Case Study - DM II New

HOLY ANGEL UNIVERSITY COLLEGE OF NURSING ANGELES CITY A Case Study Presented to the College of Nursing In Partial Fulfillment
of the Requirements for the subject NCM 104 Related Learning Experience:
DIABETES MELLITUS TYPE II

Ms. Jenny Rose Leynes, RN MAN Clinical Instructor Submitted by: GROUP 4-A N-303 Catap, Marjorie G. Guarin, Merry Christine B. Liwanag, Angelica Erika S. Luntao, Aina Marie Pangan, Astley
January 31, 2011
TABLE OF CONTENTS
I.
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-4 NURSING HISTORY a. Personal History a. Demographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Socio-economic and Cultural Factors. . . . . . . . . . . . . . . . . . . . b. Family-Health Illness History . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. History of Past Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. History of Present Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. Genogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PHYSICAL ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
II.
5 5-6 6 6-7 7 8 9-12
III. IV.
DIAGNOSTIC AND LABORATORY PROCEDURES. . . . . . . . . 13-26 THE PATIENT AND HIS ILLNESS a. Anatomy and Physiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-31 b. Pathophysiology i. Book-Based. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-36 ii. Patient-Based . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-40 THE PATIENT AND HIS CARE a. Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i. Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii. Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii. Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
V.
VI.
41-42 43-52 53-54 55 56-58
VII.
NURSING CARE PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59-68 ACTUAL SOAPIE(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69-70 DISCHARGE PLANNING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71-72 LEARNING DERIVED FROM THE STUDY. . . . . . . . . . . . . . . . 73-74 REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
VIII. IX. X.
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INTRODUCTION Diabetes is a lifelong disease involving glucose (sugar) in the blood. It is caused by a problem in the way the body makes or uses insulin. Insulin, a hormone is necessary for glucose to move from the blood to the inside of the cells. Unless glucose gets into the cells, the body cannot use it for energy. Diabetes occurs when the body has too much blood glucose due to either the pancreas does not produce enough insulin or the body cannot effectively use the insulin produced. In type 2 diabetes (formerly called non-insulin-dependent diabetes or adult-onset diabetes), the pancreas continues to produce insulin, sometimes even at higher-thannormal levels. However, the body develops resistance to the effects of insulin, so there is not enough insulin to meet the body's needs. Diabetes Mellitus is a chronic health disorder; it means that the condition lasts for many years. Diabetes can cause serious health problems. It is an endocrine disorder causing various metabolic changes in the body leading to severe complications such as damage to the eyes, kidneys, nerves, heart and blood vessels. The causes of diabetes mellitus are unclear. Both heredity and environment may be involved. Studies have shown that certain genetic factors may be responsible for diabetes. Genes are chemical units found in all cells, which tell cells what functions they should perform. Genes are passed down from parents to children. If parents carry a gene for diabetes, they may pass that gene onto their children. It not treated properly, type 2 diabetes can cause kidney damage, poor circulation, and numbness in the feet. The main consequence of this condition, however, is heart disease, which claims the lives of approximately 80% of all diabetic patients (Sy, 2007). At least 171 million people worldwide have diabetes. This figure is likely to be more than double by 2030. A diabetes epidemic is underway. An estimated 30 million people worldwide had diabetes in 1985. A decade later, the global burden of diabetes was estimated to be 135 million. The latest WHO estimate for the number of people with diabetes, worldwide, in 2000 is 171 million. This is likely to increase to at least 366 million by 2030 (WHO, 2003). Diabetes Mellitus based on statistics here in the Philippines is one of the top ten leading causes of mortality and it is ranked 9th. The number of mortality of the said disease per 100,000 population is 16,552 on both sexes, 7,970 are males and 8,582 are females [The 2004 Philippine statistics updated last February 11, 2008]. According to the website Science Daily (November 29, 2010) Medical scientists at the University of Leicester have identified for the first time a new way in which our body controls the levels of sugar in our blood following a meal. They have discovered the part played by a particular protein in helping to maintain correct blood sugar levels. The breakthrough was made in the University of Leicester by a team led by Professor Andrew Tobin, Professor of Cell Biology, who is a Wellcome Trust Senior Page | 4
Research Fellow. The research is published online ahead of print in the international scientific journal the Proceedings of the National Academy of Sciences. Professor Tobin said: "The work, which was done wholly at the University of Leicester, is focused on the mechanisms by which our bodies control the level of sugar in our blood following a meal. "We found that in order to maintain the correct levels of sugar, a protein present on the cells that release insulin in the pancreas has to be active. This protein, called the M3-muscarinic receptor, is not only active but also needs to undergo a specific change. This change triggers insulin release and the control of blood sugar levels." Professor Tobin added: "Without the change in the M3-muscarinic receptor protein sugar levels go up in the same way that we see in diabetes. We are of course testing if the mechanism of controlling sugar levels we have discovered is one of the mechanisms disrupted in diabetes. If this were the case then our studies would have important implications in diabetes." Basically, there are a significant number of Diabetes Mellitus Type II cases in the country, and this is the reason why thorough study of this case is needed. This case study has enabled the nurse to be more familiarized with the different aspects of such condition. Thus, confirming the belief that when the nurse become more knowledgeable, the more effective he/he becomes in the provision of nursing care. The nurse-researcher also thinks that the knowledge he has acquired regarding this type of disease would benefit him especially in his practice of the nursing profession. At the same time, having large variety of information about the said topic will enable us, health care provider, to provide explanations and health teachings about the clients condition.
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Objectives (Nurse Centered) After 2 days of nurse-patient interaction and data gathering, student nurses will be able to: Cognitive Identify the underlying cause(s) or risk factors that contributed to the condition of the patient; Enumerate the signs and symptoms of the disease and the pathologic changes occurring during the course of the disease; Develop critical thinking abilities so as to determine appropriate interventions and medical management of the disease condition and care indicate. Discuss thoroughly the nature of Sugar cancer and the disease process Affective Recognize the importance of developing a practice of performing accurate and complete assessment findings Display the proper knowledge and skills in providing effective nursing care to the patient Psychomotor Perform a cephalocaudal assessment on the patient Monitor and evaluate patients recovery during hospitalization Provide health teachings to the patient especially factors that will contribute to the continuity of care.
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II. NURSING HISTORY 1. Personal History a. Demographic Data Mr. Sugar is a 56 year old male who currently resides at a certain barrio in Bacolor, Angeles City. He was born on the 11th day of August 1954. He is married for 19 years to Mrs. Insulin, and they were blessed with only 1 child. b. Socio-economic and Cultural Factors b.1 Occupational mode of expenditure According to Mr. Sugar, he started working as a taxi driver since he was 20 years old. Likewise, he worked as a construction worker but considered it only as a part-time job. Their monthly family income is 6, 000 pesos. A breakdown of their monthly expenses was enumerated by Mrs. Insulin: P 300.00 is allotted for their electricity; P4, 000 for their foods and other basic needs; P 1, 200 goes to the allowance of their child; P 120.00 and if ever there is money left, it goes to their savings. b.2 Educational Attainment Mr. Sugar shared that his highest educational attainment was high school. He belongs to a big family (according to him) 7 members, parents and 5 siblings. According to him, he was not able to continue into college because of poverty. b.3 Religious Affiliation Mr. Sugar is a Roman Catholic. He attends masses every Sundays and special occasions like birthdays, Christmas, etc. b.4 Cultural factors affecting the health of the family Unlike other Filipino residing in barrios, Mr. Sugar shared that their family does not believe and adhere to superstitious beliefs, but they adhere to using herbal plants as alternatives. According to him, only physicians have the ability to cure and diagnose people. Whenever a member of their family gets ill, either they consult a physician or resort to self-medication. Mefenamic Acid, Biogesic are the most often used medications for pain, while Tuseran, Lagundi, and Oregano are the ones taken for cough. He usually sleeps at 11:00 pm and usually wakes up at around 7:00 am to work as a taxi driver. He also added that he does not perform routine exercises since after his work, he prefers to stay home watching television. Mr. Sugar mentioned that he did not have any vices since he was young. He neither smoked, nor drink alcoholic beverages. He was just fond of drinking softdrinks, specifically Coke. He even added that his day will not be complete without drinking almost 3-4 bottles of softdrinks per day. He was aware that he should minimize if not totally avoid drinking softdrinks since this greatly increases his sugar level, but according to him, he cant comply with his physicians advice because he considers this as his favourite drink. With food preferences, he is also fond of eating sweets, salty, and most Page | 7
especially fatty foods like chicharon, and taba ng baboy. He does not like eating high fiber foods like vegetables. Their usual foods are pork, chicken, sardines, and tuyo. According to him, he wanted to limit his high-fat intake since their family has a history of hypertension and Diabetes. 2. Family-Health Illness History a. Hereditary disease in the family According to Mr. Sugar, the significant diseases that run in their family are Hypertension, Diabetes Mellitus Type II, and kidney problems like having kidney stones. His father died of heart attack a complication of Diabetes at the age of 68. His mother died of unknown cause when she was 52 years old. Also, three of them inherited their fathers condition of having kidney stones and Diabetes Type II. 3. History of Past Illness Included in the past illnesses of Mr. Sugar are the usual childhood illnesses like mumps, chickenpox, common colds and diarrheal problems. According to him, he considers himself as having weak immune system since he easily gets sick and infected. Formerly, at the age of 46 years old (October, 2000), he was diagnosed of having kidney stones and was advised by his physician to undergo surgery (Nephrolithiasis) on that same year. In the year 2005, he shared that he started feeling some known signs and symptoms of Diabetes Type II like blurring of vision, frequent urination (polyuria), frequent feeling of thirst (polydipsia), and the like but he refused to seek medical advice because according to him, his physician would surely prescribe medications which their budget cannot afford. It took him 3 years before he went to his physician where he was diagnosed and confirmed of having Diabetes Mellitus Type II. Since then, he had no choice but to take his maintenance drugs: Metfromin and Clindamycin twice a day to maintain his blood glucose and improve the effectiveness of insulin in his body. According to him, he has been controlling his serum glucose levels to the standard range although he does not have his own CBG kit. He also shared that he often boils the leaves of ampalaya since for him, this was known to be a herbal medicine for diabetic patients. In line with this, Mr. Sugar shared that he experienced drastic weight loss since the year 2006. His weight before was 200 lbs (2006), then in 2008, it decreased to 180, and now he is currently weighing 140 lbs. Obviously, he had lost 40 lbs. for only a period of 2 years. According to him, this seems to be impossible because ever since he was diagnosed with Diabetes, he has an intense increase in appetite. He even verbalized balamu eku kakabsi. (polyphagia)
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Mr. Sugar does not have allergies or even sensitivities with the food he eats. Aside from this, he did not have any serious injuries such as burns and severe bleeding. 4. History of Present Illness Mr. Sugar was admitted at a certain hospital in the City of San Fernando last January 13, 2011, was managed as a case of Diabetes Mellitus Type II and was discharges last January 24, 2011. Mr. Sugar shared that he had a wound on his middle finger on the left dorsal foot. According to him, this was due to a burn which he got from accidentally staying close to a motors machine. When asked by the student nurses when the incident happened, Mrs. Insulin only answered last December 2010 since she cannot remember the exact date. Also since then, the wound started manifesting signs of swelling though Mr. Insulin does not report of experiencing any pain.. No medications were taken and no consultation to a physician was done. Two weeks prior to admission, Mr. Sugar complained of feeling of numbness in his lower extremities. And because of this, he was not able to recognize that he already had a wound on his right dorsal foot. When asked by the student nurses, he really did not have any idea with the cause of his wound. Last January 2, 2011, the wound started manifesting signs of swelling. For one week, Mr. Sugar still managed to work because according to him, he does not feel any pain at all. It is also in this time when his wound (burn) on the middle finger of his left foot started to have foul smell. In cleaning the wound, they made use only of Betadine. Up to this time, no medications were taken and no consultation to a physician was done. A week prior to admission, Mr. Sugar complained of fever and reported that his wound grew worse. He also reported signs of weakness and irritability. Mrs. Insulin added that her husband loss his appetite and has not been eating well for 2 weeks. Still, no medications were taken and no consultation to a physician was done. One day prior to admission, the wound burst filled with blood and pus. This time, they decided to go to the hospital where he was advised to have his right foot amputated since it was already considered gangrenous. Also, the physician advised to perform debridement in his left foot. The physicians clinical impression was: Metgangrene, plantar and dorsal aspect foot (Right) with areas of necrosis DM II.
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5. Genogram
Fath er Mothe r Father Mothe r
60 y/o
58 y/o
Mr. Sugar56 y/o
53 y/o
49y/o
Mrs. Sugar55 y/o
53y/ o
50y/ o
19 y/o
Legend: MALE DIABETES TYPE II FEMALE PROBLEM DECEASED HYPERTENSION KIDNEY
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III. PHYSICAL ASSESSMENT Head- EENT (Eyes, Ears, Nose, Throat) pale palpebral conjunctiva Chest: lungs: (-) crackles auscultated on both lung fields Cardiovascular: NRRR (-) murmur Clinical Impression: Metgangrene, plantar and dorsal aspect foot (Right) with areas of necrosis DM II Nurse-Patient Interaction (January 17, 2011) General Appearance: Mr. Sugar was wearing white shirt. When the group arrived, he was seen lying on bed, conscious and coherent with an ongoing IVF of # 1 PNSS 1L x 30-31 gtts/min at 600cc level infusing well on left hand. During the nurse-patient interaction last January 17, 2011, the group obtained the following vital signs: 8:00 am BP: 120/80 mmHg RR: 26 bpm 10:00 am BP: 120/80 mmHg RR: 24 bpm PR: 70 bpm Temp: 36 0C PR: 70 bpm Temp: 36 0C
Nurse-Patient Interaction (January 18, 2011) General Appearance: Mr. Sugar was wearing white shirt. When the group arrived, he was seen lying on bed, sleeping with an ongoing IVF of # 2 PNSS 1L x 30-31 gtts/min at 700cc level infusing well on left hand. During the nurse-patient interaction last January 18 2011, the group obtained the following vital signs: 8:00 am BP: 120/80 mmHg RR: 22 bpm 10:00 am BP: 130/80 mmHg RR: 22 bpm PR: 73 bpm Temp: 36 0C PR: 72 bpm Temp: 36 0C
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Physical Examination: Skin Inspection: Pale skin Poor skin turgor Dryness noted Palpation: cold, clammy skin prolonged capillary refill time of 3 seconds
Head and neck Inspection: symmetrical facial movements has coordinated head movements with no difficulty upon flexion, extension and rotation. Palpation: no masses lymphadenopathies not noted on cervical area Eyes Inspection: hair of the eyebrows are evenly distributed symmetrically aligned eyebrows eyelids close symmetrically pale palpebral conjunctiva noted blurred vision pupils equally round and reactive to light accommodation Ears Inspection: color same as facial skin auricle aligned with outer canthus of eye Palpation: no masses and tenderness noted Nose and Sinuses Inspection: symmetric and straight uniform color nasal septum intact and in midline Both nares are patent Mouth and Teeth Inspection: dry pale lips Page | 12
pale gums dry mucous membranes acetone breath (fruity odor) With dentures Tongue is on central position, moves freely
Thorax Inspection: expands bilaterally without retractions uses accessory muscles when breathing Auscultation: no adventitious breath sounds noted Cardiovascular Palpation: normal rate, regular pulse rhythm capillary refill test: more than 3 seconds narrow pulse on extremities Auscultation: no murmurs Abdomen Inspection: Presence of diagonal scar on lower right abdominal region approximately 5 inches long due to nephrolithiasis last October 2000 Auscultation: (+) borborygmy Palpation: direct pain noted at RUQ with a pain scale of 7/10 (-) palpable mass no pain and tenderness noted Urinary Inspection:

