INTRODUCTION:

Type 2 diabetes mellitus

Type 2 diabetes mellitus is characterized differently due to insulin resistance or reduced insulin sensitivity, combined with reduced insulin secretion. The defective responsiveness of body tissues to insulin almost certainly involves the insulin receptor in cell membranes. In the early stage the predominant abnormality is reduced insulin sensitivity, characterized by elevated levels of insulin in the blood. At this stage hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver. As the disease progresses the impairment of insulin secretion worsens, and therapeutic replacement of insulin often becomes necessary. There are numerous theories as to the exact cause and mechanism in type 2 diabetes. Central obesity (fat concentrated around the waist in relation to abdominal organs, but not subcutaneous fat) is known to predispose individuals for insulin resistance. Abdominal fat is especially active hormonally, secreting a group of hormones called adipokines that may possibly impair glucose tolerance. Obesity is found in approximately 55% of patients diagnosed with type 2 diabetes. Other factors include aging (about 20% of elderly patients in North America have diabetes) and family history (type 2 is much more common in those with close relatives who have had it). In the last decade, type 2 diabetes has increasingly begun to affect children and adolescents, likely in connection with the increased prevalence of childhood obesity seen in recent decades in some places. Environmental exposures may contribute to recent increases in the rate of type 2 diabetes. A positive correlation has been found between the concentration in the urine of bisphenol A, a constituent of polycarbonate plastic, and the incidence of type 2 diabetes. Type 2 diabetes may go unnoticed for years because visible symptoms are typically mild, nonexistent or sporadic, and usually there are no ketoacidotic episodes. However, severe long-term complications can result from unnoticed type 2 diabetes, including renal failure due to diabetic nephropathy, vascular disease (including coronary artery disease), vision damage due to diabetic retinopathy, loss of sensation or pain due to diabetic neuropathy, and liver damage from nonalcoholic steatohepatitis. Type 2 diabetes is usually first treated by increasing physical activity, decreasing carbohydrate intake, and losing weight. These can restore insulin sensitivity even when the weight loss is modest, for example around 5 kg (10 to 15 lb), most especially when it is in abdominal fat deposits. It is sometimes possible to achieve long-term, satisfactory glucose control with these measures alone. However, the underlying tendency to insulin resistance is not lost, and so attention to diet, exercise, and weight loss must continue. The usual next step, if necessary, is treatment with oral antidiabetic drugs. Insulin production is initially only moderately impaired in type 2 diabetes, so oral medication (often used in various combinations) can be used to improve insulin production (e.g., sulfonylureas), to regulate inappropriate release of glucose by the liver and attenuate insulin resistance to some extent (e.g., metformin), and to substantially attenuate insulin resistance (e.g., thiazolidinediones). According to one study, overweight patients treated

with metformin compared with diet alone, had relative risk reductions of 32% for any diabetes endpoint, 42% for diabetes related death and 36% for all cause mortality and stroke.[15] Oral medication may eventually fail due to further impairment of beta cell insulin secretion. At this point, insulin therapy is necessary to maintain normal or near normal glucose levels.

Signs and symptoms

The classical triad of diabetes symptoms is polyuria, polydipsia and polyphagia, which are, respectively, frequent urination, increased thirst and consequent increased fluid intake, and increased appetite. Symptoms may develop quite rapidly (weeks or months) in type 1 diabetes, particularly in children. However, in type 2 diabetes symptoms usually develop much more slowly and may be subtle or completely absent. Type 1 diabetes may also cause a rapid yet significant weight loss (despite normal or even increased eating) and irreducible fatigue. All of these symptoms except weight loss can also manifest in type 2 diabetes in patients whose diabetes is poorly controlled.

Signs and symptoms

The classical triad of diabetes symptoms is polyuria, polydipsia and polyphagia, which are, respectively, frequent urination, increased thirst and consequent increased fluid intake, and increased appetite. Symptoms may develop quite rapidly (weeks or months) in type 1 diabetes, particularly in children. However, in type 2 diabetes symptoms usually develop much more slowly and may be subtle or completely absent. Type 1 diabetes may also cause a rapid yet significant weight loss (despite normal or even increased eating) and irreducible fatigue. All of these symptoms except weight loss can also manifest in type 2 diabetes in patients whose diabetes is poorly controlled

Genetics
Both type 1 and type 2 diabetes are at least partly inherited.There is a stronger inheritance pattern for type 2 diabetes. Those with first-degree relatives with type 2 have a much higher risk of developing type 2, increasing with the number of those relatives.

