Diabetes Mellitus Type II

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INTRODUCTION

WHAT IS DIABETES MELLITUS? Diabetes is a disease in which the body doesn't produce or properly use insulin. Insulin is a hormone produced in the pancreas, an organ near the stomach. Insulin is needed to turn sugar and other food into energy. When you have diabetes, your body either doesnt make enough insulin or cant use its own insulin as well as it should, or both. This causes sugars to build up too high in your blood. Diabetes mellitus is defined as a fasting blood glucose of 126 milligrams per deciliter (mg/dL) or more. Pre-diabetes is a condition in which blood glucose levels are higher than normal but not yet diabetic. People with pre-diabetes are at increased risk for developing type 2 diabetes, heart disease and stroke, and have one of these conditions:

impaired fasting glucose (100 to 125 mg/dL) impaired glucose tolerance (fasting glucose less than 126 mg/dL and a glucose level between 140 and 199 mg/dL two hours after taking an oral glucose tolerance test)

EPIDEMIOLOGY

The World Health Organization (WHO) estimates that more than 180 million people worldwide have diabetes. This number is likely to more than double by 2030.

In 2005, an estimated 1.1 million people died from diabetes.1 Almost 80% of diabetes deaths occur in low and middle-income countries. Almost half of diabetes deaths occur in people under the age of 70 years; 55% of diabetes deaths are in women.

WHO projects that diabetes deaths will increase by more than 50% in the next 10 years without urgent action. Most notably, diabetes deaths are projected to increase by over 80% in upper-middle income countries between 2006 and 2015

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TYPES OF DIABETES:

Type 1 diabetes (previously known as insulin-dependent or childhood-onset) is characterized by a lack of insulin production. Without daily administration of insulin, Type 1 diabetes is rapidly fatal.

Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly.

Type 2 diabetes (formerly called non-insulin-dependent or adult-onset) results from the bodys ineffective use of insulin. Type 2 diabetes comprises 90% of people with diabetes around the world, and is largely the result of excess body weight and physical inactivity.

Symptoms may be similar to those of Type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, once complications have already arisen.

Until recently, this type of diabetes was seen only in adults but it is now also occurring in obese children.

Gestational diabetes is hyperglycaemia which is first recognized during pregnancy.

Symptoms of gestational diabetes are similar to Type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening, rather than reported symptoms.

Impaired Glucose Tolerance (IGT) and Impaired Fasting Glycaemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes, although this is not inevitable.

Causes of Type 1 Diabetes:

Autoimmune response: For unknown reasons, in some people the immune system mistakenly destroys the insulin producing cells (called beta cells) in the pancreas. It is thought that some people inherit genes that mistakenly tell the body to recognize its beta cells as foreign invaders; then, when one gets the flu or some 66

type of virus, as the body is busy killing the foreign virus, it also kills its own beta cells because it mistakenly thinks the beta cells are invaders as well. Researchers have learned that there are certain types of gene combinations that predispose some people to type 1 diabetes.

Oxygen free radicals: These are formed as a by-product of chemical reactions in the body, from exposure to smoke, air pollution, diet, and other things. Some researchers believe that oxygen free radicals could contribute to the destruction of pancreatic cells.

Chemicals and drugs: There are certain rare drugs that can cause diabetes.

Causes of Type 2 Diabetes:

Genetics Insulin resistance: Researchers are still looking for the cause of insulin resistance, but in essence either there are not enough receptors on the cell, or the receptors aren't responding properly.

Aging, obesity, and lifestyle: Obesity is much more common in diabetes, and there may be a genetic cause for obesity. We know from recent results of the Diabetes Prevention Trial that lifestyle changes (modest weight reduction and moderate regular exercise) can prevent the development of type 2 diabetes in some people. Age is also a factor, partly due to the fact that as people age, they might become more overweight and more sedentary, although that is not always the case; some people simply inherit the defect that causes their pancreas to decrease insulin production as they age.

Causes of Gestational Diabetes

Hormones: During pregnancy, the placenta produces hormones important for the baby's growth; but these hormones cause some insulin resistance and make the body resemble that of a person with type 2 diabetes.