Amber-colored urine Consumes 3 wet and soaked diapers in an hour
Musculoskeletal Inspection: limited range of motion both lower extremities noted generalized weakness noted slowed movement difficulty turning from side to side to sitting position
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Patient manifested numbness and tingling sensation on lower extremities Amputated right leg (stump limb) Debridement performed on the middle finger of left dorsal foot Neurologic Neurological Vital Signs (NVS) = 14 Eye Opening: 4 Verbal Response: 5 Motor Response: 5 a. Mental Status Consciousness Lethargic Responds slowly Restless/agitated Posture relaxed in a supine position Grooming/hygiene clean and short fingernails and toenails Facial expressions grimace and guarding behavior noted Speech/Mood responds slowly to questions
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IV. DIAGNOSTIC AND LABORATORY PROCEDURES
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Diagnostic/ Laboratory Procedure Complete Blood Count Hematocrit
Indication/Purpose
Date Ordered/ Date Results were released DO: January 13, 2011
Results
Normal Values(units used in the hospital)
Analysis and Interpretation of Results
DR: This test measures the amount of space January 13, 2011 (volume) red blood cells take up in the blood. The value is given as a percentage of red blood cells in a volume of blood. It closely reflects the Hgb and RBC values. Used to measure RBC number and volume to screen for anemia or polycythemia or is measured on a person to determine the extent of the said conditions. The white blood cells also called as leukocytes, are the blood cells responsible for both immunity and the bodys response to infectious organisms. This measures the number of WBC in the blood during the process of infection in the body The hemoglobin concentration is a measure of the total amount of Hgb in the peripheral blood which reflects the number of RBC in the blood. Hgb serves as a vehicle for oxygen and carbon dioxide transport. It is used to detect any presence of anemia. It measures the amount of oxygen-carrying protein in the blood. Neutrophils are the most common type of WBC and this test may determine any bodys response to acute body stress, whether from infection, infarction, trauma, emotional distress, or other noxious stimuli. This is done to check viral infection.
32%
40-52%
Mr. Sugars result is below the normal range which implies that Mr. Sugar has no enough RBC volume in his blood.
White Blood Cell
37.1 x 109/L
4.8-10.8 x 109/L
The result is above the normal range which may indicate that Mr. Sugar has an infection.
Hemoglobin
108 g/L
125-175 g/L The result is within the normal range which reflects that Mr. Sugar is not suffering from anemia.
Neutrophils
80 %
45-65 %
The result is above the normal range, which means that Mr. Sugars body responds to a Page certain infection. | 16 The result is within the
Lymphocytes
15 %
20-35 %
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Diagnostic/ Laboratory Procedure Complete Blood Count Platelet
Indication/Purpose
Date Ordered/ Date Results were released DO: January 14, 2011 DR: January 14, 2011
Results
Normal Values(units used in the hospital)
This test will determine the coagulating ability of the patient. And also to detect possible bleeding.
472 x 109/L
150-400 x 109/L
The result is highly deviated from the normal values. This is then suggestive that Mr. Sugar is having bleeding. The result is below the normal range which implies that Mr. Sugars RBC sizes are deviated from normal.
MCV (Mean Corpuscular Volume)
This test is a measure of the average size of red blood cells (RBC), also called erythrocytes. Knowing your MCV is important to assure that you are in good health. It is also a good way to discover if you have an illness that may still be asymptomatic. This test is conducted to know the average weight of hemoglobin that is present inside a red blood cell.
79.4 femtolitres
82-98 femtolitres
MCH (Mean Corpuscular Hemoglobin)
27.2 picograms
28-33 picograms
The result is slightly decreased from the normal range which may imply that the RBCs of Mr. Sugar are not carrying sufficient hemoglobin. The result is below the normal range. This can then support the values gathered from the above tests performed. They all indicate that Mr. Sugar may be suffering Page from bleeding. | 18 This indicates that Mr. Sugar may be suffering
MCHC (Mean Corpuscular Hemoglobin Concentration)
MCHC and MCV, or mean corpuscular volume, levels are both used to test a person for anemia. MCHC tests for the levels of hemoglobin in the blood. This identifier in a blood test can help a doctor diagnose a patient with anemia.
31.3 %
32-38 %
Reticulocyte Count This test is used to evaluate erythropoietic activity; Increased in acute and chronic
0.8 %
1-5 %
Nursing Responsibilities for Complete Blood Count: Before the procedure: Check the Doctor's Order. Identify the patient. Check the Vital signs. Reduce the patient's anxiety by explaining the procedure and why it has to be performed. Acknowledge questions regarding the safety of the procedure. During the procedure: Stay with the patient. Assist with the collection of the specimen if allowed. Observe sterile technique. After the procedure: Check the site for bleeding, cyanosis or swelling. Apply pressure and warm compress for five to ten minutes. Check vital signs for any changes. In case of hematoma formation, instruct the patient to apply warm compress. Document the data (attach result on the chart)
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Diagnostic/ Laboratory Procedure Blood Chemistry
Indication/Purpose
Normal Date Ordered/ Values(units Date Results were Results used in the released hospital) Date Ordered: January 13, 2011 Date Released: January 13, 2011
Random Blood Sugar
Random blood sugar testing checks glucose levels randomly throughout the day, regardless of meal times. Reasons for testing glucose levels are to check for diabetes, to monitor treatment of diabetes, and to check for hypoglycemia. The creatinine test is used to diagnose impaired kidney function and to determine renal (kidney) damage.
30.89 mmol/L
3.85-9.0 mmol/L
The result is highly increased from the normal range. This clearly indicates that Mr. Sugar has diabetes. The result is highly deviated from the normal. An elevated serum creatinine levels generally indicate that Mr. Sugar has an impaired kidney function. The result is above the normal range. This then supports the result of the Creatinine level which is also increased. Both indicates that Mr. Sugar has an impaired kidney function which is known to be one of the complications of his diabetes. The result implies that Mr. Sugars low total Page | 21 body water and sodium levels may be due to dehydration since he reports of urinating
Creatinine
165.2 mmol/L
60-120 umol/L
Blood Urea Nitrogen
It measures the amount of urea nitrogen (urea is a chemical waste product cleared by the kidney) in the blood. It is done to help diagnose a number of other conditions, such as liver failure, urinary tract obstruction, congestive heart failure or gastrointestinal bleeding.
16.6 mmol/L
1.7-8.3 mmol/L
Electrolytes: Sodium
The sodium levels are measured to detect whether there is the right balance of sodium and liquid in the blood to carry out functions like regulating the amount of water in the body and transmitting electrical signals in the brain and in the
111.3 mEq/L
136-145 mEq/L
Diagnostic/ Laboratory Procedure Blood Chemistry
Indication/Purpose
Normal Date Ordered/ Values(units Date Results were Results used in the released hospital) Date Ordered: January 13, 2011 Date Released: January 13, 2011
Random Blood Sugar
Random blood sugar testing checks glucose levels randomly throughout the day, regardless of meal times. Reasons for testing glucose levels are to check for diabetes, to monitor treatment of diabetes, and to check for hypoglycemia. The sodium levels are measured to detect whether there is the right balance of sodium and liquid in the blood to carry out functions like regulating the amount of water in the body and transmitting electrical signals in the brain and in the muscles. This test is made to diagnose or monitor kidney disease. It is also measured to check people with high blood pressure.
21.97 mmol/L
3.85-9.0 mmol/L
The result is highly increased from the normal range. This clearly indicates that Mr. Sugar has diabetes. The result implies that Mr. Sugars low total body water and sodium levels may be due to dehydration.
Electrolytes: Sodium
113.0 mEq/L
136-145 mEq/L
Potassium
5.03 mEq/L
3.5-5.0 mEq/L
The result indicates that Mr. Sugar experiences kidney impairment or is suffering from loss of potassium. Page | 22
Diagnostic/ Laboratory Procedure
Indication/Purpose
Normal Date Ordered/ Values(units Date Results were Results used in the released hospital) Date Ordered: January Ordered/ Date 14, 2011 Results
Blood Chemistry Nursing Responsibilities: Diagnostic/ Indication/Purpose Laboratory Random Blood Random blood sugar testing checks Procedure Sugar glucose levels randomly throughout the day, regardless of meal times. Reasons for Blood Chemistry testing glucose levels are to check for diabetes, to monitor treatment of diabetes, and to check for hypoglycemia. Electrolytes: Sodium The sodium levels are measured to detect whether there is the right balance of Random Blood Random blood sugar testing checks sodium and liquid in the blood to carry out Sugar glucose levels randomly throughout the functions like regulating the amount of for day, regardless of meal times. Reasons water in the body and are to check for testing glucose levels transmitting electrical to monitorthe brain and diabetes, diabetes, signals in treatment of in the muscles. and to check for hypoglycemia. Electrolytes: Albumin An albumin levels arebe ordered as detect Sodium The sodium test may measured to part of a liver panel to evaluate liver function, whether there is the right balance of along with aliquid in the blood to (Blood sodium and creatinine and BUN carry out Urea Nitrogen) and to evaluate a person's functions like regulating the amount of nutritional status. and transmitting water in the body electrical signals in the brain and in the muscles. Potassium This test is made to diagnose or monitor kidney disease. It is also measured to check people with high blood pressure.
Normal Analysis Date Results were Values(units and Date Released: 14.18 3.85-9.0 released used in the The result is highly Interpretation January 14, 2011 mmol/L mmol/L increased from the hospital) of Results normal range. This clearly indicates that Mr. Date Ordered: Sugar has diabetes. January 15, 2011 Date Released: January 15, 2011 116.5 mEq/L 18.75 mmol/L 136-145 mEq/L 3.85-9.0 mmol/L The result implies that Mr. Sugars low total The result is highly body water and the increased from sodium levels may be due to normal range. This dehydration. clearly indicates that Mr. Sugar has diabetes. The resultsimplies that result depict that Mr. Sugar has a total Sugars low decreased nutritional body water and sodium status. may be due to levels dehydration.
33.0 117.6 g/L mEq/L
34-50 136-145 g/L mEq/L
5.53 mEq/L
3.5-5.0 mEq/L
The result indicates that Page | 23 Mr. Sugar experiences kidney impairment or is suffering from loss of potassium.
Before the procedure: Check the doctors order Explain procedure to the patient Review clients record for medication that may prolong bleeding such as anti-coagulants Assess the clients skin at the puncture site to determine if it is intact and the circulation is not compressed. If the patient will undergo blood chemistry that will need fasting, NPO for at least 8-10 hours is required. During the procedure: Direct the patient to breathe normally and to avoid unnecessary movement. Label the specimen, and promptly transport it to the laboratory. After the procedure: Observe venipuncture site for bleeding or hematoma formation. Apply pressure bandage. Evaluate test results in relation to the patients symptoms and other tests performed.
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Diagnostic/ Laboratory Procedure Urinalysis
Indication/Purpose
Date Ordered/ Date Results were released Date Ordered: January 13, 2011 Date Released: January 13, 2011
Results Color: Amber Transparency: Turbid
Normal Values(units used in the hospital) Color: Light Yellow to Dark amber Transparency: Transparent
Urinalysis can reveal diseases that have gone unnoticed because they do not produce striking signs or symptoms. Nursing Responsibilities for Urinalysis: mellitus, Examples include diabetes various forms of glomerulonephritis, and chronic urinary tract infections.
Turbid or cloudy urine may be due to excessive cellular debris or proteins. Positive sugar and albumin is due to the DM of Mr. Sugar which is concerned for the excretion of glucose in the urine (glucosuria). The acidity of Mr. Sugar will prevent his from acquiring infections. This result indicates that Mr. Sugar has a good-functioning kidney and is able to concentrate the urine. The presence of pus cells is indicative of an infection.
Glucose and Albumin: 3+
Glucose and Albumin: 3+
pH: Acidic
pH: Acidic
Specific Specific Gravity: Gravity: 1.020 1.006-1.025
Pus Cells: Pus Cells: Negative 0-1/HPF (high power field) Epithelial Cells: few
Epithelial Cells: few Some epithelial cells from the skin surface or from the outer urethra can appear in the urine.Page | 25 Some forms of crystals appear in the urine of healthy individuals.
Before the procedure: Check the doctors order Explain procedure to the patient Tell the SO of the patient and/or that no fasting is required. During the procedure: Instruct patient to get the midstream of his urine. After the procedure: Label the specimen, and promptly transport it to the laboratory. Urine should be delivered to the laboratory within 30 minutes for the accuracy of results.
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V. THE PATIENT AND HIS ILLNESS 1. Anatomy and Physiology
THE PANCREAS
The function of the pancreas is to make digestive enzymes which digest food materials in the small intestines. In addition, the pancreas also makes insulin which controls the blood glucose levels. As chyme floods into the small intestine from the stomach, two things must happen: acid must be quickly and efficiently neutralized to prevent damage to the duodenal mucosa macromolecular nutrients - proteins, fats and starch - must be broken down muinterestinglych furthis before their constituents can be absorbed through the mucosa into blood The pancreas plays a vital role in accomplishing both of these objectives, so vital in fact that insufficient exocrine secretion by the pancreas leads to starvation, even if the animal is consuming adequate quantities of high quality food. In addition to its role as an exocrine organ, the pancreas is also an endocrine organ and the major hormones it secretes - insulin and glucagon - play a vital role in carbohydrate and lipid metabolism. They are, for example, absolutely necessary for maintaining normal blood concentrations of glucose.
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Every cell in the human body needs energy in order to function. The bodys 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 rathis entering the cells. Exocrine Function of the Pancreas The bulk of the pancreas is composed of pancreatic exocrine cells and their associated ducts. Embedded within this exocrine tissue are roughly one million small clusters of cells called the Islets of Langerhans, which are the endocrine cells of the pancreas and secrete insulin, glucagon and several other hormones. Pancreatic exocrine cells are arranged in grape-like clusters called acini. The exocrine cells are packed with membrane-bound secretory granules which contain digestive enzymes that are exocytosed into the lumen of the acinus. From there, these secretions flow into larger intralobular ducts, which eventually combine into the main pancreatic duct which drains directly into the duodenum. Endocrine Function of the Pancreas The endocrine pancreas refers to those cells within the pancreas that synthesize and secrete hormones. The endocrine part of the pancreas takes the form of many small clusters of cells called Islets of Langerhans. Pancreatic islets house three major cell types, each of which produces a different endocrine product: Alpha Cells (A cells) secrete the hormone glucagon Beta Cells (B cells) produce insulin which are the most abundant of the islet cells Delta Cells (D cells) secrete the hormone somatostatin, which is also produced by a number of other endocrine cells in the body
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The different cell types within an islet are not randomly distributed beta cells occupy the central portion of the islet and are surrounded by a rind of alpha and delta cells. Islets are highly vascularized, allowing their secreted hormones ready access to the circulation. Although islets comprise only 1 to 2% of the mass of the pancreas, they receive about 10 to 15% of the pancreatic blood flow. Additionally, they are innervated by parasympathetic and sympathetic neurons, and nervous signals clearly modulate secretion of insulin and glucagon. Control of Insulin Secretion Insulin is secreted in primarily in response to elevated blood concentrations of glucose. This makes sense because insulin is "in charge" of facilitating glucose entry into cells. Some neural stimuli (e.g. sight and taste of food) and increased blood concentrations of other fuel molecules, including amino acids and fatty acids, also promote insulin secretion. Our understanding of the mechanisms behind insulin secretion remain somewhat fragmentary. Nonetheless, certain features of this process have been clearly and repeatedly demonstrated, yielding the following model: Glucose is transported into the beta cell by facilitated diffusion through a glucose transporter; elevated concentrations of glucose in extracellular fluid lead to elevated concentrations of glucose within the beta cell. Elevated concentrations of glucose within the beta cell ultimately leads to membrane depolarization and an influx of extracellular calcium. The resulting increase in intracellular calcium is thought to be one of the primary triggers for exocytosis of insulin-containing secretory granules. The mechanisms by which elevated glucose levels within the beta cell cause depolarization is not clearly established, but seems to result from metabolism of glucose and other fuel molecules within the cell, perhaps sensed as an alteration of ATP:ADP ratio and transduced into alterations in membrane conductance. Increased levels of glucose within beta cells also appears to activate calciumindependent pathways that participate in insulin secretion. Insulin and Carbohydrate Metabolism Glucose enters the blood stream after the small intestine hydrolyzes carbohydrates such as starch and sucrose to form glucose. High concentrations of glucose in the blood stimulate insulin secretion. This insulin then acts on various cells throughout the body to stimulate uptake, utilization and storage of glucose. Two important effects are:
1. Insulin facilitates entry of glucose into muscle, adipose and several other
tissues. The only mechanism by which cells can take up glucose is by facilitated diffusion through a family of hexose transporters. In many tissues, such as muscle, the major transporter used for uptake of glucose (called GLUT4) is made available in the plasma membrane through the action of insulin.
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In the absence of insulin, GLUT4 glucose transporters are present in cytoplasmic vesicles, where they are useless for transporting glucose. Binding of insulin to receptors on such cells leads rapidly to fusion of those vesicles with the plasma membrane and insertion of the glucose transporters, thereby giving the cell an ability to efficiently take up glucose. When blood levels of insulin decrease and insulin receptors are no longer occupied, the glucose transporters are recycled back into the cytoplasm. Please note that some tissues, such as the brain and liver, do not need insulin for efficient uptake of glucose. This is because they use a glucose transporter that is not insulin dependent. 2. Insulin stimulates the liver to store glucose in the form of glycogen. A large fraction of glucose absorbed from the small intestine is immediately taken up by hepatocytes, which convert it into the storage polymer glycogen. Insulin has several effects in liver which stimulate glycogen synthesis. First, it activates the enzyme hexokinase, which phosphorylates glucose, trapping it within the cell. Coincidently, insulin acts to inhibit the activity of glucose-6-phosphatase. Insulin also activates several of the enzymes that are directly involved in glycogen synthesis, including phosphofructokinase and glycogen synthase. The net effect is clear: when the supply of glucose is abundant, insulin "tells" the liver to store as much of it as possible for use later. A well-known effect of insulin is to decrease the concentration of glucose in blood, which should make sense considering the mechanisms described above. Another important consideration is that, as blood glucose concentrations fall, insulin secretion ceases. In the absence of insulin, a majority of the cells in the body become unable to take up glucose, and begin a switch to using alternative fuels like fatty acids for energy. Neurons, however, require a constant supply of glucose, which in the short term, is provided from glycogen reserves. In the absence of insulin, glycogen synthesis in the liver ceases and enzymes responsible for breakdown of glycogen become active. Glycogen breakdown is stimulated not only by the absence of insulin but by the presence of glucagon, which is secreted when blood glucose levels fall below the normal range.
Insulin and Lipid Metabolism The metabolic pathways for utilization of fats and carbohydrates are deeply and intricately intertwined. Considering insulin's profound effects on carbohydrate metabolism, it stands to reason that insulin also has important effects on lipid metabolism. Important effects of insulin on lipid metabolism include the following:
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Insulin promotes synthesis of fatty acids in the liver. As discussed above, insulin is stimulatory to synthesis of glycogen in the liver. However, as glycogen accumulates to high levels (roughly 5% of liver mass), further synthesis is strongly suppressed. When the liver is saturated with glycogen, any additional glucose taken up by hepatocytes is shunted into pathways leading to synthesis of fatty acids, which are exported from the liver as lipoproteins. The lipoproteins are ripped apart in the circulation, providing free fatty acids for use in other tissues, including adipocytes, which use them to synthesize triglyceride. Insulin inhibits breakdown of fat in adipose tissue by inhibiting the intracellular lipase that hydrolyzes triglycerides to release fatty acids. Insulin also facilitates entry of glucose into adipocytes, and within those cells, glucose can be used to synthesize glycerol. This glycerol, along with the fatty acids delivered from the liver, is used to synthesize triglyceride within the adipocyte. By these mechanisms, insulin is involved in further accumulation of triglyceride in fat cells. From a whole body perspective, insulin has a fat-sparing effect. Not only does it drive most cells to preferentially oxidize carbohydrates instead of fatty acids for energy, insulin indirectly stimulates accumulation of fat in adipose tissue.
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2. Pathophysiology A. Book-Based a. Schematic Diagram (Flow Chart) Non Modifiable