Epidemiology
In 2000, according to the World Health Organization, at least 171 million people worldwide suffer from diabetes, or 2.8% of the population Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will almost double Diabetes mellitus occurs

throughout the world, but is more common (especially type 2) in the more developed countries. The greatest increase in prevalence is, however, expected to occur in Asia and Africa, where most patients will likely be found by 2030. The increase in incidence of diabetes in developing countries follows the trend of urbanization and lifestyle changes, perhaps most importantly a "Western-style" diet. This has suggested an environmental (i.e., dietary) effect, but there is little understanding of the mechanism(s) at present, though there is much speculation, some of it most compellingly presented. For at least 20 years, diabetes rates in North America have been increasing substantially. In 2005 there were about 20.8 million people with diabetes in the United States alone. According to the American Diabetes Association, there are about 6.2 million people undiagnosed and about 41 million people that would be considered prediabetic. However, the criteria for diagnosing diabetes in the USA mean that it is more readily diagnosed than in some other countries.

GENERAL INFORMATION:

Name: Mrs J.C Address: # 27 Bunsuran II Pandi Bulacan Age: 80 y/old Sex: Female Date of Birth: August 29,1937 Place of Birth: Hagonoy,Bulacan Religion: Roman Catholic Civil Status: Widow Number of Children) 11 / 6 boys/ 5 girls Name of Hospital: Nazarenuz College and Hospital Foundation Inc. Chief Complain:Body weaknesses Diagnosis: DM II Final Diagnosis: Metabollic Ecephalopathy Hypernatemia/ DMII Attending Physicians: Dr. Limcauco Date/Time of admission: October 18.2008/7:20 p.m.

HISTORY OF PRESENT ILLNESS: Present condition started few hours prior to admission an 80 y/old woman with the chief complain of body weakness under the service of Dr.Limcauco, seen and examined by the ROD. With orders made and carried out, hooked IVF PNSS/D5LR as ordered. V/S taken and recorded: ER Data: B/P: 120/80 CR: 96 bpm RR: 22bpm TEMP: 36.7 C LOC: Conscious and coherent

PAST HEALTH HISTORY: Last September she was hospitalized in Balagtas Doctors for body weakness, she lasted there for 2 days as she immediately response on medications was given to her. So She was discharge immediately. FAMILY HISTORY AND ILLNESS: (+) DM Maternal (+) Heart Disease Maternal (+) HPN Paternal RR: 16bpm TEMP: 38 C LOC: Conscious and coherent Medications Given: IV fluids: 09/17/2008: PLR + 2NB 1 liter 25gtts/min PAST HEALTH HISTORY:

Last year she was hospitalized on the same reasons difficulty of swallowing as she remembers the same procedure and treatment were given to her though she has a diabetus mellitus for 10 years she controls the food she is eating as she doesnt want her blood sugar to shoot up and thats the reasons why her blood sugar is in controlled.

FAMILY HISTORY AND ILLNESS: (+) DM Maternal (+) Heart Disease Maternal (+) HPN Pattern

LIFESTYLE PATTERN:

Personal Habits:
1. She usually takes a bath regularly.

2. She loves to sweep in their backyard. 3. She supervise her daughter to pack charcoals

Diet:
Since she is a diabetic she watch on the food she is eating more on vegetables and fish.Limits intake of sweets and meats.

Social Data:
MrsJ.C. is a widower, she has children 6 sons and 5 daughters which they have their owns family. Her one daughter stayed with her as her companions, they are close family,though all her childrens has their own family every Sunday she prepares food for her children.

Ethnical History:

She use some herbal medicines, believes in HILOTS and TAWAS as a traditional way of healings and religious healings.

Educational History:
She is elementary undergraduate in Hagonoy Elementary School

Occupational History:
She has a Charcoal business.

Social History:
Close family ties.

Community: They visits health centers as well hospital when ever they are not feeling well
and somebody is sick

Economic Status:
They depends on the income of the business and with the help of her children

Family Planning:
She doesnt use any contraceptives. Obstetrical History: G11P11 TPAL=11-0-0-11

ACTIVITIES OF DAILY LIVING:

Pre Hospitalizations:
A.M. Activities: 10/ 17/2008 4:30 - awakes do bathroom privileges 5:00- 6:00- Prepares breakfast 6:15-7:00- do some sweeping the backyard 7:30- 8:00- Eats breakfast with her daughter 8:30 -10:30- Do household chores 10:30- 11:30- Prepares and cook lunch 11:30-12:00- Eats lunch with here daughter P.M. Activities: 12:15-1:00- helps daughter to wash dishes 1:00-2:30- Watch television with daughter and grandchildren 2:30- 4:00- Sleeps with her grandchildren/ 4:00 -5:00 - Go to the backyard pick some dried leaves 5:30 - 6:30- cooked for dinner 6:45-7:15 - Eats dinner 7:15-7:45: Washes the dishes 7:45 -9:30- Watch television 10:00 - Sleeping time

