
Apply warm compress if Hematoma develops at the venipuncture site.
•
Apply pressure on the site to avoid bleeding.
Diagnostic/ Laboratory Procedures
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
Sodium (Na)
To reflect water balance.
135.2 mmol/L
137 – 145 mmol/L
Potassium (K)
To evaluate fluid and electrolyte balances and identify renal dysfunction. Potassium is critical to neuromuscular function, specifically skeletal and cardiac muscle activity. It reflects a change in the dilution or concentration of the ECF and does so in direct proportion to sodium concentration.
3.6 mmol/L
3.6 – 5.0 mmol/L
The result is below the normal range which indicates that there is a relative increase in the amount of body water relative to sodium. The result is within the normal level which indicates normal osmotic pressure and cardiac and neuromuscular electrical conduction.
97 mmol/L
96 – 110 mmol/L
Serum Electrolytes
Chloride (Cl)
Date Ordered Date results IN 11/17/09
The result is within the normal range which indicates normal balance of fluids.
Before the procedure: •
Explain to the patient that the test is used to evaluate the electrolytes content of blood.
•
Inform the patient that he need not restrict food or fluids before the test, NPO post midnight
•
Check the patient’s history for use of drugs that may influence test results.
•
Inform the patient that the test requires blood sample. Explain whom will perform the venipuncture and when
During the procedure: •
Explain to the patient that may experience slight discomfort from the needle puncture and the tourniquet but that collecting the sample usually takes less than 3 minutes
•
Instruct the patient to calm down to avoid uneasiness.
After the procedure: •
Apply warm compress if Hematoma develops at the venipuncture site.
•
Apply pressure on the site to avoid bleeding.
Diagnostic/ Laboratory Procedures Fasting Blood Sugar (FBS)
Date Ordered Date results IN 11/18/09
Nursing Responsibilities:
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
To measure blood glucose after you have not eaten for at least 8 hours. It often is the first test done to check and monitor treatment of diabetes.
146 mg/dl
70 – 110 mg/dl
The result is above normal range which indicates too little insulin/ diabetes mellitus.
Prior to the procedure: •
Ask patient if he/she had not eaten at least 8 hours.
•
Wash your hands thoroughly before beginning procedure.
•
Ready your meter according to on-screen instructions or owner's manual (every meter is slightly different).
During the procedure: •
Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry or dry with gauze.
•
Wipe away the first drop of blood
•
Squeeze slowly and rhythmically, gripping the digit firmly between the base of thumb and first finger.
After the procedure: •
Check for sample acceptance and allow time for the machine to work. Apply firm pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
•
Record your glucose level and follow your physician's guidelines pertaining to necessary actions for low or high glucose levels.
III.
ANATOMY AND PHYSIOLOGY
Every cell in the human body needs energy in order to function. The body’s primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells. Anatomy of the pancreas: The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small
intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). The pancreas is made up of two types of tissue: •
Exocrine tissue The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that the main pancreatic duct, which runs the length of the pancreas.
•
Endocrine tissue The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.
Functions of the pancreas: The pancreas has digestive and hormonal functions: •
The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum.
•
The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones.
Anatomy of kidney
The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells.
The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term "renal" is derived from the Latin name for kidney.) The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine (Cr). Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells.
IV. THE PATIENT AND HIS ILLNESS a. Schematic diagram Pathophysiology (book–based)
b.1. Definition of the disease Diabetes Mellitus Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly known as adult-onset diabetes, it usually affects people aged over 40 and progresses gradually. In this type the pancreas has not ceased to produce insulin, but the quantity is insufficient, or the hormone is not stimulating the glucose uptake in muscles and tissues required for energy. The result is a build-up of glucose in blood and urine. Although the cause of
this
malfunctioning
is
unclear,
non-insulin
dependent diabetes mellitus tends to run in families. Other risk factors, such as increasing age, obesity, and a sedentary lifestyle, probably contribute to its increased incidence in developed countries. Non-insulin dependent diabetes mellitus can often be controlled initially by diet alone, or in combination with tablets that reduce the amount of blood glucose. There are two main types of blood glucose-reducing drugs: sulphonylureas work mainly by stimulating the pancreas’s islet cells (known as the islets of Langerhans) to produce more insulin and biguanides increase the effectiveness of insulin on cells. Eventually, however, patients may need insulin injections. Prerenal Acute Renal Failure It is categorized as an acute renal failure which is characterized by inadequate blood circulation (perfusion) to the kidneys, which leaves them unable to clean the blood properly. Many patients with prerenal ARF are critically ill and experience shock (very low blood pressure).There often is poor perfusion within many organs, which may lead to multiple organ failure. Prerenal ARF is associated with a number of preexisting medical conditions, such as atherosclerosis ("hardening" of the arteries with fatty deposits), which reduces blood flow. Dehydration caused by drastically reduced fluid intake or excessive use of diuretics (water pills) is a major cause of prerenal
ARF. Many people with severe heart conditions are kept slightly dehydrated by the diuretics they take to prevent fluid buildup in their lungs, and they often have reduced blood flow (underperfusion) to the kidneys b.2. Predisposing Factors •
Age - Type 2 DM usually occurs at the age 40 years old and above. Type 2 DM occurs most commonly in people older than 30 years who are obese.
•
Family history of DM - Type 2 DM has a strong genetic component. Although the major gene that places the patient at risk is not yet identified, it is clear that the disease is polygenic and multifactorial. Individuals with a parent with type 2 DM have an increased risk for diabetes. Genetic factors are thought to play a role in insulin résistance and impaired insulin secretion in type 2 DM.
•
Race (African-Americans, Hispanic-Americans) - The risk for type 2 diabetes varies among population groups. Diabetes also seems to pose higher or lower risks for specific complications among racial groups.