Genetics: Researchers suspect that the genes responsible for type 2 diabetes and gestational diabetes may be similar.

Obesity: Gestational diabetes is more common in women who are obese. 67

SIGNS AND SYMPTOMS of hyperglycemia: 1. Frequent urination ( the body tries to rid itself of excess sugar through urine ) 2. Thirst (to flush the system of the excess sugar). 3. Weight loss (the body breaks down stored fats to use as energy). 4. Constant hunger (trying to meet the bodys need for energy). 5. Feeling weak and tired (cells are starving, not receiving sugar for energy). 6. Itchy or dry skin 7. Blurry eyesight 8. Skin or bladder infections 9. Slow healing of cuts/bruises 10. Some people show no signs at all Hypoglycemia also called: Low blood sugar/Insulin reaction/insulin shock/too little sugar/too much insulin/too many diabetic pills. Low blood sugar usually comes on quickly sometimes in minutes.

Causes of low blood sugar: 1. Skipping a meal or snack 2. Too much or wrong type of insulin or diabetic pills 3. Injecting insulin into or near muscles 4. Prescription or nonprescription medications can lower blood sugar

Signs and symptoms of hypoglycemia 1. Headache 2. Sweat 3. Feeling hungry 4. Tired/sleepy 5. Behavior change, irritable or cross 6. Blurry vision 7. Passing out (syncope)

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WHAT ARE COMMON CONSEQUENCES OF DIABETES? Over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves.

Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment.

Diabetic neuropathy is damage to the nerves as a result of diabetes, and affects up to 50% of people with diabetes. Although many different problems can occur as a result of diabetic neuropathy, common symptoms are tingling, pain, numbness, or weakness in the feet and hands.

Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.

Diabetes is among the leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure.

Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).

The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes.

EXAMS AND TESTS If the patient is having symptoms but are not known to have diabetes, evaluation should always begin with a thorough medical interview and physical examination. The healthcare provider will about symptoms, risk factors for diabetes, past medical problems, current medications, allergies to medications, family history of diabetes or other medical problems such as high cholesterol or heart disease, and personal habits and lifestyle.

A number of laboratory tests are available to confirm the diagnosis of diabetes. Finger stick blood glucose: This is a rapid screening test that may be performed anywhere, including community-based screening programs. Fingerstick blood glucose values may be inaccurate at very high or very low levels, so this test is only a preliminary 69

screening study. This is the way most people with diabetes monitor their blood sugar levels at home. Fasting plasma glucose: The patient will be asked to eat or drink nothing for 8 hours before having blood drawn (usually first thing in the morning). If the blood glucose level is greater than or equal to 126 mg/dL without eating anything, they probably have diabetes. If fasting plasma glucose level is greater than 100 but less than 126 mg/dL, then the patient has what is called impaired fasting glucose, or IFG. This is considered to be pre-diabetes. The patient does not have diabetes, but they are at high risk of developing diabetes in the near future. Oral glucose tolerance test: This test involves drawing blood for a fasting plasma glucose test, then drawing blood for a second test at two hours after drinking a very sweet drink containing 75 grams of sugar. If the blood sugar level after the sugar drink is greater than or equal to 200 mg/dL, the patient has diabetes. If the blood glucose level is between 140 and 199, then the patient has impaired glucose tolerance (IGT), which is also a pre-diabetic condition. Glycosylated hemoglobin or hemoglobin A1c: This test is a measurement of how high blood sugar levels have been over about the last 120 days (the average life-span of the red blood cells on which the test is based).

HOW CAN THE BURDEN OF DIABETES BE REDUCED? Without urgent action, diabetes-related deaths will increase by more than 50% in the next 10 years. To help prevent type 2 diabetes and its complications, people should:

Achieve and maintain healthy body weight. Be physically active - at least 30 minutes of regular, moderate-intensity activity on most days. More activity is required for weight control.

Early diagnosis can be accomplished through relatively inexpensive blood testing. Treatment of diabetes involves lowering blood glucose and the levels of other known risk factors that damage to blood vessels. Tobacco cessation is also important to avoid complications. Interventions that are both cost saving and feasible in developing countries include: 70

Moderate blood glucose control. People with type 1 diabetes require insulin; people with type 2 diabetes can be treated with oral medication, but may also require insulin;

Blood pressure control; Foot care.