Intra Hospitalizations:
A.M. Activities: 10/18/2008 4:30- wake up time, do bathroom privileges with assistance/ 6:15-7:00- morning care was done with assistance and changing clothes. 7:15 -7:45- Eats breakfast 8:00- 8:30- Vital signs/Medications administration 9:00- 11:00- sleep 11:00 -11:15- Doctors Rounds 11:30- 12:15- eats lunch soft diet porridge PM Activities: 1:00 -3:30- sleeps 4:00-5:00- talks with relatives who visits her 6:00- Dinner 8:30- asleep

Intra Hospitalizations:
A.M. Activities: 10/21/2008 5:30- wake up time, do bathroom privileges with assistance 6:15-7:00- Morning care washing face, gargling, changing clothes 7:15 -7:45- Eats breakfast DAT 8:00- 8:30- Vital signs/Medications administration 9:00- 10:00- sleep 10:15- 10:30- take snacks 11:00 -11:15- Doctors Rounds 11:30- 12:15- eats lunch DAT PM Activities: 1:00 -2:00- Chatting with her daughters 2:15 -4:30- sleeps 6:00- eat suffer 7:00 -7:30- lying down while talking with her daughters and granchildren, 8:30- asleep

POST HOSPITALIZATIONS:
Needs to rest for a couple of days and resume what she is used to do during her pre hospitalization as Its her routines in her everyday life.

Pre Hospitalizations: A.M. Activities: 4:30 - awakes do bathroom privileges 5:00- 6:00- Prepares breakfast 6:15-7:00- Do some dusting in the house 7:30- 8:00- Eats breakfast w 8:30 -10:30- rest and relax 10:30- 11:30- Prepares and cook lunch 11:30-12:00- Eats lunch with her husband P.M. Activities: 12:15-1:00- Washes the dishes 1:00-2:30- Watch television with husband and grandchildren 2:30- 4:00- Sleeps with her grandchildren 4:00 -5:00 - Go to the backyard to check her chicken 5:30 - 6:30- rest while talking her grandaughters 6:45-7:15 - Eats dinner 7:15-7:45: Washes the dishes 7:45 -9:30- Watch television 10:00 - Sleeping time

PHYSIOLOGIC CUES
(October 21 2008)

GENERAL APPEARANCE 1. Height

NORMAL VALUES 4-6ft/ 129 182cm. (*Basic Nutrition For Filipinos 5th ed.-Virginia Claudio & Ofelia Dirige) 51.9 - 63.4 kg 165.10cm(Ht)100x10%=58.59( Ave IBW) %Deviation=ABWIBW)IBW % deviation+14.56% (* Basic Nutrition for Filipinos 5th ed.) Relaxed Erect posture, coordinated movements(*Fundamental of Nursing- Kozier 5th ed. Chapter 22, p 473) Hygienic care of the skin feet, nails mouth, hair, ears and nose.(* Fundamental of NursingKozire,5th ed. Chapter 31) Normal digestion. Absorption and diet using the food pyramid guide. (*Fundamental of Nursing5th ed.; Chapter 45) Maintain sensory function ,orientatation, normal level of sensorium(* Fundamental of Nursing Kozier,7th ed.; Chapter 36)

ACTUAL FINDINGS 56=170.68cm

INTERPRETATIONS

Normal

2. Weight

78kg =171.6

Not Normal

Posture Gait

relaxed no movements.

coordinate Not Normal

4. Personal Hygiene 5.Nutritional Status

Sponge bath every day, and brush his teeth, no breath odor and body odor Normal 171.6-100=71.67.16=64.44x2.2=141.768170.68= 28.912% deviation. Not Normal Concious, coherent,oriented to time and place with appropriate speech. Normal

6.Sensory Status

PHYSICAL ASSESSMENTS HEAD TO TOE:

Physical Examination Normal Findings Actual Findings Round, smooth skull contour,and absence of masses. Normal Interpretation Round, norm,cephalic and, A.Head Skull (Inspection symmetric, with frontal. Parietal and Palpation) , and occipital prominence) Smooth skull contour,uniform consistency and absence of masses(*Fundametal of th Nursing-Kozier 5 ed.; Unit 6,Chapter 22p.481) No infection and manifestation of lice or dandruff B. Scalp (inspection) (*Fundamental of Nursing Kozier5th ed.;Unit 6 chapter 22 p. 478) Normal hair is evenly distributed, thick, silky and resilient. No infection or C. Hair (Inspection) infestation variable body hair.(* Fundamental of Nursing-Kozier 5th ed.; unit 6 Chapter 22,p.478) Symmetric or slightly facial features, palpebral features, equal in size, symmetric D. Face (inspection) nasolabial folds, symmetric facial; movements.(* Fundamental of Nursing-Kozier 5th ed.; unit 6 Chapter 22,p.478) E. Eyes (Inspection) Eyes should be aligned, Symmetrical without protruding or appearing sunken. (* Manual of Nursing Care-Joan Lackman p.120)

no presence of Normal dandruff or any other infection Normal hair is evenly distributed, thick, silky and resilient. Normal