Precipitating Factors •
Obesity - Elevated levels of free fatty acids, a common feature of obesity, may contribute to the pathogenesis of type 2 DM. It can impair glucose utilization in skeletal muscles, promote glucose production by the liver and impair beta cell function.
•
Environmental Factors/Stress – An increase in stress hormone triggers the release of epinephrine and norepinephrine which will promote the secretion of glucose leading to hyperglycemia.
•
Inactive 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.
•
Diet – Foods rich in carbohydrates can easily promote the increasing level of glucose along the bloodstream.
Prerenal Risk Factors •
Atherosclerosis cause obstruction to the flow of blood reaching the kidneys
•
Blood loss can lead to the constriction of the arteries carrying blood throughout the body, reducing the volume of blood reaching various organs including the kidney
•
Heart disease can lead to a reduction in the pumping effect of the heart, reducing the amount of blood reaching the kidneys and other organs. b.3. Signs and Symptoms with Rationale Diabetes Mellitus HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) •
May be due to lack of physiologically active insulin that transports glucose from extracellular to intracellular leading to accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams.
POLYURIA •
Increased frequency of urination. This may be due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination.
POLYDIPSIA •
Increased thirst and fluid intake. This may be due to the activation of the thirst center in the hypothalamus resulting form the intracellular dehydration or volume depletion.
POLYPHAGIA •
Increased hunger and food intake. This may be due to the decrease glucose uptake by the cells leading the stimulation of the satiety center in the hypothalamus resulting to the ‘hunger sensation.”
WEAKNESS/ FATIGUE •
This is due to the decreased glucose uptake by the cells leading to decreased energy production.
GLYCOSURIA •
The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine.
•
Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine.
GASTROPARESIS (Stomach fullness) ,CONSTIPATION and BLOATING •
This is due to changes in nerves and damages the blood vessels
that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve. The stomach fails to empty properly and is likely due to the generalized neuropathy. NAUSEA/ VOMITING •
Due to stomach fullness, there will be an involuntary emptying of stomach contents that are forcefully expelled by the mouth.
•
A compensatory mechanism due to acidity of body because of decrease excretion of metabolic waste.
PALE •
Due to decreased production of erythropoietin.
Schematic diagram of the disease PATHOPHYSIOLOGY(client-centered)
b.1. Predisposing/ Precipitating Factors Predisposing Factors •
Age- 52 years old.
•
Heredity- patient’s grandfather and father has DM
Precipitating Factors •
Sedentary lifestyle
b.2. Signs and Symptoms •
Gastroparesis( Stomach fullness) and Constipation o November 13, 2009 o
This is due to changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve. The stomach fails to empty properly and is likely due to the generalized neuropathy.
•
Nausea/vomiting o November 15, 2009 o Due to stomach fullness, there is a involuntary emptying of stomach contents that are forcefully expelled by the mouth. o A compensatory mechanism due to acidity of body because of decrease excretion of metabolic waste.
•
Hyperglycemia o November 17, 2009 o Due to lack of physiologically active insulin that transports glucose
from
extracellular
to
intracellular
will
lead
to
accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams. •
Hypertension o November 17, 2009
160/110 mmHg
o Due to increase in osmotic pressure, fluid goes to the vascular space increasing the blood volume. •
Weakness/fatigue o November 17, 2009 o
Due to decreased glucose uptake by the cells leading to decreased energy production.
•
Pale o
November 17, 2009
o
Due to decreased production of erythropoietin.
V. PATIENT AND HIS CARE 1. Medical Management a. IVF Medical Management Treatment Plain Normal
Date Ordered/ Date Performed/ General Date Description Changed/ D/C 11/17/09 An aqueous
Indication or Purpose
Client’s response to the treatment
It can be used for The drug was
Saline
solution of 0.9
hydration, and,
istered
Solution
percent sodium
as a solvent for
properly, with
(PNSS)
chloride,
drugs that are to
expected effects
1L x
isotonic with the
be istered
achieved, and
40gtts/min.
blood and tissue
parenterally.
the patient did
fluid, used in
not experience
medicine chiefly
dehydration.
for bathing tissue and, in sterile form.
Nursing Responsibilities: Prior the procedure: •
Read the doctor’s order
•
Check IV label
During the procedure: •
Check for patency of tubing
•
Regulate as ordered
After the procedure:
•
Check IV infusion and amount every 2 hours
b. Drugs Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
11/17/09
1 amp, IV
An anti-emetic
The patient did
STAT then q 8
drug that blocks
not vomit the
dopamine, but also
day after the
Brand Name:
stimulates
medication was
Plasil
acetylcholine to
given and has
increase gastric
bowel
emptying. It
movement.
Name of Drug
Generic Name: metoclopramide
General Action, Classification Mechanism of Action
increases the force of gastric contraction, relaxes pyloric sphincter, and increases peristalsis in the duodenum and jejunum without affecting the motility of the large intestine. Nursing Responsibilities: Prior to istration
Client’s response to the medication
-Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor bowel movement. -Instruct patient not to drink alcohol during therapy. Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
11/17/09
2 tabs,
General Action, Classification Mechanism of Action
Client’s response to the medication
It is laxative that is
The patient had
Name:
used as a short-term
defecated.
Senna
treatment of
Name of Drug
Generic
constipation and to evacuate the colon Brand Name:
for bowel or rectal
Senokot
examinations.
Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor bowel movement. -Instruct patient not to drink alcohol during therapy.