Family History of DM 35 and above (degenerative) Age Physical Inactivity Decreased sensitivity to insulin
Modifiable
Hypertension Metabolic Syndrome (together with obesity) Obesity Increased number of adipose tissue cells (adipocytes) Releases NEFA into the circulation Reduces muscle glucose uptake and promotes hepatic glucose output (consistent w/ insulin resistance) Causes decreased insulin secretion (chronic exposure)
Identical twin 80% chance of developing DM
Parents 40% chance of acquiring the disease
Children/Adolescents /Young adults Puberty Growth hormone
Insulin secretory failure / insulin resistance
Decreased cellular glucose uptake Increase blood osmolarity Cellular dehydration Polydipsia Polyuria
Increased hepatic glucose production Hyperglycemi a Cellular starvation Polyphagia
No glucose would enter the cell Cell demand for glucose source Production of glucose from proteins and fats Wasting of lean body mass weight loss Increased ketones Acidosis
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acetone breath
Chronic elevations in blood glucose Glycoprotein cell wall deposits
Small vessel disease
Atherosclerosis Coronary Artery Disease
Impaired immune function FREQUENT INFECTIONS DELAYED WOUND HEALING
Diabetic Neuropathy SYMMETRICAL LOSS OF PROTECTIVE SENSATION
Diabetic Nephropathy End Stage Renal Failure
Diabetic Retinopathy BLURRING OF VISION / BLINDNESS
NUMBNESS AND TINGLING SENSATION IN THE LOWER EXTREMITITES CHARCOT FOOT
DIABETIC FOOT ULCERATION
Stage IV cancer has Page 33 spread to other organs |in the body such as the lungs/liver surrounds the colon
b. Synthesis of the disease b.1 Definition of the disease Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar (specifically, glucose) in the blood. Glucose in the blood gives you energy to perform daily activities, walk briskly, run for a bus, ride your bike, take an aerobic exercise class, and perform your day-today chores. Diabetes is due to one of two mechanisms:
1. Inadequate production of insulin (which is made by the pancreas