Symmetric facial movements palpebral fissures equal in size, with uniform body color Normal Symmetrical without protruding or appearing sunken. Symmetrically aligned eye Normal movement able to read with out eyeglasses. Symmetrically aligned,hair Normal evenlydistributed, skin intact.

F.Eyebrows/eyelashes (inspection)

Hair evenly distributed, skin intact, eyebrows symmetrically aligned, equal movement. .(* Fundamental of Nursing-Kozier 5th ed.; unit 6 Chapter 22,p.483)

G. Eyelid (Inspection)

Skin intact, no discharge, no discoloration, lid close symmetrically, bilateral blinking, no visible sclera above cornea and upper and lower borders of cornea are slightly covered. .(* Fundamental of Nursing-Kozier 5th ed.; unit 6 Chapter 22,p.483)

Intact skin discoloration, closely symmetrically,

no lid Normal

H. Lower and upper Shiny, smooth, Pink or red in Shiny, smooth, pink N. Ear Canal (inspection) Distal third contains hair Distal third contains color. (* Fundamental of in color conjunctiva (Inspection) follicles and glands.cerumen in hair and glands with Normal Nursing- Kozier 5th ed.:Unit 6 Normal various shade of brown. .(* dry cerumen Chapter 22 p. 484) Fundamental of NursingI.Sclera (Inspection) Should appear white(* Slightly yellow in Kozier 5th ed.;Unit 6 Chapter 22 Fundamental of Nursing- appearance Normal p. 492) th Kozier 5 ed.:Unit 6 Chapter 22 O.Hearing Acuity Able to hear whisper words1-2 Able to hear p. 484) feet. (* Nurse handbook of J. Cornea (Inspection) Transparent and shiny and Transparent and shiny Health Assessment Weber and Normal smooth, client blinks when Janet p.112) cornea touched indicating the P. Nose (Inspection) Symmetric and straight, no Symmetric and trigeminal curve is intact. Normal discharge or flaring, no lesions, straight, no discharge Fundamental of Nursinguniform in color air moves or flaring,uniform Kozier 5th ed.:Unit 6 Chapter 22 freely as the client breathes color. p. 485) through the nares .(* Normal K. Iris (Inspection) Flat and round no shadows of Flat and round no Normal Fundamental of Nursinglight in the iris. (*Fundamental shadows of light in Kozier 5th ed.;Unit 6 Chapter 22 of Nursing- Kozier 5th ed.:Unit the iris. p. 497) 6 Chapter 22 p. 486) Q. Mouth/Lips Uniform pink in color, soft No lesions,has the L. Pupils (inspection) Black in colorequal in size, Reactive to light , moist and smooth in textures ability to purse the normal round, smooth borders.(* pupils are equal symmetric of contour and lips but lips are dry in Fundamental of Nursing- ,black in color . round Normal ability toth purse lips .(* appearance brown in Kozier 5 ed.;Unit 6 Chapter 22 and has a smooth Fundamental of Nursing- color p. 485) border. Kozier 5th ed.;Unit 6 Chapter 22 p. 499) M. Ears( Inspection) Color same as the facial skin, Same R. Gums (inspection) Pink gums, moist firm in texture Moist noshade as theNot normal retraction symmetric position. Line drawnbut darker in color facial skin, symmetricDue to gums, no retraction pulling to from the lateral Normal away from teeth angle of the eye position. smokingl point where where top of S. Teeth( inspection) 32 topermanent teeth, smooth,the1 tooth left Not Normal auricle joins head white shiny enamel, in horizontal, imaginary lines drawn color, T. Tongue(inspection) Central position , pink in from thePink in color moist Normal top bottom of the coating moist tothin whitish ears variesmoves freely and no more lateral margins , smooth in than 10 degrees fromcentral in position vertical. .(* Fundamental moves freely no lesions and of th Nursingtenderness.(*Kozier 5 ed.;Unit 6 Fundamental of Chapter 22 p. 5th Nursing- Kozier492) ed.;Unit 6 Chapter 22 p. 501) U. Frenelum( Inspection) Smooth tongue based with Smooth tongue with Normal prominent veins.(* prominent Fundamentals of NursingKozier 5th ed.; unit 6, chapter 22 p.509