Name of Drug
Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
Generic
11/17/09
1 tab, PO, OD
General Action, Classification Mechanism of Action
Client’s response to the medication
Metoprolol is in a
Patient’s blood
Name:
group of drugs
pressure is still
metoprolol
called beta-
high. From
blockers. It is a
160/110 mmHg
selective inhibitor
upon ission
Brand Name:
of beta1-adrenergic
rises to 170/ 90
Neobloc
receptors affecting
mmHg.
the heart and circulation. It is used to treat angina and hypertension. Nursing Responsibilities: Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor for signs of tachycardia, palpitations and especially blood pressure -Instruct patient to sit before standing Name of Drug
Date Ordered/ Date Taken/ Date Changed/
Route of istration, Dosage and Frequency of istration
General Action, Classification Mechanism of Action
Client’s response to the medication
D/C Generic
11/17/09
1 tab, PO, OD
Losartan is in a
Patient’s blood
Name:
group of drugs
pressure is still
losartan
called angiotensin II
high. From
receptor
160/110 mmHg
antagonists.
upon ission
Brand Name:
Losartan keeps
rises to 170/ 90
Combizar
blood vessels from
mmHg.
narrowing, which lowers blood pressure and improves blood flow. It is also used to slow long-term kidney damage in people with type 2 diabetes who also have high blood pressure
Nursing Responsibilities: Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor for signs of tachycardia, palpitations and especially blood pressure -Instruct patient to sit before standing
Name of Drug
Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
Generic
11/17/09
1 tab, PO, OD
General Action, Classification Mechanism of Action
Client’s response to the medication
It decreases hepatic
Glucose level of
Name:
glucose production,
the patient may
metformin
decreasing
decrease. ( No
intestinal absorption available data) of glucose and Brand Name:
improves insulin
Glucophage
sensitivity
Nursing Responsibilities: Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. During istration -Instruct the patient to calm down to avoid uneasiness. After istration -Monitor glucose level closely in this patient because severe hypoglycemia may result before the patient develops symptoms. -Advice patient to avoid vigorous exercise immediately after dose.
-Inform patient to avoid alcohol, which lowers glucose level. c. Diet Type of diet Nothing per
Date started/ Date changed 11/17/19
orem (NPO)
General description It is a type of diet that withholds oral fluids and foods.
Indication or purpose. Indicated for patients unable to consume a regular diet and patients wild mild G.I. problems.
Client’s response and/or reaction to the diet Since the patient was oriented and understands needed interventions, he followed with the doctors prescriptions.
•
Nursing Responsibilities Prior • doctor’s order. • Explain the diet prescribed to the patient. • Instruct patient to withhold oral fluids and foods. During • Ensure that the patient strictly follow the diet. After Assess for patient’s condition; how he responds to the diet. d. Exercise/ Activity
Type of exercise
Keep rested
General description
Indication or Purpose
An activity Indicated to where strenuous avoid fatigue. activities should be avoided. Bed rest should be implemented but with assisted
Date Ordered, Date Started, Date Changed or D/C 11/17/09
Client’s Response and/or reaction to activity Patient responded to doctor’s order and stated decreased body weakness.
bathroom privilege to avoid further aggravation of the gangrene and to reduce pain as well. Nursing Responsibilities Prior •
Check doctor’s order for any other considerations needed.
•
Explain the activity to the patient.
•
Explain why it is important and what it could improve in her condition.
During •
Assess patient’s present condition.
•
Reinforce information as appropriate.
After •
Note patient’s response to activity.
VI. NURSING CARE PLAN
VII. DISCHARGE PLANNING 1. General Condition of the Client Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left hand. He reported that he had already two bowel movements. 2. METHODS M-edication Metoprolol 1tab PO,OD Losartan 1tab PO,OD Metformin 1tab PO,OD
E-xercise •
Instruct to exercise at least 3 days a week and avoid strenuous activity. >Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes
T-reatment •
Follow-up check up on his private doctor.
•
Instruct pt. to comply with the given diet.
•
Explain the importance of exercise in maintaining or losing weight.
•
Advise patient to check blood glucose level before doing any activities and to eat
H-
carbohydrate snack before exercising to avoid hypoglycemia.
>Blood glucose levels should be monitored before and after exercise to establish blood glucose response patterns to the exercise regimen. If blood glucose is >250 mg/dl, the patient should delay the exercise session. O-PD follow-up D-iet •
Diabetic Diet >Carbohydrates should provide 45 - 65% of total daily calories. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Carbohydrate counting or meal planning exchange lists. >Fats should provide 25 - 35% of daily calories. Limit saturated fat. >Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient individual health requirements
•
Avoid eating too much sweet foods.
•
Eat foods rich in fiber such as banana.
VIII. CONCLUSION In this study, the student nurses’ aim is to understand the disease more, manifestations, risk factors and complications. 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. Mr. Sugar’s diabetes mellitus was caused mainly by his sedentary lifestyle, his food preference and due to hereditary factor since his grandfather and his father both had diabetes. Diabetic retinopathy, a complication of diabetes mellitus, also occurred and Mr. Sugar opted to undergo laser therapy a month ago. It is best managed with a team approach to empower the client to successfully manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines involved; provides care and education and promotes the client’s health and well being. Diabetes is a major public health worldwide. Its complications cause many devastating health problems. Through this case study, we should be able to learn and understand the disease Diabetes Mellitus type 2 and therefore give us knowledge in proper management, prevention and treatment. As a student nurse, it is very important to know many things including the said disease condition. After the hardships of completing our case study, a reward of self-fulfillment and credential to our knowledge and skills has been added to us being student nurses as well as professionals in the near future.
IX. RECOMMENDATION The researchers would recommend the further study of this case as this is a disease that is interesting. It would be better if another causative factor would be studied to be able to provide diverse information about this disease and to be able to compare to spot similarities and differences in the manifestations of this disease if there is a different causative factor. To be able to appreciate the physical manifestations of this disease, we advise future researchers to investigate this case on the onset of the disease to be able to assess and note more overt manifestations both for educational and documentation purposes.
X. BIBLIOGRAPHY http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-thephilippines-and-worldwide/ http://nursingcrib.com/diabetes-mellitus-case-study/ Brunner&Suddarth.Textbook of medical-surgical nursing.2008.Lippincott Williams & Wilkins.