Other costs saving interventions include:

Screening for retinopathy (which causes blindness); Blood lipid control (to regulate cholesterol levels); Screening for early signs of diabetes-related kidney disease.

These measures should be supported by a healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use.

HOW IS DIABETES TREATED? When diabetes is detected, a doctor may prescribe changes in eating habits, weight control and exercise programs, and even drugs to keep it in check. It's critical for people with diabetes to have regular checkups. Work closely with your healthcare provider to manage diabetes and control any other risk factors. For example, blood pressure for people with diabetes and high blood pressure should be lower than 130/80 mm Hg

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PATIENTS PROFILE

Name: F.L.

Age: 57 years old

Gender: Female

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Address: Tagbilaran City, Bohol

Date Admitted: January 21, 2013

Chief Complain: Loss of motor strength

Attending Physician: Dr. Belonguel

Final Diagnosis: Diabetes Mellitus Type II

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NURSING HISTORY

Past Health History

According to the patient she has completed the different immunizations such as DPT, BCG, OPV, TT and measles. She had experienced childhood illnesses such as chickenpox, measles, colds, fever and cough.

Family Health History

According to the patient, their family has history of heart disease, hypertension, arthritis and diabetes. There are no other diseases related aside the mentioned above.

Present Health History

Eight (8) days prior to admission, the patient had experienced body malaise with weakness. She then had loss of motor strength a day after. The following day, she was brought to Holy Name University at Bohol and was admitted. On January 21, 2013, she was referred to Perpetual Succour Hospital for further management.

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GORDONS 11 FUNCTIONAL PATTERN

1. Health Perception/Health Management Pattern Before Hospitalization The patient stated that being healthy is important to be able to do her activities. She also put emphasis on the idea that giving importance to health should be made right from the start. She manages her health by taking a bath once a day and brushing her teeth once or twice a day. During Hospitalization The patient verbalized that since she is being hospitalized, there is really something wrong with her health. She can not take a bath, brush her teeth, and even comb her hair without assistance.

2. Nutritional-Metabolic Pattern Before hospitalization: The SO verbalized that the patient eats three meals a day (breakfast, lunch and dinner) with snacks in the morning and in afternoon. She eats whatever food is served. The patient also added that whenever she feel something bad, she just eat 5 spoons per meal. She drinks 7-8 glasses of water and another glass of juice a day. Her weight was 75 kg. During hospitalization: The patient has a diabetic diet and she eats three times a day. She eats with the help and assistance of the SO. She also drinks about 1, 120 ml of water during our shift. Her weight was decreased to 70 kg.

3. Elimination Pattern Before Hospitalization: According to the SO, the patient usually defecates once a day with a color of brown, consistency is semi- solid. She regularly voids three times during day time and during night, the clients arenola (medium size) is full, its color is yellow amber without difficulty in urinating and defecating. 74

During Hospitalization The patient urinates four times during our shift about 480 ml, has a color of dark yellow and she did not defecate.

4. Activity- Exercise Pattern Before Hospitalization: The patient could not perform any exercise due to body weakness. According to the SO, she can not do any heavy works and she needs assistance in walking or when she go outside their house. She stays at home spending 5-6 hrs. of sitting and the rest of the time the patient perform simple activities such as watching TV, eating, lying on bed and chatting with her children and grandchildren.

During Hospitalization The patient is under CBR without BRPs so she stays on her bed the whole day.

5. Cognitive-Perceptual Pattern Before Hospitalization: The clients senses are at work except for her eyes, she experiences blurring vision. Her sense of hearing is not impaired. As to her sense of taste, she has no problem. She is well oriented with time, place, persons and events.

During Hospitalization The patient has no problems with regards to her speaking capabilities even though she delivers her statement in a very soft voice. She answers questions relevantly. She is well oriented with time, place, persons around her and event.

6. Sleep-Rest Pattern Before Hospitalization Her typical sleep hour is from 8pm to 8am, about 10-12 hrs. her usual nap time is 30 mins.after lunch.