cigarettes

V. Cheeks(palpation)

Moist smooth soft glistening, and elastic texture. Uniform pink in color. (* Fundamentals of Nursing- Kozier 5th ed.; unit 6, chapter 22 p.499) W. Palate Light pink and smooth soft Soft Palate and Hard Palate palate. lighter pink hard palate (inspection) moist. pink in color. (* Fundamentals of Nursingth Kozier 5 ed.; unit 6, chapter 22 p.502) X. Uvula(inspection) Position is in the midline of soft palate, (* Fundamentals of Nursing- Kozier 5th ed.; unit 6, chapter 22 p.502) Y. Tonsils( Inspection) Pink and smooth, no discharge and normal size , (* Fundamentals of NursingKozier 5th ed.; unit 6, chapter 22 p.502) Z. Voice No hoarseness and well modulated A1.Neck Muscle equal in size head Inspection/palpation) centered, coordinated, smooth movements w/no discomfort. Lymph nodes are palpable. , (* Fundamentals of NursingKozier 5th ed.; unit 6, chapter 22 p.505) B1. Thorax (IPPA) Chest symmetric and spine vertically aligned. Skin is intact uniform in temperature,chest wal intact no tenderness bilateral symmetry of vocal RR 12-20. , (* Fundamentals of Nursing- Kozier 5th ed.; unit 6, chapter 22 p.505) C1.Chest (inspection No discoloration, no sternum /palpation) retraction upon breathing, doesnt use accessory muscles for respiration and shoulders no grunting with abdominal push

Moist smooth soft Normal Uniform pink in color. pink and smooth Normal

In the midline of the Normal soft palate The tonsils are swollen and red and often have purulent exudates. Not normal

Hoarseness and Not difficulty to talk Normal Muscle equal in size Normal head centered, coordinated, smooth movements w/no discomfort. Lymph nodes are palpable Intact skin Normal symmetrical movements, no tenderness resonance percussion respiratory rate of 20. No discoloration, no Normal sternum retraction upon breathing, doesnt use accessory muscles for

during exhalation, symmetrical respiration normal contour ,no tenderness no masses normal muscle tone.

D1. Lungs (auscultation)

E1. Heart F1. Breast (Inspection)

G1. Areola (inspection) H1. Nipples (Inspection)

J1. Abdomen (IAPP)

K1. Upper Extremities

Breath sound should normally sound symmetrical; inspiration should approx.= to expiration in duration.adventitious sounds(crackles,gurgles.wheeze rubs) be absent . HandbookAssesstment of the Chest and Lungs Pages 211-216) Normal cardiac rate is 60-100 beats per minute Skin uniform in color smooth and intact no tenderness and masses. (Fundamentals of th Nursing- Kozier 5 ed.; unit 6, chapter 22 p.529-530) Round or oval and bilaterally the same color varies widely from light pink to dark brown Round,everted and equal in size similar in color, soft and smooth both nipples point in the same direction. No discharges or masses or lesions(* Fundamentals of Nursingth Kozier 5 ed.; unit 6, chapter 22 p.530), Unblemish skin, uniformin color, flat rounded (convex) no evidence of enlargement of liver and spleen symmetric in movements caused by respiration audible bowel sounds tymphany over the stomach, no tenderness.(* Fundamentals of Nursingth kozier 5 ed.; Unit 6 Chapter 22, p.534-535) Muscle not tender, firm, equal

No sound

adventitious normal

85 beats per minute

Normal

Skin uniform in color Normal smooth and intact no tenderness and masses Round brown and color Normal

Round equal in size, Normal no masses or lesions

Normal Unblemish skin, uniformin color, flat rounded (convex) no evidence of enlargement of liver and spleen

Muscle not tender, Normal

(inspection /Palpation)

in size, bilaterally w/o fasciculation, lumps or bulges. Clean fingers equal in number and no abnormalities, symmetrical, well aligned and proportion relative to body trunk. (*Manual of Nursing Care- Joan Luckman 141)

firm, equal in size, bilaterally w/o fasciculation, lumps or bulges. Clean fingers equal in number and no abnormalities, symmetrical.

K1. Upper Extremities (inspection /Palpation)

L1. Mobility

M1.Lower Extremities (inspection/palpation)

Muscle not tender, firm, equal in size, bilaterally w/o fasciculation, lumps or bulges. Clean fingers equal in number and no abnormalities, symmetrical, well aligned and proportion relative to body trunk. (*Manual of Nursing Care- Joan Luckman 141) Able to perform the different ranges of motion(abduction adduction rotation, flexion extension)without difficulty. (* Fundamentals of Nursingth Kozier 5 ed.; unit 6, chapter 22 p.546-549), Equals in numbers clean and symmetrical, hair distribution is even equal numbers of digits, Skin smooth, same color , slight moist and no lesions or masses. Muscle not tender,

Muscle not tender, Normal firm, equal in size, bilaterally w/o fasciculation, lumps or bulges. Clean fingers equal in number and no abnormalities, symmetrical. able to perform the normal different ranges of motion Find difficulty.