In Partial Fulfillment of Requirements in NCM104-RLE
Diabetes Mellitus Type 2 A CASE STUDY
Group 3/ Subgroup 2 N-405
I.
INTRODUCTION 1. Description Diabetes mellitus is a group of metabolic diseases characterized by high blood
sugar (glucose) levels that result from defects in insulin secretion, or action, or both. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime. Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Over time, diabetes can lead to blindness, kidney failure, and nerve damage. These types of damage are the result of damage to small vessels, referred to as microvascular disease. Diabetes is also an important factor in accelerating the hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease, and other large blood vessel diseases. There are an estimated 23.6 million people in the U.S. (7.8% of the population) with diabetes with 17.9 million being diagnosed, 90% of whom are type 2. With prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as an epidemic. World Prevalence of diabetes worldwide
2000 World Philippines
2030
171,000,000 366,000,000 2,770,000
7,798,000
Chan-Cua said the Philippines is still low on this score compared with other countries, especially Scandinavian nations like Finland, Sweden, and Norway, but we are also seeing an increase every year. Moreover, mathematical modeling on projection yields that 380 million people are expected to develop diabetes by 2025 based on International Diabetes Federation/World Health Organization data, a good percentage will be coming from Southeast Asian countries, including the Philippines. This finding is no longer astonishing considering the latest statistics on Filipinos afflicted with diabetes and hypertension which continues to increase on the scale of medical records. This goes to show that statistics on Diabetes Mellitus in the Philippines continues to be unfavorable to the general population because of the continuous rise in the number of Filipinos developing diabetes every year which adds to the number of people who cannot enjoy life and are becoming less productive due to this disease. Objectives The researches have the following objectives in this case study:
Described and explained Diabetes Mellitus together with the risk factors contributing to the occurrence of the condition.
Reviewed the anatomy and physiology of the organs involved.
Interpreted the results in the laboratory and diagnostic procedures done with the patient including their purposes, and specific nursing responsibilities before, during and after the procedure.
Enumerated the different medications istered for the condition, their indications and specific nursing responsibilities.
Formulated significant nursing diagnoses, with their significantly related nursing care plans.
II.
NURSING HISTORY 1. PERSONAL HISTORY a. Demographic data Mr. Sugar, a 52 years old male who is not married and has no children, was born on June 27, 1957 at Porac Pamapanga. He is pure Filipino. Mr. Sugar graduated Business and ancy at the college of Holy Angel University. After graduation, he worked for 16 years at Saver’s Bank Guagua. He presently resides at Baidbid, Porac Pampanga with his younger brother. b. Socio-economic and Cultural factors Mr. Sugar used to work at the bank for 16 years. Due to a confidential incident at work, Mr. Sugar was asked to leave the company. When he did, he decided to stay with his brother and help at the bakery. He never smoked and used to drink. When he was diagnosed, he stopped drinking. He regularly has a walk in the morning as a form of exercise. He is not choosy in eating foods and loves to eat fruits regularly. Mr. Sugar is a Roman Catholic. Last 3 years ago he made a habit of going to Apo to visit the church there but rarely attends mass. Since he grows up at Porac, he usually speaks the dialect Kapampangan and Tagalog. When it comes to health practices, he usually practices self medicate when the sickness isn’t severe and tolerable. Paracetamol is the usual medications they use for treating colds and colds. He doesn’t use herbs or seek herbalarios or albularyo. If his condition gets worse, medical attention is sought. He usually goes to Porac District Hospital for check-ups and emergency cases. Aside from emergencies, he has an annual check up with his private doctor.
2. FAMILY HEALTH ILLNESS HISTORY
Mr. Sugar is eight child of twelve children. Diabetes Mellitus runs in the family. His grandfather and father had Diabetes 2 while his mother was diagnosed with hypertension and died because of a stroke. Among his siblings, one has hypertension and the two has Diabetes Mellitus while the others are almost at pre-hypertension. His brother before him is his twin who experiences almost the same as he does. 3. HISTORY OF PAST ILLNESS Mr. Sugar was a drinker before. When he is working, he noticed that he got really weak and easily fatigue, so he decided to get a check up and was diagnosed to have Diabetes Mellitus type 2 on 1985. Medications were given to control his situation such as Metformin and a device such as Glucoplus to monitor his blood glucose. Hypertension arised last 3 months ago and was prescribed a maintenance of Neoblock one tab every morning and Combizar at night.