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During Hospitalization: The patient was not able to sleep at night because of the vital signs taking every 2 hrs. and drug administering.

7. Role-Relationship Pattern Before Hospitalization Being a responsible mother, she proudly says that she was able to fulfill her duties and responsibilities. She has a very good relationship with her family. She claims that her family is her priority. She emphasized that since all of them do their tasks and perform their responsibilities well, they have a strong family ties. The moment she had her illness and other signs of aging, she started to think she could no longer perform her duty

During Hospitalization The SO verbalized that though her mother is suffering from DM and other illness, the patient still have a close relationship with her family .

8. Self- Perception Pattern Before hospitalization: She views herself as a good mother and she added that she is strong woman who can withstand the crisis she is currently facing in life. She believes that with the support of her family, she could surpass whatever test of life comes her way.

During hospitalization: She never changed her perception to herself. Though she felt being bed ridden because she could not move that easily, with her familys unending assistance, she gets her strength from them not to give up no matter how painful her situation is.

9. Sexual- Reproductive Pattern Before hospitalization: The patient verbalized that she lives with her family in a compound. She has 4 children: 2 boys and 2 girls. She had her menarche when she was in grade 6. Her 76

menstruation period lasts at about 3 or 5 days and it was regular (monthly). Sometimes, she was suffering from dysmenorrhea. She had menopause.

During hospitalization: Due to old age and her condition, she is no longer sexually active.

10. Coping- Stress Pattern Before hospitalization: She copes with stress by resting and sleeping. Whenever she thinks of her condition, she prays to God to comfort herself.

During hospitalization: The patient copes with stress by just merely talking to her daughter and she sleeps when she feels drowsy. She also prays as her sign that shell never give up.

11. Value- Belief Pattern The patient is a Roman Catholic. When the client was not yet suffering from DM, they go to mass as a family but when she was diagnosed with this kind of disease and due to aging; they could no longer attend mass; so they are just having their TV mass every Sunday.

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LABORATORY RESULTS Urinalysis January 21, 2013 PARAMETERS Color Transparency Reaction Specific Gravity Sugar Protein RESULTS Yellow Turbid 6 1.020 Trace Trace Normal Due to increase urine concentration Normal Normal Due to decrease renal threshold Due to increase breakdowns of ANALYSIS

protein; increased osmotic diuresis Microscopic Examination PARAMETERS Squamous Epithelial Cells Mucus Thread Few Due to infection as a result of increase accumulation of sugar in the urine Pus Cells 8-10 Due to infection as a result of increase accumulation of sugar in the urine RBC 3-4 Due to glomerular damage as a result of renal strictures secondary to disease process Armorp. Urates / Few Phosphates Normal RESULTS Few ANALYSIS Normal

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BLOOD CHEMISTRY January 21, 2013 PARAMETERS Random blood sugar NORMAL FINDINGS 70 120 md/dL ACTUAL FINDINGS 463 mg/dl ANALYSIS Increased; due to inability of the body to

utilize

glucose

as a result of impaired insulin production Creatinine Sodium F: 50-100 135-155 mmol/L 81.4 umol/L 131 mmol/L Normal Decreased; due to dieresis Potassium 3.6-5.5 mmol/L 4.78mmol/L Normal osmotic

January 22, 2013 NORMAL FINDINGS ACTUAL FINDING 487 mg/dl

PARAMETERS Random Sugar

ANALYSIS Increased; due to

Blood 70 120 md/dL

inability of the body to utilize result glucose of as a

impaired

insulin production Uric Acid 178-345 mmol/L 247 mmol/L Normal

Fasting Sugar

Blood 3.89-5.84 mmol/dL

21.43 mmol/dL

Increased;

due

to

inability of the body to utilize glucose as a 79

result

of

impaired

insulin production Cholesterol 3.87mmol/dL 6.71 7 mmol/dL Increased; due to

metabolization of stored fats as a result of free cholesterol in the blood

HDL C

Female: mmol/L

>1.7 0.7 mmol/L

Decreased; increased intake

due dietary

to fat

LDL C Triglyceride

< 3.88 mmol/L Female: 0.46 1.6

0.63 mmol/L 1.50

Normal Normal

January 23, 2013 PARAMETERS RANDOM BLOOD SUGAR NORMAL FINDINGS 70 120 md/dL ACTUAL FINDINGS 289 mg/dl ANALYSIS Increased; due to inability body to of the