N1. Nails (inspection)

Convex curvature, smooth texture, high vascular and pink in light skinned clients. Intact epidermis and prompt return of ink or usual color, (* Fundamentals of Nursing-

Equals in numbers Normal. clean and symmetrical, hair distribution is even equal numbers of digits, Skin smooth, same color ,Cant able to flex legs no tenderness from waist to down has a slight paralysis Convex curvature, Normal smooth texture, high vascular and pink in light skinned clients. Intact epidermis and prompt return of ink

O1. Skin (inspection)

Kozier 5th ed.; unit 6, chapter 22 or usual color, p.479), Skin is soft, smooth, clean and Skin is intact and Normal intact. Maintained skin cleaned , integrity. Skin when pinch goes back to previous state. Skin is moist temperature is 36.4- 37.4 (* Fundamentals of NursingKozier 7th ed.; chapter 34)

LABORATORY RESULTS: ( October 19,2008) Test Hemoglobin Normal Results Values M:140127 170gm/l F: 120150gm/l M: 45-56 F: 37-47 M: 4.6 - 6.2 F: 4.2 - 5.40 Adult:5x10 / L NB: 9-10x 10 /L Adult: 60-70 NB:40-80 Adult:25-40 NB: 0-31 2-6 1-4 0.5-0.10 Adult:150450 80-100 fl 27-31 31-36 0.357 4.26 Analysis normal Significance

Hematocrit RBC

Normal Normal

WBC Count

11.41

Not Normal

Infection

Neutrophils Lymphocytes Monocytes Eosinophiles Basophils Platelet count MCV MCH MCHC

68.2 18 0.127 0.004 0.0001 284 84 30 35.60%

Normal Normal Normal Normal Normal normal Normal Normal Normal

LABORATORY RESULTS: ( October 18,2008) Test Hemoglobin Normal Results Values M:140124 170gm/l F: 120150gm/l M: 45-56 F: 37-47 M: 4.6 - 6.2 F: 4.2 - 5.40 Adult:5x10 / L NB: 9-10x 10 /L Adult: 60-70 NB:40-80 Adult:25-40 NB: 0-31 2-6 1-4 0.5-0.10 Adult:150450 80-100 fl 27-31 31-36 0.347 4.18 Analysis normal Significance

Hematocrit RBC

Normal Normal

WBC Count

10.07

Normal

Neutrophils Lymphocytes Monocytes Eosinophiles Basophils Platelet count MCV MCH MCHC

68.2 15 0.124 0.004 0.0001 264 84 30 35.70%

Normal Normal Normal Normal Normal normal Normal Normal Normal

IV FLUID SHEET: Date 10/18/08 10/19/08 10/20/08 10/21/08 10/22/08 Bottle # #1 #2 #3 #4 #5 Solutions PNSS D5LR PNSS PNSS PNSS PNSS volume 1 liter 1 liter 1 liter 1liter 1liter gtts / min Time started 20gtts/min 7:00 pm 20gtts/min 7:30pm 100gtts/min 7:00am 20gtts/min 4:00pm 20gtts/min 4:00am 20gtts 4:00pm consumed 7:00am 7:30am 4:00pm 4:00am 4:00pm 4:am

INTAKE AND OUT PUT: Date Oct.20, 2008 Water/juices and soup-1200 Oct.21, 2008 Oct 22,2008 IVF-1000 Water/juices and soup-800 IVF- 1000 Water/juices/and soup 1000 (+ )BM Urine output-1500 (-) BM Urine output- 1750 (-) BM Intake IVF- 1000 Output Urine output-1800

Fluid Serum:October 19, 2008 Test Sodium Uric acid Normal Values 137-145 2.5-6-4 Results 128mmu/l 9.4mg/dl

CHEST X-RAY: October 21, 2008 Chest xray (AP) view -non homogenous opacities are seen in both upper lobes Heart is not enlarge Aorta tortuous and sclerotic Diaphragm and sulci are intact Impression: PTB both upper lobes Atheromatous aorta

HEMOGLOBIN AIC: October 19, 2008 Patients result 9.1% reference value 4.5%-6.4%

I. Title Page II. Acknowledgement III. Brief Information IV. Theoretical Framework V. General Information VI. Activities of Daily Living VII. (Pre, Intra, And Post Hospital) VIII. Head to toe Assessment IX. Anatomy and Physiology X. Pathophysiology XI. Drug Study, Brand name, Generic name XII. Laboratory findings) XIV. Discharge Plan XV. Reflection and Insights Results (significant