Mr. Sugar thought his medications would maintain his health but one month ago, his eyes started to swell and the doctor said that it was diabetic retinopathy. Thus, he had undergone laser therapy to prevent further damage. 4. HISTORY OF PRESENT ILLNESS On November 13, 2009, Mr. Sugar started to have the feeling of fullness but didn’t affect his appetite. He also noticed that his bowel pattern started to change because the urge to defecate is gone. After 2 days, he started to vomit a lot of times. He mentioned that “parang hindi nadigest ang mga kinakain ko.” Mr. Sugar was afraid to go to the hospital but his brother noticed him getting weak and pale. He went to Porac District Hospital on November 17, 2009 at 7:30pm with a chief complaint of body weakness and abdominal pain. Diagnostics exams were done and his tentative diagnoses were constipation, Diabetes Mellitus type 2 and Pre-renal disease. He was then itted for observation and treatment. A stool softener, Senokot 2 tabs was prescribed so that he can eliminate and to lessen the abdominal pain. On November 18, 2009 when the student nurses had their nurse-patient interaction, the patient stated he defecated twice and the pain eased. 5. PHYSICAL EXAMINATION November 17, 2009 (ission) Vital Signs: Bp- 160/110 mmHg; PR- 90bpm; RR- 19bpm; T- 36.4 ºC\ Chief complaint: Constipation and body weakness General Appearance: SKIN: • Pale • No lesions observed • Dry skin HEENT: Head • Hair is thin and quite moist, black with minimal white hair strands • Even distribution of hair
• No dandruff observed Eyes • Pale palpebral conjunctiva • Anicteric sclera • Patient has blurred vision Ears • External canal is clean • No discharge noted Nose • No discharge seen Tongue and mouth • Incomplete set teeth • Pale lips • Dry lips • No breath odor LUNGS: • Chest expands during inhalation ABDOMEN: • Rigid upon palpation MUSCULOSKELETAL: • No edema November 18, 2009 Vital Signs: Bp- 170/90 mmHg; PR- 80bpm; RR- 20bpm; T- 36 ºC General Appearance: Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left hand. Assessment: SKIN: • No lesions observed •
Skin is moist and warm
HEENT: Head •
Hair is black with minimal white hair strands
•
Even distribution of hair
•
No dandruff observed
Eyes •
Pale palpebral conjunctiva
•
Anicteric sclera
•
Patient has a blurred vision
•
Pupils are constrict when in light and dilates when the light is removed
Ears •
External canal is clean
•
No discharge noted
•
Pinna recoils after it is folded (<2secs)
Nose •
No discharge seen
•
Can breath with one nostril occluded
Tongue and mouth •
Dry lips
•
Incomplete set of teeth
•
No breath odor
NECK: •
Lymph nodes are palpable
LUNGS: •
chest expands during inhalation
ABDOMEN: •
Non-tender upon palpation
•
Flabby
•
With bowel movement (twice in one day as stated by patient)
GENITO-URINARY: •
With urinary frequency
UPPER AND LOWER EXTREMITIES •
With dry cracking fissures on the soles of the feet.
•
With non-pitting edema on both lower extremities
•
Capillary refill: 1-2 secs.
6. DIAGNOSTICS AND LABORATORY PROCEDURES Diagnostic/ Laboratory Procedures Complete Blood Count (CBC) WBC count
Lymphocytes
Eosinophils
Hemoglobin
Date Ordered Date results IN 11/17/09
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
-Measures the number of WBCs in a cubic mm of blood. -It is used to detect infection or inflammation and to monitor client’s response to or adverse effects of chemotherapy or radiation therapy. -To determine immune function, provides a gross measure in nutritional status. -To fight infection and control mechanism associated with allergies and asthma. -To evaluate the hemoglobin content (iron status and O2 carrying
11.7 x 10g/L
5-10 x 10 g/L
The result is slightly above the normal range which may signify infection.
0.21
0.20 - 0.40
The result is within the normal range.
0.01
0.01 - 0.06 The result is within the normal range.
107g/L
140 - 180 g/L
The result is below the normal range which indicates
Hematocrit
capacity) of erythrocytes by measuring the no. of grams of hemoglobin /dl of blood. - Measures the volume of RBCs in whole blood expressed as a percentage. - It is also a useful in the diagnosis of anemia, polycythemia, and abnormal hydration states. -Value is roughly three times the hemoglobin concentration.
anemia.
0.32
0.40 – 0.54
The result is below the normal range which indicates anemia.
Nursing Responsibilities: Prior to the procedure: •
Explain the procedure to the pt. and why it is indicated
•
Inform the patient that fluid and food restriction is not required
•
Inform the patient that a blood sample will be taken.
•
Tell the patient that he may experience transient discomfort from the needle pincture
•
Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.
During the procedure: •
Inform the patient that pain may be felt through prick in the needle
•
Instruct the patient to calm down to avoid uneasiness.
After the procedure: •
Apply brief pressure to prevent bleeding
•
Apply warm compress if Hematoma will develop at the venipuncture site.
Diagnostic/ Laboratory Procedures Random Blood Sugar
Date Ordered Date results IN 11/17/09
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
To measure blood glucose regardless of when you last ate.
145.3 mg/dl
< 140 mg/dl
The result is above the normal range which indicates too little insulin/ diabetes mellitus.
Nursing Responsibilities: Prior to the procedure: •
Inform patient that there are no food restrictions.
•
Wash your hands thoroughly before beginning procedure.
•
Ready your meter according to on-screen instructions or owner's manual (every meter is slightly different).
During the procedure: •
Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry or dry with gauze.
•
Wipe away the first drop of blood
•
Squeeze slowly and rhythmically, gripping the digit firmly between the base of thumb and first finger.
After the procedure: •
Check for sample acceptance and allow time for the machine to work. Apply firm pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
•
Record your glucose level and follow your physician's guidelines pertaining to necessary actions for low or high glucose levels.
Diagnostic/ Laboratory Procedures Kidney Function Test
Date Ordered Date results IN 11/17/09
Createnine
Indication or Purpose
Results
To monitor renal 3.7 function, mg/dl specifically the ability of the kidney to excrete waste products
Normal Values
Analysis and Interpretation of results
0.4-1.4 mg/dl
Creatinine level is above the normal range which indicates kidney impairment.
Nursing Responsibilities: Prior to the procedure: •
Explain to the patient the purpose of the procedure.
•
Inform the patient that he need not restrict food or fluids before the test, NPO post midnight
•
Check the patient’s history for use of drugs that may influence test results.
•
Inform the patient that the test requires blood sample. Explain whom will perform the venipuncture and when it will be done
During the procedure: •
Explain to the patient that may experience slight discomfort from the needle puncture and the tourniquet but that collecting the sample usually takes less than 3 minutes
•
Instruct the patient to calm down to avoid uneasiness.
After the procedure: •
Apply warm compress if Hematoma develops at the venipuncture site.
•
Apply pressure on the site to avoid bleeding.
Diagnostic/ Laboratory Procedures
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
Sodium (Na)
To reflect water balance.
135.2 mmol/L
137 – 145 mmol/L
Potassium (K)
To evaluate fluid and electrolyte balances and identify renal dysfunction. Potassium is critical to neuromuscular function, specifically skeletal and cardiac muscle activity. It reflects a change in the dilution or concentration of the ECF and does so in direct proportion to sodium concentration.