utilize

glucose as a result of impaired

insulin production SODIUM 135-155 mmol/L 140 mmol/L Normal

POTASSIUM

3.6-5.5 mmol/L

4.91mmol/L

Normal

HEMATOLOGY January 21, 2013 PARAMETERS WBC NORMAL FINDING 5 x 10 g/L 8.9 ACTUAL FINDING ANALYSIS Normal 80

RBC: Hemoglobin

Female: 12 16 11.4 g/dL g/dL

Decreased; due to inadequate oxygen

supply to cells as a result Female: 37 48% of blood

vessel constriction Hematocrit 35% Decreased; due to inadequate oxygen

supply to cells as a result of blood

vessel constriction Differential Count: Segmenters 0.60 0.70 0.94 Increased; due to inflammatory response Lymphocytes 0.20 - .30 0.06 Decreased; due to presence of infection

January 22, 2013 PARAMETERS WBC NORMAL FINDING 5 x 10 g/L 11.5 ACTUAL FINDING ANALYSIS Increased; due to inflammatory response RBC: Hemoglobin Hematocrit Differential Count: Segmenters 0.60 0.70 0.90 Increased; inflammatory response due Female: 12 16 g/dL Female: 37 48% 13 g/dL 40% Normal Normal

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Lymphocytes

0.20 - .30

0.10

Decreased; due to presence infection of

HEMOGLUCO TEST (HGT)

DATE January 22, 2013

TIME 11:45 A.M. 1:00 P.M. 8:00 P.M.

NORMAL ACTUAL FINDING 80-120 80-120 80-120 80-120 80-120 80-120 FINDING 408 333 307 326 487 274 Increased; Increased;

ANALYSIS due to increased

secretion of insulin

January 23, 2013

12:30 A.M. 2:30 A.M. 5:00 P.M

due

to

increased

secretion of insulin

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PATHOPHYSIOLOGY Precipitating: - Diet - Lifestyle - Obesity Predisposing - Family history - Age

Number of insulin at receptor site Insulin / zero insulin uptake in the cell

Metabolism

Protein Metabolism

Fat Metabolism

Lipolysis of adipose tissue Liver is to unable to store glucose Glucose cannot enter the cells of muscle and adipose tissues CHON catabolism CHON synthesis ketone bodies hyperlipedimia

glycogenolysis

fuel polyphagi

amino acid converted to glucose

-muscle weakness -failure to grow

incomplete oxidation

deposits lipid in the lumen

C D E

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A hyperglycemia kidneys secreted excess glucose to restore balance

B lungs acetone & CO2 retention

C kidneys acetone excretion

D BP bursting of small capillaries in eyes S/SX: blurring vision

E persistent CVD BP

RR dycosuria glucose in the urine acts as osmotic diuretic urine output

ketonuria

Na retention H2O loss blood volume

osmotic pressure

fluid volume deficit C.O DEHYDRATION organ perfusion SHOCK

severe tissue anorexia

paradoxin of lactic acid

eyes (retinal neuropathy) peripheral neuropathy

kidney neuropathy

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blindness

tingling sensation poor wound healing

ketones in the blood

ketosis

further in the urine output

nausea & vomiting

H+; PH

H2O loss polyuria

metabolic acidosis diabetic coma

H+ enters cells

K+ moves out of the cell going to the blood

dehydration hypokalemia cardiacdysrythmias

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NURSING CARE PLAN

ASSESSMENT Objective Data: -warm to touch -flushed skin - T= 37.7 o C - RR= 34 cpm

DIAGNOSIS Altered

PLANNING

INTERVENTION vital signs & >To

RATIONALE determine temperature,

EVALUATION basal Goal met. The to patient was able

body At the end of one >Monitor hour, the patient recorded will be able to temperature body

temperature: Hyperthermia r/t

particularly body

have baseline data & to to obtain core have a basis for body the temperature of within range. surface normal

increased obtain of temperature

production

evaluating effectiveness interventions. >Provided the patient >To promote

pyrogens in the within body range.

normal

continues TSB

cooling and heat lose by evaporation conduction. and

>Positioned the patient in a > Promote client safety & comfortable position. and safe to maintain patent airway to address increased

respiratory rate. >Provided proper room >To promote surface

ventilation by opening the cooling & heat loss by

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fan & window panes. to change the

convection.