XIII. Nursing Care Plan

XVI. Reference

ACKNOWLEDGEMENT:

We the BSN-III- B Group V-A would like to acknowledge to extend our perpetual thanks and appreciation to the following people who in many ways inspired us, became part of this case presentations. First our Lord who always guides us in our daily life, our beloved parents, love ones who never ceases to supports us and providing us whatever we need some financial. Our mentors who nurtures us knowledge, when it comes to theories. Our Clinical Instructors :

Mam Cristina Chua: our very supportive C.I. patiently supervising us in our skill teaches
every details of the procedures. A warm and accommodating CI whenever we approach her.

Mam Editha Vicente: warmhearted Clinical Coordinator who never embarrass us she always
ready to listen whatever problems and plight we have.

Mam Mary Ann D. Valenzuela: our beloved DEAN who is very supported and always
provide us good education and better facility for developing our skills to be a successful NURSE someday.

Lastly the whole groups who patiently did their best to do this output. GOD BLESS US.

DISCHARGE PLANNING:

MEDICATION: Follow up on the intake of medicine on time appropriate interest Monitor of blood glucose EXERCISE: Walking for 30 minutes and stretching and regular exercise walking and swimming THERAPY: Medical nutrition therapy for diabetesencourage client to intake low sugar. Fibers will slow the glucose absorption . HEALTH TEACHING: Thorough explanation to be extra careful to prevent any further complications and effective health teaching to reduce stress, anxiety and promotes adherence to plan care. OUT-PATIENT FOLLOW UP: Responds for follow up check up for continuing care and management. DIET: Eat diet high in fiber, avoid foods which high in sugar as well LOW FAT LOW SALT diet.

INSIGHT AND REFLECTION:

Experience is the best way to learn, practice is one way of mastering our craft. We could never imagine that were now in the level where we could develop our self esteem, self confidence, establishing rapport to our client is such an experience to us. We never ceases to us some vital information on our C.I about the concept we have. An experience we could never forget and it will stays in our hearts and mind that what we have learned and gained that could lead us into a better future and be competent nurse in the future. Looking forward I knew that what ever endeavor we have in our way this will serve us our tool in reaching our goals.

IV FLUID SHEET: Date 09/17/08 09/18/08 09/18/08 09/19/08 Bottle # #1 #2 #3 #4 Solutions PLR+2NB PLR+2NB PNSS PNSA volume 1 liter 1 liter 1liter 1liter gtts / min 25gtts/min 25gtts/min 20gtts/min 20gtts/min Time started 5:40am 5:00am 3:00pm 3:00am consumed 4:40am 3:00pm 3:00am 3:00pm

INTAKE AND OUT PUT: Date September 18 2008 Intake IVF- 1000 Water/juices and soup-1200 Output Urine output-1800 (+ )BM

Anatomy and physiology

Human Endocrine System The human endocrine system modulates several processes of the body by the function of hormones. The endocrine system secretes hormones that control how bodily functions work. Thus, the human endocrine system watches over and coordinates all the systems of the body by the use of hormones. Pituitary gland The pituitary gland is located at the base of the human brain. The gland consists of two parts: the anterior lobe (adenohypophysis) and the posterior lobe (neurohypophysis). The anterior lobe secretes at least seven hormones. One hormone, the human growth hormone (HGH), promotes body growth by accelerating protein synthesis. Another hormone of the anterior pituitary is prolactin, also called lactogenic hormone (LH). This hormone promotes breast development and milk secretion in females. A third hormone is thyroidstimulating hormone (TSH). The function of TSH is to control secretions of hormones from the thyroid gland. A fourth hormone is adrenocorticotropic hormone (ACTH). This hormone controls the secretion of hormones from the adrenal glands. There are three more hormones produced in the anterior lobe of the pituitary gland. The first is follicle-stimulating hormone (FSH). In females, FSH stimulates the development of a follicle, which contains the egg cell; in males, the hormone stimulates sperm production. The next hormone is luteinizing hormone (LH). In females, LH completes the maturation of the follicle and stimulates the formation of the corpus luteum, which temporarily secretes female hormones. In males, LH is interstitial cell-stimulating hormone (ICSH), which stimulates the production of male hormones in the testes. The final hormone is melanocytestimulating hormone (MSH), which stimulates production of the pigment melanin.