3.6 mmol/L
3.6 – 5.0 mmol/L
The result is below the normal range which indicates that there is a relative increase in the amount of body water relative to sodium. The result is within the normal level which indicates normal osmotic pressure and cardiac and neuromuscular electrical conduction.
97 mmol/L
96 – 110 mmol/L
Serum Electrolytes
Chloride (Cl)
Date Ordered Date results IN 11/17/09
The result is within the normal range which indicates normal balance of fluids.
Before the procedure: •
Explain to the patient that the test is used to evaluate the electrolytes content of blood.
•
Inform the patient that he need not restrict food or fluids before the test, NPO post midnight
•
Check the patient’s history for use of drugs that may influence test results.
•
Inform the patient that the test requires blood sample. Explain whom will perform the venipuncture and when
During the procedure: •
Explain to the patient that may experience slight discomfort from the needle puncture and the tourniquet but that collecting the sample usually takes less than 3 minutes
•
Instruct the patient to calm down to avoid uneasiness.
After the procedure: •
Apply warm compress if Hematoma develops at the venipuncture site.
•
Apply pressure on the site to avoid bleeding.
Diagnostic/ Laboratory Procedures Fasting Blood Sugar (FBS)
Date Ordered Date results IN 11/18/09
Nursing Responsibilities:
Indication or Purpose
Results
Normal Values
Analysis and Interpretation of results
To measure blood glucose after you have not eaten for at least 8 hours. It often is the first test done to check and monitor treatment of diabetes.
146 mg/dl
70 – 110 mg/dl
The result is above normal range which indicates too little insulin/ diabetes mellitus.
Prior to the procedure: •
Ask patient if he/she had not eaten at least 8 hours.
•
Wash your hands thoroughly before beginning procedure.
•
Ready your meter according to on-screen instructions or owner's manual (every meter is slightly different).
During the procedure: •
Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry or dry with gauze.
•
Wipe away the first drop of blood
•
Squeeze slowly and rhythmically, gripping the digit firmly between the base of thumb and first finger.
After the procedure: •
Check for sample acceptance and allow time for the machine to work. Apply firm pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.
•
Record your glucose level and follow your physician's guidelines pertaining to necessary actions for low or high glucose levels.
III.
ANATOMY AND PHYSIOLOGY
Every cell in the human body needs energy in order to function. The body’s primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells. Anatomy of the pancreas: The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small
intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). The pancreas is made up of two types of tissue: •
Exocrine tissue The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that the main pancreatic duct, which runs the length of the pancreas.
•
Endocrine tissue The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.
Functions of the pancreas: The pancreas has digestive and hormonal functions: •
The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum.
•
The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones.
Anatomy of kidney
The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells.
The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term "renal" is derived from the Latin name for kidney.) The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine (Cr). Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells.
IV. THE PATIENT AND HIS ILLNESS a. Schematic diagram Pathophysiology (book–based)
b.1. Definition of the disease Diabetes Mellitus Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly known as adult-onset diabetes, it usually affects people aged over 40 and progresses gradually. In this type the pancreas has not ceased to produce insulin, but the quantity is insufficient, or the hormone is not stimulating the glucose uptake in muscles and tissues required for energy. The result is a build-up of glucose in blood and urine. Although the cause of
this
malfunctioning
is
unclear,
non-insulin
dependent diabetes mellitus tends to run in families. Other risk factors, such as increasing age, obesity, and a sedentary lifestyle, probably contribute to its increased incidence in developed countries. Non-insulin dependent diabetes mellitus can often be controlled initially by diet alone, or in combination with tablets that reduce the amount of blood glucose. There are two main types of blood glucose-reducing drugs: sulphonylureas work mainly by stimulating the pancreas’s islet cells (known as the islets of Langerhans) to produce more insulin and biguanides increase the effectiveness of insulin on cells. Eventually, however, patients may need insulin injections. Prerenal Acute Renal Failure It is categorized as an acute renal failure which is characterized by inadequate blood circulation (perfusion) to the kidneys, which leaves them unable to clean the blood properly. Many patients with prerenal ARF are critically ill and experience shock (very low blood pressure).There often is poor perfusion within many organs, which may lead to multiple organ failure. Prerenal ARF is associated with a number of preexisting medical conditions, such as atherosclerosis ("hardening" of the arteries with fatty deposits), which reduces blood flow. Dehydration caused by drastically reduced fluid intake or excessive use of diuretics (water pills) is a major cause of prerenal
ARF. Many people with severe heart conditions are kept slightly dehydrated by the diuretics they take to prevent fluid buildup in their lungs, and they often have reduced blood flow (underperfusion) to the kidneys b.2. Predisposing Factors •
Age - Type 2 DM usually occurs at the age 40 years old and above. Type 2 DM occurs most commonly in people older than 30 years who are obese.
•
Family history of DM - Type 2 DM has a strong genetic component. Although the major gene that places the patient at risk is not yet identified, it is clear that the disease is polygenic and multifactorial. Individuals with a parent with type 2 DM have an increased risk for diabetes. Genetic factors are thought to play a role in insulin résistance and impaired insulin secretion in type 2 DM.
•
Race (African-Americans, Hispanic-Americans) - The risk for type 2 diabetes varies among population groups. Diabetes also seems to pose higher or lower risks for specific complications among racial groups.
Precipitating Factors •
Obesity - Elevated levels of free fatty acids, a common feature of obesity, may contribute to the pathogenesis of type 2 DM. It can impair glucose utilization in skeletal muscles, promote glucose production by the liver and impair beta cell function.
•
Environmental Factors/Stress – An increase in stress hormone triggers the release of epinephrine and norepinephrine which will promote the secretion of glucose leading to hyperglycemia.