and lowers blood glucose) 2. Inadequate sensitivity of cells to the action of insulin. The pancreas secretes insulin, but the body is partially or completely unable to use the insulin. This is sometimes referred to as insulin resistance. The body tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they do not continue to secrete enough insulin to cope with the higher demands. The signs and symptoms of both types of diabetes include increased urine output and decreased appetite as well as fatigue. Diabetes is diagnosed by blood glucose testing, the glucose tolerance test, and testing of the level of glycosylated hemoglobin (glycohemoglobin or hemoglobin A1C). The mode of treatment depends on the type of the diabetes. The major complications of diabetes include dangerously elevated blood sugar, abnormally low blood sugar due to diabetes medications, and disease of the blood vessels which can damage the eye, kidneys, nerves, and heart. b.2 Predisposing and Precipitating factors Predisposing Factors: a. Age. i. 35 years old and above (degenerative). As people gets older, they tend to exercise less and also gain weight because their metabolism gets slower than normal. i. Children/adolescents/young adults. Individuals falling in this category are expected to undergo the puberty stage. Puberty is associated with an increase secretion of growth hormone, which in turn promotes a transient state of physiologic insulin resistance.
b. Family History of Diabetes.
i. Parents.
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Genetic components has a stronger basis for type 2 DM than type 1
DM. Although no definite and consistent genes have been identified, multifactorial inheritance is the most important factor in the development of type 2 DM. A person with one parent having type 2 DM is at an increased risk of getting diabetes, but if both parents have type 2 DM, the risk in the offspring rises to 40%. i. Identical Twin. There is approximately 80% chance of developing diabetes in the other identical twin if the other twin has the disease. Precipitating Factors: a. Physical Inactivity. Physical activity helps in controlling weight, uses up glucose as energy and makes cells more sensitive to insulin. b. Hypertension. Hypertension, together with obesity, is known to be under Insulin Resistance Syndrome which basics are glucose tolerance and insulin resistance. Hypertension attempts the body to compensate for insulin resistance but later, this compensatory mechanism fails and elevated blood glucose levels result. c. Obesity. In obesity, there are increased number of adipose tissue cells (adipocytes) which are known to release non-esterified fatty acids (NEFA) into the circulation. These NEFAs affect cells causing decreased insulin secretion in chronically exposed patients. Likewise, NEFA reduces muscle glucose uptake promoting hepatic glucose output, known to be consistent with insulin resistance. b.3 Signs and symptoms with rationale Polyphagia (increased hunger). If cells have no glucose intake, there will be cellular starvation which then stimulates the satiety center of the hypothalamus to increase the urge of the person to eat excessive amounts of food. Polydipsia (increased thirst). If cells are not able to absorb the glucose, there will be intracellular and extracellular dehydration. As a compensatory mechanism of the body, the person will have the urge to drink more water. Polyuria (increased urination). The excessive drinking of water leads to increased blood volume, wherein the kidneys consequently functions to excrete large volumes of urine in an attempt to regulate excess vascular volume. Weight loss. Despite eating more than usual to relieve hunger, you may lose weight. Without the ability to use glucose, the body uses alternative fuels stored in muscle and fat. Calories are lost as excess glucose is released in the urine. Page | 35
Acetone breath. This is due to the acidosis caused by the presence of ketones and is characterized by a fruity-odor breath. Ketones lead to acidosis because these interfere with the bodys acid-base balance by producing hydrogen ions resulting to decrease in pH. In addition, when ketones are excreted, sodium is also eliminated resulting in sodium depletion and further acidosis. Blurring of vision/blindness. This is primarily due to Diabetic Retinopathy one of the known complications of DM Type 2. Increasing levels of blood glucose causes blood to become viscous. Viscous blood tends to put high pressures on the minute blood vessels in the eyes, which may cause rupture of the blood vessels overtime. Delayed wound healing. This is due to the sluggishness of blood and distance of wound because lesser blood supply reaches the extremities. Frequent infections. When hyperglycemia exceeds 200 mg/dl, leukocyte and granulocyte function substances which are known to defend the body against foreign materials and infectious diseases, becomes impaired. Poorly controlled DM is likened to a starved state, and malnutrition is closely linked to depressed immune function. Symmetrical loss of protective sensation and Numbness/Tingling Sensation. This is one of the effects of Diabetic Neuropathy, a complication of Type 2 DM. This is due to the progressive loss of nerve fibers leading to nerve damage which then results to loss of sensation. Charcot Foot. Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). This causes bones to be fractured easily because the ability to sense pain is diminished. Diabetic foot ulceration. As diabetic patients lose their ability to sense pain or hot/cold, the risk of acquiring feet injuries increases.
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B. Pathophysiology (PATIENT-BASED) Non Modifiable