>Advised the patients SO >Loose clothing & light patients colored clothing

clothing to loose & light promotes body surface colored clothes. cooling. Light colored clothes absorbent diaphoresis. >Advised the patient to >To replace fluids & increase fluid intake to 8-10 electrolyte glasses/day. circulatory to support & are to more address

volume

tissue perfusion and to prevent dehydration. >Instructed the client to >To maintain bed rest. reduce & metabolic oxygen

demands

consumption. >Administered antipyretics >To restore normal body & due medications temperature & to treat underlying conditions.

intravenously as ordered.

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ASSESSMENT Subjective Data: Masakit ang katawan ko kapag ginagalaw ko, as verbalized by the patient - pain scale of 8/10

DIAGNOSIS Pain r/t musculoskeletal impairment

PLANNING At the end of the shift, the patient will be able to: > report pain if relieved/ controlled and a decreased in pain scale of 0/10

INTERVENTION > Determined level of pain from 8/10

RATIONALE > to be able to know what particular intervention to relieve pain

EVALUATION Goal partially met. The patient reported pain controlled and a decreased in pain scale of 5/10

> Positioned patient comfortably on bed > Provided patient adequate rest

> To promote wellness > to prevent fatigue

Objective Data: facial grimace expressive behavior restlessness

> Provided quiet environment > Provided comfort measures such as changing the patients position frequently > Administered

> to be able to have enough rest > to alleviate pain caused by pressure on nerve endings

> to maintain

analgesia as ordered acceptable level of pain

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ASSESSMENT Subjective Data: Hindi ako mapakali kasi sumasakit ang katawan ko, as verbalized by the patient.

DIAGNOSIS Impaired physical mobility r/t discomfort

PLANNING At the end of the shift, the patient will be able to: >verbalize understanding of situation and individual treatment

INTERVENTION > Determined diagnosis that contribute to immobility such as arthritis > Assessed degree of pain by listening to clients description and facial expression > Noted emotional or behavioral responses to problems of immobility

RATIONALE > to determine immediate deviation or complication on patients condition

EVALUATION Goal partially met.

At the end of the shift, the patient

> to provide necessary intervention to lessen clients discomfort

was able to verbalized understanding of situation and

> Feelings of frustrations/powerlessness may impede attainment of goals

individual treatment regimen and safety measures but did not increase d the strength and function of affected body part

Objective Data:

regimen and safety measures

>Facial grimace >Difficulty in turning >Slowed movement >Jerky movement

>increase strength and function of affected body part > Supported affected body parts by using pillows

> to maintain position of function and reduce risk of pressure on the affected area

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ASSESSMENT Subjective data: Madali akong mapagod kahit na mag iba lang ako ng pososyon, as verbalized by the patient.

DIAGNOSIS Activity intolerance r/t body weakness

PLANNING At the end of the shift , the patient will be able to: >Participate willingly in necessary activities > report

INTERVENTION > Monitored vital signs every 2 hours

RATIONALE > to provide baseline data; to evaluate the degree of condition and the effectiveness of the intervention

EVALUATION Goal met. At the end of the shift, the patient was able to: >Participate willingly in necessary activities > report measurable increase in activity intolerance

> Encouraged expression of feelings contributing to the condition > Planned care with

> to determine the necessary intervention to be made for the clients condition

Objective Data:

measurable increase in

> to reduce fatigue and

BP: 110/70 mmHg RR: 24 cpm PR: 104 bpm Body weakness

activity intolerance

rest periods between to have enough rest activities > Involved client and SO in planning periods. > involvement of client and SO during the plan

of activities as much of care helps to attain as possible goals

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ASSESSMENT Subjective data: Paputol putol ang tulog ko dahil sa pagbibigay ng gamut ko at pagmonitor sa akin, as verbalized by the patient.