•
Inactive 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.
•
Diet – Foods rich in carbohydrates can easily promote the increasing level of glucose along the bloodstream.
Prerenal Risk Factors •
Atherosclerosis cause obstruction to the flow of blood reaching the kidneys
•
Blood loss can lead to the constriction of the arteries carrying blood throughout the body, reducing the volume of blood reaching various organs including the kidney
•
Heart disease can lead to a reduction in the pumping effect of the heart, reducing the amount of blood reaching the kidneys and other organs. b.3. Signs and Symptoms with Rationale Diabetes Mellitus HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) •
May be due to lack of physiologically active insulin that transports glucose from extracellular to intracellular leading to accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams.
POLYURIA •
Increased frequency of urination. This may be due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination.
POLYDIPSIA •
Increased thirst and fluid intake. This may be due to the activation of the thirst center in the hypothalamus resulting form the intracellular dehydration or volume depletion.
POLYPHAGIA •
Increased hunger and food intake. This may be due to the decrease glucose uptake by the cells leading the stimulation of the satiety center in the hypothalamus resulting to the ‘hunger sensation.”
WEAKNESS/ FATIGUE •
This is due to the decreased glucose uptake by the cells leading to decreased energy production.
GLYCOSURIA •
The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine.
•
Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine.
GASTROPARESIS (Stomach fullness) ,CONSTIPATION and BLOATING •
This is due to changes in nerves and damages the blood vessels
that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve. The stomach fails to empty properly and is likely due to the generalized neuropathy. NAUSEA/ VOMITING •
Due to stomach fullness, there will be an involuntary emptying of stomach contents that are forcefully expelled by the mouth.
•
A compensatory mechanism due to acidity of body because of decrease excretion of metabolic waste.
PALE •
Due to decreased production of erythropoietin.
Schematic diagram of the disease PATHOPHYSIOLOGY(client-centered)
b.1. Predisposing/ Precipitating Factors Predisposing Factors •
Age- 52 years old.
•
Heredity- patient’s grandfather and father has DM
Precipitating Factors •
Sedentary lifestyle
b.2. Signs and Symptoms •
Gastroparesis( Stomach fullness) and Constipation o November 13, 2009 o
This is due to changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve. The stomach fails to empty properly and is likely due to the generalized neuropathy.
•
Nausea/vomiting o November 15, 2009 o Due to stomach fullness, there is a involuntary emptying of stomach contents that are forcefully expelled by the mouth. o A compensatory mechanism due to acidity of body because of decrease excretion of metabolic waste.
•
Hyperglycemia o November 17, 2009 o Due to lack of physiologically active insulin that transports glucose
from
extracellular
to
intracellular
will
lead
to
accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams. •
Hypertension o November 17, 2009
160/110 mmHg
o Due to increase in osmotic pressure, fluid goes to the vascular space increasing the blood volume. •
Weakness/fatigue o November 17, 2009 o
Due to decreased glucose uptake by the cells leading to decreased energy production.
•
Pale o
November 17, 2009
o
Due to decreased production of erythropoietin.
V. PATIENT AND HIS CARE 1. Medical Management a. IVF Medical Management Treatment Plain Normal
Date Ordered/ Date Performed/ General Date Description Changed/ D/C 11/17/09 An aqueous
Indication or Purpose
Client’s response to the treatment
It can be used for The drug was
Saline
solution of 0.9
hydration, and,
istered
Solution
percent sodium
as a solvent for
properly, with
(PNSS)
chloride,
drugs that are to
expected effects
1L x
isotonic with the
be istered
achieved, and
40gtts/min.
blood and tissue
parenterally.
the patient did
fluid, used in
not experience
medicine chiefly
dehydration.
for bathing tissue and, in sterile form.
Nursing Responsibilities: Prior the procedure: •
Read the doctor’s order
•
Check IV label
During the procedure: •
Check for patency of tubing
•
Regulate as ordered
After the procedure:
•
Check IV infusion and amount every 2 hours
b. Drugs Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
11/17/09
1 amp, IV
An anti-emetic
The patient did
STAT then q 8
drug that blocks
not vomit the
dopamine, but also
day after the
Brand Name:
stimulates
medication was
Plasil
acetylcholine to
given and has
increase gastric
bowel
emptying. It
movement.
Name of Drug
Generic Name: metoclopramide
General Action, Classification Mechanism of Action
increases the force of gastric contraction, relaxes pyloric sphincter, and increases peristalsis in the duodenum and jejunum without affecting the motility of the large intestine. Nursing Responsibilities: Prior to istration
Client’s response to the medication
-Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor bowel movement. -Instruct patient not to drink alcohol during therapy. Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
11/17/09
2 tabs,
General Action, Classification Mechanism of Action
Client’s response to the medication
It is laxative that is
The patient had
Name:
used as a short-term
defecated.
Senna
treatment of
Name of Drug
Generic
constipation and to evacuate the colon Brand Name:
for bowel or rectal
Senokot
examinations.
Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor bowel movement. -Instruct patient not to drink alcohol during therapy.