Family History of DM Parents 40% chance of acquiring the disease 35 and above (degenerative) Age (54 years old when he was diagnosed) Physical Inactivity Decreased sensitivity to insulin
Modifiable
Obesity (wt: 200lbs/90.91kg; ht: 58/2.98m2) (BMI: 30.51 kg/m2) Increased number of adipose tissue cells (adipocytes) Releases NEFA into the circulation Reduces muscle glucose uptake and promotes hepatic glucose output (consistent w/ insulin resistance)
Causes decreased insulin secretion (chronic exposure)
Signs of dehydration: (PA) cold, clammy skin prolonged capillary refill of 3 seconds Poor skin turgor Pale skin Dryness noted pale palpebral conjunctiva dry pale lips pale gums dry mucous membranes Lab results: (Jan. 15, 2011) Sodium: 117.6 mEq/L
Insulin secretory failure / insulin resistance
Decreased cellular glucose uptake Increase blood osmolarity Cellular dehydration Polydipsia (HPI) Polyuria (HPI; PA 3 wet and soaked diapers in 1 hour)
Increased hepatic glucose production Hyperglycemi a Cellular starvation Polyphagia (HPI)
No glucose would enter the cell Cell demand for glucose source Production of glucose from proteins and fats Increased ketones Acidosis acetone breath (PA)
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Chronic elevations in blood glucose Glycoprotein cell wall deposits
Small vessel disease Diabetic Neuropathy
Diabetic Nephropathy KIDNEY AFFECTATION
Diabetic Retinopathy BLURRING OF VISION / BLINDNESS (HPI; PA)
Impaired immune function DELAYED WOUND HEALING (1 WEEK PTA)
Narrow pulse on extremities (PA)
SYMMETRICAL LOSS OF PROTECTIVE SENSATION (2 WEEKS PTA) NUMBNESS AND TINGLING SENSATION IN THE LOWER EXTREMITITES (2 WEEKS PTA; PA) DIABETIC FOOT ULCERATION (1 WEEK PTA)
13, 2011) Creatinine: 165.2 mmol/L Blood Urea Nitrogen: 16.6mmol/L
Lab results: (Jan.
Amputated right leg (stump limb): Jan. 16, 2011 (PA) Debridement of middle finger on left dorsal foot Jan. 16, 2011 (PA)
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b.2 Predisposing and Precipitating factors Predisposing Factors: a. Age (62 years old) i. 35 years old and above (degenerative). When Mr. Sugar was diagnosed, he was 54 years old, therefore he is already in the degenerative phase. And as we all know, as people gets older, they tend to exercise less and also gain weight because their metabolism gets slower than normal. b. Family History of Diabetes. i. Parents. Mr. Sugars father died of Diabetes, therefore, the said disease runs in their family. Genetic components has a stronger basis for type 2 DM than type 1 DM. Although no definite and consistent genes have been identified, multifactorial inheritance is the most important factor in the development of type 2 DM. A person with one parent having type 2 DM is at an increased risk of getting diabetes, but if both parents have type 2 DM, the risk in the offspring rises to 40%. Precipitating Factors: a. Physical Inactivity. Mr. Sugar shared that he is not active in exercising. Likewise, he does not do household chores since he finds himself weak and irritable most of the time. Physical activity helps in controlling weight, uses up glucose as energy and makes cells more sensitive to insulin. b. Obesity. Mr. Sugar is said to be obese since his body mass index is 30.51falling on the 30.0-34.9 obese I range. In obesity, there are increased number of adipose tissue cells (adipocytes) which are known to release non-esterified fatty acids (NEFA) into the circulation. These NEFAs affect cells causing decreased insulin secretion in chronically exposed patients. Likewise, NEFA reduces muscle glucose uptake promoting hepatic glucose output, known to be consistent with insulin resistance. b.3 Signs and symptoms with rationale Polyphagia (increased hunger). If cells have no glucose intake, there will be cellular starvation which then stimulates the satiety center of the hypothalamus to increase the urge of the person to eat excessive amounts of food. Also, because of inability to produce insulin, the hormone necessary for glucose to enter cells and fuel their functions leaves your muscles and organs energy depleted. A symptom of hunger makes you feel like eating more until your stomach is full, but the hunger persists because, without insulin, the glucose produced from dietary carbohydrates never reaches your body's energy-starved tissues. Page | 39
Polydipsia (increased thirst). If cells are not able to absorb the glucose, there will be intracellular and extracellular dehydration. As a compensatory mechanism of the body, the person will have the urge to drink more water. Likewise, a high level of blood glucose pulls water from the body's tissues, making the patient thirsty. Polyuria (increased urination). The excessive drinking of water leads to increased blood volume, wherein the kidneys consequently functions to excrete large volumes of urine in an attempt to regulate excess vascular volume. Acetone breath. This is due to the acidosis caused by the presence of ketones and is characterized by a fruity-odor breath. Ketones lead to acidosis because these interfere with the bodys acid-base balance by producing hydrogen ions resulting to decrease in pH. In addition, when ketones are excreted, sodium is also eliminated resulting in sodium depletion and further acidosis. Delayed wound healing. This is due to the sluggishness of blood and distance of wound because lesser blood supply reaches the extremities. Symmetrical loss of protective sensation and Numbness/Tingling Sensation. This is one of the effects of Diabetic Neuropathy, a complication of Type 2 DM. This is due to the progressive loss of nerve fibers leading to nerve damage which then results to loss of sensation. Diabetic foot ulceration. As diabetic patients lose their ability to sense pain or hot/cold, the risk of acquiring feet injuries increases.
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VI. THE PATIENT AND HIS CARE 1. Medical Management A. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Thisapy, etc. Medical Management Plain Normal Saline Solution/ 0.9% Sodium Chloride Regulation: 30-31 gtts/min Date Ordered, Date Performed, Date Changed /discontinued Date Ordered: January 14, 2011 Date Started: January 14, 2011 Clients Response to Treatment Mr. Sugar tolerated the said management.
General Description 0.9% Sodium Chloride is an isotonic Solution which has the same concentration as blood and plasma. It is used to restore vascular volumes.
Indication or Purpose 0.9% Sodium Chloride is indicated for use in adults and children as sources of electrolytes and water for hydration. It is also indicated for extracellular fluid replacement, treatment of metabolic alkalosis in the presence of fluid loss and mild sodium depletion, and may be used to initiate and terminate blood transfusions without hemolyzing red blood cells.
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Nursing Responsibilities: Before the Procedure: Check the physicians order for IV solution and explain to the client the procedure. Check the patency of the IV and the needle. Check the type of infusion, condition of the vein and medical condition of the patient. During the procedure: Maintain aseptic technique and proper procedure and steps in infusion of IV solution After the procedure: Monitor IV infusion at least every 2 hours. Inspect site for pain, swelling, coolness or pallor at site of insertion, which may indicate infiltration of IV Inspect site for redness, swelling, heat and pain which may indicate phlebitis. Monitor client for fluid overload.
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Drugs Generic Name/ Brand Name/ Dosage/ Route/ Frequency of Administration Generic Name: Ranitidine
B.
General Action Ranitidine inhibits the action of histamine H2-receptors of the parietal cells in the stomach and prevents histamine-mediated gastric acid secretion. It does not affect pepsin secretion, pentagastrin-stimulated factor secretion or serum gastrin. A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever
Indication or Purpose Prophylaxis of acid aspiration during general anesthesia.
Date ordered Date performed/ Date Changed/ discontinued Date ordered: January 16, 2011 Date Performed: January 16, 2011
Clients Response to Treatment Mr. Sugar experienced adverse reactions like headache, and dizziness.
Brand Name: Aceptin 50 mg/ IV every 8 hours Generic Name: Tramadol Hydrochloride Brand Name: Ultram 50 mg IV every 8 hours Generic Name: Paracetamol Brand Name: Biogesic, Tempra 300 mg IV every 4 hours
Management of moderate to severe pain
Date ordered: January 16, 2011 Date Performed: January 16, 2011
Mr. Sugar did not experience any side effects such as N/V diarrhea, dizziness, or headache
It is given to treat Mr. Sugars fever.
Mr. Sugars temperature decreased from 380C to 37.40C
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x T > 37.80C Generic Name: Promethazine Hydrochloride Brand Name: Phenergan 50 mg/ IM on call
through central action in the hypothalamic heat-regulating center. Promethazine is a phenothiazine derivative that competitively blocks histamine H1 receptors without blocking the secretion of histamine. It also is a very weak dopamine antagonist. It has sedative, anti-motion-sickness, anti-emetic, and anti-cholinergic effects. An anticholinergic that inhibits acetylcholine at the parasympathetic neuroeffector junction, blocking vagal reflects on the SA and AV nodes, enhancing conduction.
Generic Name: Atropine Sulfate Brand Name: Sal-Tropine 0.5 g IM on call Generic Name: Clindamycin Hydrochloride Brand Name:
For preoperative sedation and to counteract postnarcotic nausea. As antiallergic medication to combat hay fever, allergic rhinitis, etc. To treat allergic reactions it can be given alone or in combination with oral decongestants like pseudoephedrine. Given preoperatively to diminish secretions and block cardiac vagal reflexes.
Mr. Sugar experienced a feeling of fatigue and drowsiness.
Mr. Sugar experienced dryness of mouth as one of the side effects of the drug.
Inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome.
Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. It is also indicated
Mr. Sugar did not experience any side effects of the said drug.
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Cleocin HCl 300 mg IV every 6 hours
Generic Name: Ceftazidime Brand Name: Ceptaz, Fortaz, Tazicef 1g IV every 8 hours Generic Name: Ferrous sulfate FeSO4 Brand Name: Feosol 200mg/tab once on DAT
Third-generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usually bactericidal.
Provides elemental iron, an essential component in the formation of hemoglobin.
in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci. Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. It is indicated for Lower Respiratory Tract Infections, Skin and SkinStructure Infections, Urinary Tract Infections, Bacterial Septicemia, and Bone and Joint Infections. The patient was given Iron supplements to prevent Iron-deficiency anemia.
Date ordered: January 16, 2011 Date Performed: January 16, 2011 Date ordered: January 16, 2011 Date Performed: January 16, 2011
Mr. Sugar did not experience any side effects of the said drug.
Mr. Sugar experienced side effects such as light headedness and loss of appetite.
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Generic Name: Insulin Brand Name: Humulin R Sliding Scale: CBG 140-160 2 u IV 161-180 4 u IV 181-200 6 u IV 201-250 8 u IV 251-300 10 u IV >301 10 u IV + 5 u SQ
Insulin is a polypeptide hormone that controls the storage and metabolism of carbohydrates, proteins, and fats. This activity occurs primarily in the liver, in muscle, and in adipose tissues after binding of the insulin molecules to receptor sites on cellular plasma membranes. insulin increases active glucose transport through muscle and adipose cellular membranes, and promotes conversion of intracellular glucose and free fatty acid to the appropriate storage forms (glycogen and triglyceride, respectively).
It is used to treat Mr. Sugars diabetes mellitus. Like other insulin products, it works by helping sugar (glucose) get into cells. It is a short-acting insulin.
Mr. Sugar did not experience any side effects like nausea and vomiting, and hypotension.
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Date/Time 1-14-11 6 pm 12 mn 1-15-11 6 am 8 am 12 mn 6 pm 1-16-11 12 mn 6 am 7 am 12 nn 1-17-11 12 mn 6 am 12 nn 6 pm 8 pm
CBG MONITORING SHEET CBG Result Type of Insulin Administered No strip available No strip available No strip available No strip available 300 mg/dl 200 mg/dl No strip available No strip available No strip available No strip available 251 mg/dl 120 mg/dl 120 mg/dl No strip available 160 md/dl Rapid Acting Insulin Rapid Acting Insulin Rapid Acting Insulin Rapid Acting Insulin Rapid Acting Insulin Rapid Acting Insulin
Dosage 10 u 8 u 10 u -
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Nursing Responsibilities: Ranitidine Before: Assess the patient accordingly. Check doctors order. Perform skin test. Wash hands properly. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. After: Wash hands properly. Document the administration. Assess for potential problems related to the medication administered like diarrheas, nausea and vomiting, enlargement of breasts and decrease in libido. Tramadol Hydrochloride Before: Check doctors order. Explain the purpose of each medication. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. After:
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Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Monitor patient for seizures. May occur within recommended dose range. Document the administration. Paracetamol Before: Check doctors order. Explain to the patient the importance of taking the medication. Tell the patient that the medication may be taken with or without meals. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Take it with a full glass of water. After: Monitor changes in patients temperature or a change in pain that causes discomfort. Emphasize to the patient that he/he might feel dizzy when taking the medication. Document the administration. Promethazine Hydrochloride Before: Assess the patient accordingly. Check doctors order. Wash hands properly. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. Tell patient to take oral form with food or milk.
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After: Wash hands properly. Document the administration. Atropine Sulfate Before: Assess the patient accordingly. Check doctors order. Perform skin test. Wash hands properly. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. After: Wash hands properly. Instruct patient to report serious or persistent adverse reactions promptly. Document the administration. Clindamycin Hydrochloride Before: Assess the patient accordingly. Check doctors order. Wash hands properly. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. After: Wash hands properly.
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Tell patient to report discomfort at IV insertion site. Instruct patient to notify prescriber of adverse reactions (especially diarrhea). Warn him not to treat such diarrhea himself because drug may cause life threatening colitis. Document the administration. Ceftazidime Before: Assess the patient accordingly. Ask if he is allergic to penicillins or cephalosporins. Check doctors order. Wash hands properly. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. After: Wash hands properly. Tell patient to report discomfort at IV insertion site. Advise patient to notify prescriber about loose stools or diarrhea. Document the administration. Ferrous Sulfate Before: Assess the patient accordingly. Check doctors order. Wash hands properly. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication.
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Assist patient in sitting position in administering oral medication then offer liquids.