DIAGNOSIS Sleep pastern disturbance r/t interruptions for therapeutics and monitoring

PLANNING At the end of the shift, the patient will be able to: verbalize understanding of sleep disturbance report improvement in

INTERVENTION >Obtained feedback from Client and SO regarding usual bedtime, number of sleep hours, and time of arising >Explained to the patient and SO the importance of taking VS and administering medicines. >Arranged care to provide for uninterrupted periods for rest >Provided quiet

RATIONALE > to determine usual sleep pattern and provide comparative baseline

EVALUATION Goal met. At the end of the shift, the patient was able to: > verbalize

>to gain cooperation from the patient

understanding of sleep disturbance >report improvement in

Objective data: dark circles under eyes frequent yawning restlessness

sleep or rest pattern report increased sense of feeling rested

>to provide adequate sleep or rest pattern sleep and rest periods > to provide comfort report increased sense of feeling rested

environment and comfort to the patient and measures (arranging the bed) have adequate sleep

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DRUG STUDY

1. Generic Name: Colchicine Brand Name: Colsalide, Novocolchine Classifications: Antigout Action: Inhibits microtubule formation of lactic acid in leukocytes which decreases phagocytosis and inflammation in joints. Uses: Prevention or treatment for gout, gouty arthritis to arrest progression of neurologic disability in multiple sclerosis Contraindications: Hypersensitivity; serious GI, renal, hepatic, cardiac disorders; blood dyscariasis Side Effects: Miscellaneous: myopathy, alopecia, reversible azoospermia, peripheral neuritis GU: Hematuria, Oliguria, Renal Damage HEMA: Anemia, thrombocytopenia GI: nausea, vomiting, anorexia, malaise, metallic taste, cramps, peptic ulcer, diarrhea INTEGU: cdhills, dermatitis, pruritis, purpura, erythema Route and Dosage: 1 tab every 1 hour Nursing Implications: Assessment: > Assess I and O ratio, observe for decrease in urinary output. > Administer on empty stomach, only to facilitate absorption Family / Client Teaching: > Instruct SO or family members to increase fluids to 3-4 L/day. > Encourage patient or SO to report any pain, redness hand area.

2. Generic Name: Omeprazole Brand Name: Prilosec Classifications: Proton Pump Inhibitor

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Action: Thought to be a gastric pump inhibitor in that it blocks the final step of acid production by inhibiting the hydrogen, potassium, ATP system at the secretory surface of the gastric parietal cell. Uses: Used to treat ulcers, gastroesophageal reflux disease or heartburn Contraindications: pain with swallowing; had heartburn for 3 months; frequent chest pain Side Effects: CNS: headache, dizziness, insomia, apathy GI: diarrhea, constipation, anorexia CV: chest pain, bradycardia, palpitation Respi: URI, cough, bronchospasm Derm: rash, severe generalized skin reaction including toxic epidermal necrolysis GU: UTI, urinary frequency, hematuria, glycosuria Hema: thrombocytopenia, anemia Musculo: Back Pain, Muscle Cramps and Weakness Misc: fever, pain, gout, fatigue, malaise, weight gain Route and Dosage: 40 mg ANST ( - ) Nursing Implications: Assessment: > Perform skin test > Check for vital signs > Monitor for any episodes of chest pain Family / Client Teaching: > The capsule should be taken 30 minutes before eating and is to be swallowed whole; it should not be opened, chewed or crushed. > Review drug associated side effects; report if diarrhea persists. Report any changes in urinary elimination or pain and discomfort.

3. Generic Name: Vigocid (Piperacillin Sodium + Tazobactam Sodium) Action: Bactericidal in action by inhibiting septum formulation and cell wall synthesis of susceptible bacteria 93

Use: used as antibiotic Contraindications: Patients with a history of allergic reactions to any of the penicillins, cephalosporins, beta-lactamase inhibitors Side Effects: nausea nad vomiting, diarrhea, constipation, rash, red skin, allergic reaction (hives), difficulty in sleeping, headache, diaphoresis, eczema Route and Dosage: 4.5 g / IV every 8 hours ANST ( - ) Nursing Implications: Assessment: > Document indications for therapy, symptom onset and weight history > Assess for other medical conditions that require careful monitoring Family / Client Teaching: > Take drug within ordered intervals to prevent further aggravation > Do not engage in activities that require mental alertness.