Name of Drug
Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
Generic
11/17/09
1 tab, PO, OD
General Action, Classification Mechanism of Action
Client’s response to the medication
Metoprolol is in a
Patient’s blood
Name:
group of drugs
pressure is still
metoprolol
called beta-
high. From
blockers. It is a
160/110 mmHg
selective inhibitor
upon ission
Brand Name:
of beta1-adrenergic
rises to 170/ 90
Neobloc
receptors affecting
mmHg.
the heart and circulation. It is used to treat angina and hypertension. Nursing Responsibilities: Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor for signs of tachycardia, palpitations and especially blood pressure -Instruct patient to sit before standing Name of Drug
Date Ordered/ Date Taken/ Date Changed/
Route of istration, Dosage and Frequency of istration
General Action, Classification Mechanism of Action
Client’s response to the medication
D/C Generic
11/17/09
1 tab, PO, OD
Losartan is in a
Patient’s blood
Name:
group of drugs
pressure is still
losartan
called angiotensin II
high. From
receptor
160/110 mmHg
antagonists.
upon ission
Brand Name:
Losartan keeps
rises to 170/ 90
Combizar
blood vessels from
mmHg.
narrowing, which lowers blood pressure and improves blood flow. It is also used to slow long-term kidney damage in people with type 2 diabetes who also have high blood pressure
Nursing Responsibilities: Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. After istration -Monitor for signs of tachycardia, palpitations and especially blood pressure -Instruct patient to sit before standing
Name of Drug
Date Ordered/ Date Taken/ Date Changed/ D/C
Route of istration, Dosage and Frequency of istration
Generic
11/17/09
1 tab, PO, OD
General Action, Classification Mechanism of Action
Client’s response to the medication
It decreases hepatic
Glucose level of
Name:
glucose production,
the patient may
metformin
decreasing
decrease. ( No
intestinal absorption available data) of glucose and Brand Name:
improves insulin
Glucophage
sensitivity
Nursing Responsibilities: Prior to istration -Check patient’s name before istration -Check the doctor’s order -Prepare the medication as ordered. -Explain the purpose, indication and possible adverse effects of the medication. During istration -Instruct the patient to calm down to avoid uneasiness. After istration -Monitor glucose level closely in this patient because severe hypoglycemia may result before the patient develops symptoms. -Advice patient to avoid vigorous exercise immediately after dose.
-Inform patient to avoid alcohol, which lowers glucose level. c. Diet Type of diet Nothing per
Date started/ Date changed 11/17/19
orem (NPO)
General description It is a type of diet that withholds oral fluids and foods.
Indication or purpose. Indicated for patients unable to consume a regular diet and patients wild mild G.I. problems.
Client’s response and/or reaction to the diet Since the patient was oriented and understands needed interventions, he followed with the doctors prescriptions.
•
Nursing Responsibilities Prior • doctor’s order. • Explain the diet prescribed to the patient. • Instruct patient to withhold oral fluids and foods. During • Ensure that the patient strictly follow the diet. After Assess for patient’s condition; how he responds to the diet. d. Exercise/ Activity
Type of exercise
Keep rested
General description
Indication or Purpose
An activity Indicated to where strenuous avoid fatigue. activities should be avoided. Bed rest should be implemented but with assisted
Date Ordered, Date Started, Date Changed or D/C 11/17/09
Client’s Response and/or reaction to activity Patient responded to doctor’s order and stated decreased body weakness.
bathroom privilege to avoid further aggravation of the gangrene and to reduce pain as well. Nursing Responsibilities Prior •
Check doctor’s order for any other considerations needed.
•
Explain the activity to the patient.
•
Explain why it is important and what it could improve in her condition.
During •
Assess patient’s present condition.
•
Reinforce information as appropriate.
After •
Note patient’s response to activity.
VI. NURSING CARE PLAN
VII. DISCHARGE PLANNING 1. General Condition of the Client Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left hand. He reported that he had already two bowel movements. 2. METHODS M-edication Metoprolol 1tab PO,OD Losartan 1tab PO,OD Metformin 1tab PO,OD
E-xercise •
Instruct to exercise at least 3 days a week and avoid strenuous activity. >Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes
T-reatment •
Follow-up check up on his private doctor.
•
Instruct pt. to comply with the given diet.
•
Explain the importance of exercise in maintaining or losing weight.
•
Advise patient to check blood glucose level before doing any activities and to eat
H-
carbohydrate snack before exercising to avoid hypoglycemia.
>Blood glucose levels should be monitored before and after exercise to establish blood glucose response patterns to the exercise regimen. If blood glucose is >250 mg/dl, the patient should delay the exercise session. O-PD follow-up D-iet •
Diabetic Diet >Carbohydrates should provide 45 - 65% of total daily calories. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Carbohydrate counting or meal planning exchange lists. >Fats should provide 25 - 35% of daily calories. Limit saturated fat. >Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient individual health requirements
•
Avoid eating too much sweet foods.
•
Eat foods rich in fiber such as banana.
VIII. CONCLUSION In this study, the student nurses’ aim is to understand the disease more, manifestations, risk factors and complications. 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. Mr. Sugar’s diabetes mellitus was caused mainly by his sedentary lifestyle, his food preference and due to hereditary factor since his grandfather and his father both had diabetes. Diabetic retinopathy, a complication of diabetes mellitus, also occurred and Mr. Sugar opted to undergo laser therapy a month ago. It is best managed with a team approach to empower the client to successfully manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines involved; provides care and education and promotes the client’s health and well being. Diabetes is a major public health worldwide. Its complications cause many devastating health problems. Through this case study, we should be able to learn and understand the disease Diabetes Mellitus type 2 and therefore give us knowledge in proper management, prevention and treatment. As a student nurse, it is very important to know many things including the said disease condition. After the hardships of completing our case study, a reward of self-fulfillment and credential to our knowledge and skills has been added to us being student nurses as well as professionals in the near future.
IX. RECOMMENDATION The researchers would recommend the further study of this case as this is a disease that is interesting. It would be better if another causative factor would be studied to be able to provide diverse information about this disease and to be able to compare to spot similarities and differences in the manifestations of this disease if there is a different causative factor. To be able to appreciate the physical manifestations of this disease, we advise future researchers to investigate this case on the onset of the disease to be able to assess and note more overt manifestations both for educational and documentation purposes.
X. BIBLIOGRAPHY http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-thephilippines-and-worldwide/ http://nursingcrib.com/diabetes-mellitus-case-study/ Brunner&Suddarth.Textbook of medical-surgical nursing.2008.Lippincott Williams & Wilkins.
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