Administer before meals and at bed time. After: Wash hands properly. Document the administration. Assess for potential problems related to the medication administered like loss of appetite, GI upset, fast heart rate, mouth sores, drop in BP and light headedness. Humulin R Before: Check doctors order. Read it before you start using this insulin and each time you get a refill, if you have any questions, consult your doctor or pharmacist. Before using, inspect this product visually for particles or discoloration. If either is present, do not use the insulin. Before injecting each dose, clean the injection site with rubbing alcohol it is important to change the location of the injection site to avoid developing problem areas under the skin. Explain the purpose of each medication. During: Check patients name and medication, including medication name, dose, route of administration, time and drug indication. Inject this medication under the skin within 30-60 minutes before eating a meal or immediately after the meal is directed by your doctor. To reduce discomfort to the injection site, do not inject cold insulin. Insulin may be injected at the abdominal wall, the thigh or the back of the upper arm. After: Store and discard needles and medial supplies safely. Tell patient about possible side effects. After pulling out the needle, apply gentle pressure on the injection site. Do not rub the area.
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Tell patient to use this medication regularly to get the most benefit from it, to help the patient remember; use it at the same time(s) each day. Document the procedure done.
C. Diet Nursing responsibilities for Nothing Per Orem (NPO): Type of Diet Nothing Per Orem (NPO) General Description No food, beverage, or even medicine is passed through the mouth. The major purpose of withholding food and fluid before surgery is to prevent aspiration. Fluid and foods are restricted preoperatively overnight. A low sodium diet is a diet that includes no more than 1,500 to 2,400 mgs of sodium per day.
Date ordered Date performed/ Indication or Purpose Date Changed/ discontinued Patient was ordered to go on Date Ordered: NPO before surgery for January 13, 2011 stomach emptying and after January 14, 2011 surgery to prevent post-midnight aspiration. January 16, 2011
Clients Response and/or Reaction to the Diet Mr. Sugar followed the said diet instructed by the physician. Also, emptying of the stomach before operation was achieved.
Low Salt Diet
Intended for patients with CRF, declining renal function and hypertension. Likewise, it is advised to decrease sodium concentration in the body and prevent uremia because kidneys cannot normally concentrate or dilute the urine if there is declining renal function, as these may cause edema and heart failure in the patient.
Date Ordered: December 05, 2010
Mr. Sugar followed the said diet instructed by the physician.
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Before: Verify doctors order. Discuss the importance of the ordered diet. Identify the type of diet. During: Explain to the significant others the reason including the health precaution for the diet given Update patient significant others of the patient diet change Monitor if the patient complies with the diet given After: Monitor clients reaction. Assess for patients condition, how he respond to the diet. Nursing responsibilities for Low Salt Diet: Before: Verify doctors order. Discuss the importance of the ordered diet. Identify the type of diet. During: Explain to the significant others the reason including the health precaution for the diet given. Update patient significant others of the patient diet change. Monitor if the patient complies with the diet given After: Monitor clients reaction. Assess for patients condition, how he respond to the diet.
D.
Activity
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Type of Activity/ Exercise Bed Rest
General Description An activity wherein the patient is not allowed to do any strenuous activity. This is a pursuit where the patient stays on bed.
Indication or Purpose General weakness was noted to Mr. Sugar and so bed rest is indicated to conserve energy and regain optimum strength.
Clients Response and/or Reaction to the Diet Mr. Sugar complied with the treatment regimen as ordered. He maintained rested on his bed and limits physical activity.
Nursing Responsibilities: Before: Checked doctors order Explained the importance of the procedure to the patient and S.O. During: Teached the patient SO proper position of the activity to prevent complication Assisted the SO in changing position of the client at least every 2 hours After: Checked for any complications like bed sores, muscle atrophy Removed all unnecessary objects to the patients bed to provide comfort Documented response of the patient and the procedure done.
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2.
Surgical Management E Below the Knee Amputation (BKA) of Right Foot, Debridement of Left Foot a. Brief Description Below the knee amputation (BKA) is a common procedure performed in diabetic patients for foot gangrene or uncontrolled foot infections. Amputations can be either planned or emergency procedures. Injury and arterial embolisms are the main reasons for emergency amputations. The operation is performed under regional or general anesthesia by a general or orthopedic surgeon in a hospital operating room. Details of the operation vary slightly depending on what part is to be removed. The goal of all amputations is twofold: to remove diseased tissue so that the wound will heal cleanly, and to construct a stump that will allow the attachment of a prosthesis or artificial replacement part. The surgeon makes an incision around the part to be amputated. The part is removed, and the bone is smoothed. A flap is constructed of muscle, connective tissue, and skin to cover the raw end of the bone. The flap is closed over the bone with sutures (surgical stitches) that remain in place for about one month. Often, a rigid dressing or cast is applied that stays in place for about two weeks. On the other hand, debridement may be considered one of the most important aspects of diabetic foot ulcer care, along with offloading and infection control. ADA guidelines recommend debridement of abscessed tissue along with incision and drainage. Debridement is the removal of necrotic tissue to decrease the risk of infection and to promote wound closure. Debridement should remove all necrotic tissue, callus, and foreign bodies down to the level of viable bleeding tissue. Wounds should be thoroughly flushed with sterile saline or a noncytotoxic cleanser following debridement. Hydrotherapy is not recommended for diabetic patients. Debridement is essential for the removal of nonviable cells and for healing. Periwound callus must also be removed, as it may contribute to periwound pressure and incomplete wound contraction. Ulcers may also be obscured by the presence of callus. Vascular status must always be determined prior to sharp surgical debridement. This may be accomplished through techniques described earlier in this manuscript. Determining local perfusion is of particular importance when debriding ulcers on the distal aspect of the foot. b. Clients response to operation Mr. Sugar had reports of pain but felt relieved of the wounds he had on both of his lower extremities.
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c.
Nursing responsibilities prior, during and after the operation PRE-OPERATIVE PHASE Preadmission Testing 1. Initiates initial preoperative assessment 2. Initiates teaching appropriate to patients needs 3. Involves family in interview 4. Verifies completion of preoperative testing 5. Verifies understanding of surgeon-specific preoperative orders 6. Assesses patients need for postoperative transportation and care Admission to Surgical Center or Unit 1. Completes preoperative assessment 2. Assesses for risks for postoperative complications 3. Reports unexpected findings or any deviations from normal 4. Verifies that operative consent has been signed 5. Coordinates patient teaching with other nursing staff 6. Reinforces previous teaching 7. Explains phases in perioperative period and expectations 8. Answers patients and familys questions 9. Develops a plan of care In the Holding Area 1. Assesses patients status, baseline pain and nutritional status 2. Reviews chart 3. Identifies patient 4. Verifies surgical site and marks site per institutional policy 5. Establishes intravenous line 6. Administers medications if prescribed 7. Takes measures to ensure patients discomfort 8. Provides psychological support 9. Communicates patients emotional status to other appropriate members of the health care team INTRAOPERATIVE PHASE Maintenance of Safety 1. Maintain aseptic, controlled environment 2. Effectively manages human resources, equipment, and supplies for individualized patient care 3. Transfers patient to operating room bed or table 4. Positions the patient 5. Applies grounding device to patient 6. Ensures that the sponge, needle, and instrument counts are correct 7. Completes intraoperative documentation
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Physiologic Monitoring 1. Calculates effects on patient of excessive fluid loss or gain 2. Distinguishes normal from abnormal cardio-pulmonary data 3. Reports changes in patients vital signs 4. Institutes measures to promote normothermia POSTOPERATIVE PHASE Transfer of Patient in Postanesthesia Care Unit 1. Communicates intraoperative information a. Identifies patient by name b. States type of surgery performed c. Identifies type of anesthetic used d. Reports patients response to surgical procedure and anesthesia e. Describes intraoperative factors (eg, insertion of drains or catheters; administration of blood, analgesic agents, or other medications during surgery; occurrence of unexpected events) f. Describes physical limitations g. Reports patients preoperative level of consciousness h. Communicates necessary equipment needs i. Communicates presence of family and/or significant others Postoperative Assessment Recovery Area 1. Determines patients immediate response to surgical intervention 2. Monitors patients physiologic status 3. Assesses patients pain level and administers appropriate pain relief measures 4. Maintains patients safety (airway, circulation, prevention of injury) 5. Administers medications, fluid, and blood component therapy, if prescribed 6. Provides oral fluids if prescribed for ambulatory surgery patient 7. Assesses patients readiness for transfer to in-hospital unit or discharge home based on institutional policy.
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VII. NURSING CARE PLAN 1. ACUTE PAIN NURSING ASSESSMENT DIAGNOSIS Subjective: Acute pain r/t > Ang sakit physical and sakit ng paa surgical ko. procedure AEB Objective: amputated > pain scale of right leg 8/10 (stump limb) > cold clammy Skin > grimace noted > guarding behaviour > restlessness and irritability noted > Amputated right leg (stump limb)
SCIENTIFIC EXPLANATION Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from seconds to 6 months. In cases of amputation of limb, pain is continuous until tissues are properly healed by the continuous flow of blood through the tissues.
OBJECTIVES After 1 hour of nursing interventions the patient will be able to demonstrate the use of relaxation skills and diversional activities to control pain and pain scale decrease from 8/10 to controllable level
NURSING INTERVENTIONS > Provide comfort measures such as repositioning, warm packs and therapeutic touch.
RATIONALE > The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications. > This may help to distract attention and reduce tension. > Focusing attention and enhancing coping with limitations can relieve pain. > Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation
EVALUATION After 1 hour of nursing interventions Mr. Sugar demonstrated the use of relaxation skills and diversional activities to control pain and pain scale decrease from 8/10 to controllable level
> Instruct use of relaxation techniques such as focused breathing or imaging. > Provide diversional activities such as chatting to the patient or listening to music. > Create a quiet, nondisruptive environment with dim lights and comfortable temperature when possible.
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technique rather than external distraction. > Encourage to change position side to side every 2 hours and situp on bed > Encourage adequate rest periods. > To promote optimum level of function and prevent further complications > To prevent fatigue that can be caused by too much pain.
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DEFICIENT FLUID VOLUME R/T ACTIVE FLUID LOSSES SECONDARY TO DM II AEB DRY MUCOUS MEMBRANES AND POOR SKIN TURGOR NURSING SCIENTIFIC NURSING ASSESSMENT OBJECTIVES RATIONALE DIAGNOSIS EXPLANATION INTERVENTIONS Subjective: Deficient In DM type 2, If After 1-2 hours > Administer/ > To rehydrate the > Pane kung Fluid Volume cells are not able of nursing Regulate fluids and patient. mangapali R/T active to absorb the interventions, electrolytes. uling inum fluid losses glucose, there will the patient will nakung inum AEB dry be intracellular be able to > Advise patient to > These tend to mucous and extracellular verbalize limit intake of exert a diuretic Objective: membranes dehydration. As a understanding of alcohol/caffeinated effect. > poor skin and poor skin compensatory causative factors beverages. turgor turgor mechanism of the and purpose of body, the person individual > Encourage the SO to > To maintain skin > appears pale will have the urge therapeutic bathe less frequently integrity and to drink more interventions using mild prevent excessive > pale water. The and medications. cleanser/soap, and dryness. palpebral excessive drinking provide optimal skin conjunctiva of water then leads care with suitable to increased blood emollients. > dry mucous volume, wherein membranes the kidneys > Note change in > These signs consequently mentation/behaviour/ indicate sufficient > dryness of functions to functional abilities dehydration to the skin noted excrete large such as confusion, cause poor cerebral volumes of urine lethargy, dizziness perfusion and/or > dry pale lips in an attempt to electrolyte regulate excess imbalance. > pale gums vascular volume.
2.
EVALUATION After 1-2 hours, Mr. Sugar verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.
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> prolonged capillary refill time of 3 seconds > Consumes 3 wet and soaked diapers in an hour
> Discuss factors related to occurrence of deficit, as individually appropriate..
> Early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia.
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IMPAIRED SKIN INTEGRITY RELATED TO SURGICAL POCEDURE SECONDARY TO DIABETIC FOOT ULCERATION AS EVIDENCED BY INTACT AND BLOOD-TINGED DRESSING OVER THE AMPUTATED RIGHT LEG (STUMP LIMB) NURSING SCIENTIFIC NURSING ASSESSMENT OBJECTIVES RATIONALE DIAGNOSIS EXPLANATION INTERVENTION Subjective: Impaired skin Disruption of After 2-3 hours > Place the client in a > To prevent > integrity R/T dermis and of nursing comfortable position backaches or surgical epidermis layers interventions, muscle aches Objective: procedure 20 of the skin caused patient will be > Appears weak diabetic foot by underlying able to > Assess skin, note > Establishes ulceration disease condition verbalize color, turgor, and comparative > Poor skin AEB intact resulting to understanding sensation, describe baseline providing turgor and bloodamputation of the of causative and measure opportunity for tinged affected part. factors and irregularities and timely intervention. > Patient dressing over necessary observed changes. manifested the amputated interventions. numbness and right leg > Demonstrate good > Maintaining tingling (stump limb) skin hygiene, like clean, dry skin sensation on washing thoroughly provides a barrier to lower and pat dry carefully. infection. Patting extremities skin dry instead of rubbing reduces > Pale skin risk of dermal trauma to fragile > Poor skin skin turgor > Instruct family to > Skin friction > Dryness noted maintain clean, dry caused by stiff or clothes, preferably rough clothes leads > Prolonged cotton fabric, to irritation of capillary refill emphasize fragile skin and
3.
EVALUATION After 2 hours, Mr. Sugar verbalized understanding of causative factors and necessary interventions.
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time of 3 seconds > Debridement performed on the middle finger of left dorsal foot > intact and blood-tinged dressing over the amputated right leg (stump limb)
importance of adequate nutrition and fluid intake. > Encourage adequate rest periods, especially before meals and other ADLs. > Encourage active ROM exercises 3x a day
increases risk for infection. > Rest between activities provides time for energy conservation and recovery. > Exercises maintain muscle strength and joint ROM. > To provide a positive nitrogen balance to aid in skin/tissue healing and to maintain general good health. > Keeps wound clean/ minimizes cross contamination and to prevent spread of infection.