4. Generic Name: Meloxicam Brand Name: Mobic Classifications: NSAID Action: Reduces the production of prostaglandin that initiate the cause of inflammation Uses: used to treat inflammation and pain of arthritis Contraindications: with asthma attacks, hives or allergic reactions Side Effects: GI: abdominal pain, diarrhea, dyspepsia, constipation, flatulence CNS: dizziness, headache, Route and Dosage: 15 mg / tab; 1 tab OD Nursing Implications: Assessment: > Perform skin test > Document indications for therapy, onset and characteristics of disease, ROM. > Determine any GI bleed or ulcer history, aspirin or other NSAID-induced asthma, urticaria or allergic type reactions. 94

Family / Client Teaching: > Take exactly as directed and at the same time each day. May take with or without food. > Avoid activities that require mental alertness until drug effects realized; may cause dizziness or

drowsiness. > Report any unusual or persistent side effects including dyspepsia, abdominal pain, dizziness and changes in stool or skin color.

5. Generic Name:Metformin HCl Brand Name: Glocophage Classifications: Antidiabetic Action: Decreases hepatic glucose production, decreases intestinal absorption of glucose and increases peripheral uptake and utilization of glucose. Uses: Alone as an adjunct to diet to lower blood glucose in client having NIDDM whose blood glucose cannot be managed satisfactorily via diet alone. Contraindications: acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Abnormal hepatic function. Side Effects: GI: Diarrhea, abdominal bloating, flatulence, anorexia, unpleasant or metallic state, abnormal stools, taste disorders CNS: lightheadedness, headache Misc: hypoglycemia, myalgia, chest discomfort, palpitation Route and Dosage: 500 mg / tab (tab BID during meals) Nursing Implications: Assessment: > Individualize dosage based on tolerance and effectiveness > Give with meals starting at a low dose with gradual escalation. This will reduce GI side effects and allow determination of the minimal dose necessary for adequate control of blood glucose. > Document age at diabetes onset, previous therapies utilized and outcome. Family / Client Teaching: > Take with food to decrease GI upset 95

> Warn users that the inactive components in the extended-release tablets may pass into the feces and appear as a soft, hydrated mass.

6. Generic Name: Humulin - N Brand Name: Isophane Insulin Human Action: intermediate-acting insulin with slower onset of action that keep blood glucose at a nearly normal level Uses: indicated for treatment of patient with diabetes mellitus who require insulin for the maintenance of glucose homeostasis Contraindications: contraindicated during episodes of hypoglycemia; also patient with hypersensitivity to human insulin Route and Dosage: OD every 9 pm Nursing Implications: Assessment: > Monitor VS particularly BP > Be alert for signs of hypoglycemia, loss of glucose control, kidney, eye or foot problems Family / Client Teaching: > Do not take if without medical advise.

7. Generic Name: Paracetamol Brand Name: Acephen, Campain Classifications: Antipyretic Action: Reduces fever by direct action on the hypothalamus, heat-regulating center with consequent vasodilatation and sweating. Uses: Fever reduction; temporary relief of mild to moderate pain. Generally, as substitute for aspirin when it is not tolerated. Contraindications: Renal insufficiency, anemia, cardiac or pulmonary disease Side Effects: rash, anorexia, nausea and vomiting, diaphoresis, abdominal pain Route and Dosage: 500 mg, 1 tab PRN for fever Nursing Implications:

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Assessment: > Do not exceed a dose of 4 g/ 24hr in adults and 75 mg/kg/day in children. > Do not take more than 5 days for pain in children, 10 days for pain in adults, or more 3 days for fever in adults or children without consulting Health care provider. Family / Client Teaching:> Warn not to combine products containing acetaminophen. > Take only as directed and with food or milk to decrease GI upset

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