> Reinforce strict DM diet as ordered
> Perform wound care
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IMPAIRED PHYSICAL MOBILITY RELATED TO DECREASED MUSCLE STRENGTH SECONDARY TO POST BELOW THE KNEE AMPUTATION AS EVIDENCED BY LIMITED RANGE OF MOTION ON BOTH LOWER EXTREMITIES NURSING SCIENTIFIC NURSING ASSESSMENT OBJECTIVES RATIONALE DIAGNOSIS EXPLANATION INTERVENTION Subjective: Impaired Due to decreased After 2-3 hours > Observe movement > To note any > Magkasakit Physical sensitivity to of nursing when client is incongruencies with kupang magMobility insulin interventions, unaware of reports of abilities. galo galo, ane related to hyperglycemia the patient will observation. kasing kasakit decreased occurs which demonstrate ing bitis ku muscle cause techniques/beha > Support the > To position of strength symmetrical loss viours that affected body part function and reduce Objective: secondary to of sensation on enable with pillows. the risk of pressure > limited range post below the lower extremities resumption of ulcers. of motion on knee which is a sign of activities both lower amputation as diabetic foot > Encourage frequent > To reduce the risk extremities evidenced by ulceration position changes. of pressure ulcers. noted limited range therefore perform of motion on BKA, after which > Instruct the SO to > To promote well> generalized both lower causes have the pt an being and weakness noted extremities immobility. adequate food and maximized energy fluid intake. production. > slowed movement > Assist in > To reduce scheduling activities fatigue. > difficulty with adequate rest turning from periods during the side to side to day. sitting position > Provide adequate > To maximize > Patient rest periods. energy production.
4.
EVALUATION After 2 hours of nursing interventions, Mr. Sugar demonstrated techniques/beha viours that enable resumption of activities such as frequent changing of positions from side to side
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manifested numbness and tingling sensation on lower extremities > Amputated right leg (stump limb) > Debridement performed on the middle finger of the left dorsal foot
> Identify energyconserving techniques for ADLs.
> Limits fatigue, maximizing participation.
> Encourage > To enhance selfparticipation in selfconcept and sense care, diversional and of independence. recreational activities. > Encourage client and SOs involvement in decision making as much as possible. > Enhances commitment to plan, optimizing outcomes.
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5. ACTIVITY INTOLERANCE R/T DECREASED TISSUE GLUCOSE UPTAKE SECONDARY TO DECREASED INSULIN PRODUCTION AEB GENERALIZED WEAKNESS NURSING SCIENTIFIC NURSING ASSESSMENT OBJECTIVES RATIONALE DIAGNOSIS EXPLANATION INTERVENTION Subjective: Activity Destruction of After 2-3 hours > Ascertain > To determine > Eku bisang intolerance liver beta cells of nursing understanding of what information gagalo. Pag R/T decreased interventions, individual needs. to provide client. gagalo ku o tissue glucose Production of patient will be kahit makakera uptake insulin is greatly able to identify > Teach methods to > To conserve mu sasakit ku secondary to decreased negative factors conserve energy such energy banda bitis decreased affecting as stopping to rest for insulin Pooling of activity 3 minutes Objective: production glucose on blood tolerance and > slowed AEB stream, decreased demonstrate > Increase activity > To increase movement generalized tissue perfusion ways to reduce levels gradually patients weakness on distal parts of their effects as independence > difficulty the body tolerated. turning > Assist with > To protect client Generalized activities such as from injury > limited range weakness due to positioning of motion decreased oxygen supply to tissues > Adjust activities to > To prevent > amputated such as muscles tolerable level overexertion right leg (stump limb) Activity > Teach patient > To conserve intolerance regarding relaxation energy and > tenderness on techniques promoter rest amputated knee > Caution client to > To avoid further > generalized avoid strenuous physiologic stress weakness activities and to decrease
EVALUATION After 2 hours, Mr. Sugar identified negative factors affecting activity tolerance and demonstrated ways to reduce their effect such as frequent repositioning and adjusting activities to a tolerable level.
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cardiac workload > Encourage patient to undergo dietary program that is appropriate for situation such as diabetic diet > Advise to elevate right hip > To avoid further accumulation of blood glucose
> To enhance ability to participate with activities >To reduce energy expenditure and preserves energy which improves endurance.
>Provide access to needed articles within reach and aid in assisting or performing ADL as indicated.
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ACTUAL SOAPIE(s) Date: January 17, 2011 S: O: > received lying on bed with an ongoing IVF of PNSS 1L regulated @ 31gtts/min infusing well on left hand @600cc level > weak in appearance, missing body part, not looking body part > with right below the knee stump with blood-tinged dressing > Vital signs taken and recorded as follows: BP: 120/80mmHg PR: 70 bpm T: 36C RR: 26 bpm A: Disturbed Body Image r/t loss of a body part AEB unwillingness to look at stump P: After 4 of nursing interventions, pt. will verbalize understanding of body changes and demonstrate ways to improve condition. I: > Monitored VS and recorded > Provided adequate bed rest > Maintained affected leg elevated > Encouraged to look affected body part > Provided comfort measure such as touch therapy > Provided assistance with self-care needs > Encouraged family members to treat patient normally > Encouraged S.O. to communicate frequently to the pt > Provided information to clients level of acceptance > Advised gradual ambulation with the use of crutches > Encouraged to sit-up in bed as tolerated E: After 4 of nursing interventions, pt. verbalized understanding of body changes and demonstrated ways to improve condition such as maintaining leg elevated.
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Date: January 18, 2011 S: Masakit yung paa ko. O: > Received lying on bed with an ongoing IVF of 0.9% NaCl 1L regulated @ 31gtts/min, infusing well on left hand @ 700cc level. > weak in appearance > guarding behavior > dependent > limited ROM > with right below the knee stump with blood tinged on dressing > with vital signs taken and recorded as follows: BP: 120/80mmHg PR: 73bpm T: 36C RR: 22bpm A: Acute pain r/t tissue and nerve trauma 2 to post below the knee amputation AEB pain scale of 7/10. P: After 4 of nursing interventions, pt. will verbalize reduction of pain from pain scale of 7/10 to 5/10 and demonstrate non-pharmacological pain management. I: > Monitored VS and recorded > Provided adequate bed rest > Encouraged frequent changing of position > Provided comfort measures such as touch therapy > Encouraged used of relaxation techniques such as deep breathing > Maintained affected leg elevated > Stretched bed linens > Observed nonverbal cues/pain behaviors > Advised diversional activities such as reading newspaper or chatting with S.O. > Advised proper wound care and stump care > Seen on rounds by Dr. Pena with orders made and carried out: 7:15am *For wound care *elevated affected limb E: Patient was able to sleep and verbalized reduction of pain from 7/10 to 5/10.
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VIII. DISCHARGE PLANNING General Condition of Client upon Discharge The condition of Mr. Sugar after confinement is progressive. He is recovering from the weakness, and his energy is gradually coming back but cannot do strenuous tasks yet. The patient is still under observation by the physician. Topic: Health Teachings on Diabetes Mellitus type 2 Time Allotment: 1 hour and 30 minutes (Lecture on post-operative care) Venue: Hospital in City of San Fernando
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Objective After 1 hour and 30 minutes of nursing interventions, Mr. Sugar will be able to verbalize full understanding of the health teachings on DM type 2.
Content
Time Allotment
Teaching Strategy Lecture/ Discussion Use of manila papers as a visual aid
Evaluation After 1 hour and 30 minutes of health teachings, Mr. Sugar understood the discussion and the respective rationale of the said health teachings on DM type 2.
1 hour and Advice the patient to 30 continue the medications that minutes are prescribed/ordered by the physician for the continuous recovery. Advice the patient to modify his lifestyle that would suit his current condition. Advice the client to have slow walk and do breathing exercises. Monitor nutritional support therapies as ordered for the recovery. The significant other should give assistance to the patient with regards to his household chores to prevent fatigue. Educate the patient about the proper hygiene and health maintenance. Instruct patient to increase fluid intake. Discuss the importance of proper nutrition. Have a regular check up to the physician in charge to assess the recovery or condition of the patient. Coping situation in positive manner and planning for the future. Encourage to follow diet prescribed by physician: DM diet. Assess the clients food preferences and discuss appropriate interventions with dietary department.
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IX. LEARNING DERIVED FROM THE STUDY In accomplishing our case study, we have only little time to do it, because, we didnt get patient early for our case study. Each member was assigned their task, and I was assigned to do the physical assessment and interview with the patient together with one of my group mates. With the assigned task to me I think was able to enhanced my confidence and the ability to used my therapeutic communication in able to get those needed information in our study. Though our chosen patient, dont want student nurses, but with the use of our therapeutic communication, we are able to talk to his. And with the cooperation of each member we are able to finish it on time. -Catap, Marjorie G. Upon the pursuance of our case study about Diabetes Mellitus type 2, we had the same routine of works just like how we did with our previous case studies. Although this case was not, at all, tackled in our classroom discussions, it did not stop us from exploring more of it. I got to know more about Sugar Cancer, as well as the proliferation of different kind of cancers to several parts of the body. Personally, I felt bad for our patient they dont have enough money to sustain all his medical treatments. I wonder why people like his still remain to continue their sedentary lifestyle even after knowing about their current disease. Just like any other group projects, Ive learned to be patient and determined enough in finishing our case study. Tasks have been distributed, shared, and successfully done. Im looking forward to have more challenging case studies some time soon. -Guarin, Merry Christine B. Our case study is about Diabetes Mellitus type 2 with HPN. I was able to really appreciate the said case, and also I was able to apply the knowledge I have attained last semester about DM type 2. Me and my other group mate was in charged to do the physical assessment and I was able to assess the patient cephalocaudal. It was my first time to saw a gangrenous foot thats why I really appreciate it. This case study taught me on how to be responsible and to do my assigned task in time and with minimal mistake. A group wont be successful without coordination and trust with each other. -Liwanag, Angelica Erika S. Doing this case study was not that easy knowing that it is my first time to make a study in line with this case. Its quite hard to make a study specially that we havent had time to converse with the patient. We have to give extra time and effort. In doing this requirement I learned the disease process of Diabetes. I had better understanding about this case. Also this made me conclude that working as a group will make the work faster, as we all know two heads are better than one. We practiced our cooperation and compiled our knowledge base on what we experienced. Aside from that, the patient that we choose in our case study gave us knowledge and learning experience in doing this study. I could say that we exerted all our efforts and gave our time to conceptualize this requirement. -Luntao, Aina Mae Page | 74
People grow through experience if they meet life honestly and courageously. This is how character is built. -- Eleanor Roosevelt Experience is the best teacher. Not everything taught within the four corners of the usual classroom are retained. The best way to see improvements on skills and concepts learned is through practice, in which through the RLE duty is done. It is my first time to handle patient having diabetes type 1 accompanied by hypertension and to complicate things out, he is a bit irritated to student nurses as well which served as a bit of a hindrance during our assessment. Case study, a deep studying and exploration about the patients disease condition, related factors on how this disease is acquired and its complications which as I stated earlier, led to hypertension and palliative and curative interventions on symptoms existing. We were able to understand more the situation the patient is undergoing and the different responsibilities nurses have. To sum everything up, the whole duty, in main ward was a great experience, dealing and caring with patients is not an easy job, but it is fun! I learned a lot, especially in terms of SOAPIE making which I was not so used to, drug responsibilities and interaction and the likes. Together with our CI and my fellow group mates we were able to have a job well done each day and an enjoyable means of learning. -Pangan, Astley
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X. REFERENCES A. Books Karch,A.M.(2010). Nursing Drug Guide. Williams and Wilkins: Philippines Seeley,et al.(2007). Essentials of Anatomy and Physiology Sixth Edition. McGraw-Hill International Edition: Philippines Weber,J.R.(2008). Nursing Health Assessment Sixth Edition. Williams and Wilkins: Philippines Huether, S. and Mccance, K. (2003). Understanding Pathophysiology. Smeltzer, S. and Bare, B. (2005). Medical Surgical Nursing. Black, J. (2008). Medical-Surgical Nursing 8th edition. Elsevier: Singapore B. Website http://www.news-medical.net/health/Diabetes-Mellitus-Type-2Pathophysiology.aspx http://www.mayoclinic.com/health/diabetes/DS01121/DSECTION=riskfactorshttp://www.medicinenet.com/diabetes_mellitus/article.htm#tocd http://emedicine.medscape.com/article/766143-overview http://pediatrics.aappublications.org/cgi/content/full/116/2/473 http://content.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_86/_40/fdiab19 _02.pdf http://highbloodpressure.about.com/od/highbloodpressure101/a/feedbackloop.ht m http://www.touchcardiology.com/articles/hypertension-and-diabetes-mellitus http://www.healingdaily.com/detoxification-diet/insulin.htm http://www.medscape.org/viewarticle/513877 http://www.kidneyatlas.org/book3/adk3-05.QXD.pdf http://emedicine.medscape.com/article/1170337-overview http://www.uptodate.com/patients/content/topic.do? topicKey=~Wx7Wc9T9hSgGi http://www.diabetes.org/living-with-diabetes/complications/kidney-diseasenephropathy.html http://www.nlm.nih.gov/medlineplus/ency/article/000494.htm http://www.epodiatry.com/charcot-foot.htm http://www.epodiatry.com/charcot-foot.htm http://ph.answers.yahoo.com/question/index?qid=20100903004907AAjS6i6 http://books.google.com.ph/books? id=zJyZfvinJ9cC&pg=PA603&lpg=PA603&dq=impaired+immune+function+in +diabetes&source=bl&ots=c2HaCOU1zR&sig=a0JJNOULAbUhYNac8JOi6ffd 0vM&hl=en&ei=BD0DTbegLMO8rAfoyZyRDw&sa=X&oi=book_result&ct=re sult&resnum=3&ved=0CCoQ6AEwAg#v=onepage&q=impaired%20immune %20function%20in%20diabetes&f=false http://www.mayoclinic.com/health/type-2diabetes/DS00585/DSECTION=symptoms http://www.merckmanuals.com/home/sec13/ch165/ch165a.html http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html http://globalnation.inquirer.net/cebudailynews/opinion/view/20080728151202/Diabetes-warning Page | 76
http://www.sciencedaily.com/releases/2010/11/101129111735.htm
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HOLY ANGEL UNIVERSITY COLLEGE OF NURSING ANGELES CITY A Case Study Presented to the College of Nursing In Partial Fulfillment

DIABETES MELLITUS TYPE II

January 31, 2011

5 5-6 6 6-7 7 8 9-12

41-42 43-52 53-54 55 56-58

Mr. Sugar56 y/o

Mrs. Sugar55 y/o

Legend: MALE DIABETES TYPE II FEMALE PROBLEM DECEASED HYPERTENSION KIDNEY

Amber-colored urine Consumes 3 wet and soaked diapers in an hour

IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Laboratory Procedure Complete Blood Count Hematocrit

Normal Values(units used in the hospital)

Analysis and Interpretation of Results

White Blood Cell

Diagnostic/ Laboratory Procedure Complete Blood Count Platelet

Normal Values(units used in the hospital)

Analysis and Interpretation of Results

MCV (Mean Corpuscular Volume)

MCH (Mean Corpuscular Hemoglobin)

MCHC (Mean Corpuscular Hemoglobin Concentration)

Diagnostic/ Laboratory Procedure Blood Chemistry

Analysis and Interpretation of Results

Random Blood Sugar

Blood Urea Nitrogen

Diagnostic/ Laboratory Procedure Blood Chemistry

Analysis and Interpretation of Results

Random Blood Sugar

Diagnostic/ Laboratory Procedure

Analysis and Interpretation of Results

33.0 117.6 g/L mEq/L

34-50 136-145 g/L mEq/L

Diagnostic/ Laboratory Procedure Urinalysis

Results Color: Amber Transparency: Turbid

Analysis and Interpretation of Results

Glucose and Albumin: 3+

Glucose and Albumin: 3+

Specific Specific Gravity: Gravity: 1.020 1.006-1.025

V. THE PATIENT AND HIS ILLNESS 1. Anatomy and Physiology

2. Pathophysiology A. Book-Based a. Schematic Diagram (Flow Chart) Non Modifiable

Identical twin 80% chance of developing DM

Parents 40% chance of acquiring the disease

Children/Adolescents /Young adults Puberty Growth hormone

Insulin secretory failure / insulin resistance

Increased hepatic glucose production Hyperglycemi a Cellular starvation Polyphagia

Chronic elevations in blood glucose Glycoprotein cell wall deposits

Small vessel disease

Atherosclerosis Coronary Artery Disease

Impaired immune function FREQUENT INFECTIONS DELAYED WOUND HEALING

Diabetic Neuropathy SYMMETRICAL LOSS OF PROTECTIVE SENSATION

Diabetic Nephropathy End Stage Renal Failure

Diabetic Retinopathy BLURRING OF VISION / BLINDNESS

NUMBNESS AND TINGLING SENSATION IN THE LOWER EXTREMITITES CHARCOT FOOT

DIABETIC FOOT ULCERATION

1. Inadequate production of insulin (which is made by the pancreas

Genetic components has a stronger basis for type 2 DM than type 1

B. Pathophysiology (PATIENT-BASED) Non Modifiable

Causes decreased insulin secretion (chronic exposure)

Insulin secretory failure / insulin resistance

Increased hepatic glucose production Hyperglycemi a Cellular starvation Polyphagia (HPI)

Chronic elevations in blood glucose Glycoprotein cell wall deposits

Small vessel disease Diabetic Neuropathy

Diabetic Nephropathy KIDNEY AFFECTATION