The posterior pituitary gland stores and then releases two hormones that are produced in the hypothalamus of the brain. The first hormone is antidiuretic hormone (ADH). This hormone stimulates water reabsorption in the kidneys. It is also called vasopressin. The second hormone is oxytocin, which stimulates contractions in the muscles of the uterus during birth. Thyroid gland The thyroid gland lies against the pharynx at the base of the neck. It consists of two lateral lobes connected by an isthmus. The gland produces thyroxine, a hormone that regulates the rate of metabolism in the body. It also produces a second hormone, calcitonin, which regulates the level of calcium in the blood. Thyroxine production depends on the availability of iodine. A deficiency of iodine causes thyroid gland enlargement, a condition called goiter. An undersecretion of thyroxine results in a condition known as cretinism (dwarfism with abnormal body proportions and possible mental retardation). In adults, an undersecretion results in myxedema (physical and mental sluggishness). Thyroxine oversecretion results in a high metabolic rate and Graves' disease. Parathyroid glands The parathyroid glands are located on the posterior surfaces of the thyroid gland. They are tiny masses of glandular tissue that produce parathyroid hormone, also called parathormone. Parathyroid hormone regulates calcium metabolism in the body by increasing calcium reabsorption in the kidneys, and by increasing the uptake of calcium from the digestive system. Adrenal glands The adrenal glands are two pyramid-shaped glands lying atop the kidneys. The adrenal glands consist of an outer portion, the cortex, and an inner portion, the medulla. The adrenal cortex secretes a family of steroids called corticosteroids. The two main types of steroid hormones are mineralocorticoids and glucocorticoids. Mineralocorticoids, such as aldosterone, control mineral metabolism in the body. Mineralocorticoid secretion is regulated by ACTH from the pituitary gland. Glucocorticoids, such as cortisol and cortisone, control glucose metabolism and protein synthesis in the body. Glucocorticoids are also anti-inflammatory agents.

Pancreas The pancreas is located just behind the stomach. Its endocrine portion consists of cell clusters called the islets of Langerhans. The pancreas produces two hormones: insulin and glucagon. Insulin is a protein that promotes the passage of glucose molecules into the body cells and regulates glucose metabolism. In the absence of insulin, glucose is removed from the blood and excreted in the kidney, a condition called diabetes mellitus. Diabetes mellitus is characterized by glucose in the urine, heavy urination, excessive thirst, and a generally sluggish body metabolism. The second pancreatic hormone, glucagon, stimulates the breakdown of glycogen to glucose in the liver. It also releases fat from the adipose tissue so the fat can be used for the production of carbohydrates. Other endocrine glands Among the other endocrine glands are the ovaries and testes. The ovaries secrete estrogens, which encourage the development of secondary female characteristics. The testes secrete androgens, which promote secondary male characteristics. Testosterone is an important androgen. The pineal gland is a tiny gland in the midbrain. Its functions are largely unknown, but it seems to regulate mating behaviors and daynight cycles. The thymus gland is located in the neck tissues. It secretes thymosins, which influence the development of the Tlymphocytes of the immune system. Prostaglandins are hormones secreted by various tissue cells. These hormones produce their effects on smooth muscles, on various glands, and in reproductive physiology. Erythropoietin is a hormone produced by the kidney cells. Erythropoietin functions in the production of red blood cells. Gastrin and secretin are hormones produced by digestive glands to influence digestive processes.

THEORETICAL FRAMEWORK: DOROTHEA OREM

Self care theory is based on four concepts, self care agency, self care requisities, and therapeutic self care demands. Self care refer to those activities an individual performs independently through out life, to promote and maintain personal ability, to perform self care activities. Most adults care for themselves , where us infants assistance with self care actrivities. Orem self care deficit theory explains not only when nursing is needed but also how people can be assisted thru five methods of helping : acting or doing for, guiding, teaching, supporting and providing an environment that promotes the individuals abilities to meet currents and future demands.

As student nurse we can guide our patients by teaching how to control and prevent any further complications of her disease.

Arterial blood gas ;October 19 2008 Patient result Ph Pco2 Po2 Hco3 So2 % 7.437 30.0mmHg 76mmHg 10.3mmol/L 96% Normal value 7.35-7.45 25-45mmHg 80-105mmHg 22-26mmol/L 95-98%

HGT MONITORING October 18,2008 12 midnight -111mg/dl 6am -147mg/dl October 19 2008 12 midnight- 159mg/dl 6am-195mg/dl October 20 2008 12 midnight- 131mg/dl 6am-139mg/dl Sugar negative October 21 2008 12 midnight- 118mg/dl 6am-107mg/dl

Urinalysis ;
Color- light yellow Appearance -slighty turbid Reaction 1.025 Albumin- +1

Microscopic Pus cell 25.30 Rbc 17.22 Epithelial cells rare Amorphous odor rare

Mucus thrend- few Others- ketone negative

Physiological Assessment Nursing diagnosis Nursing goal Nursing intervention Rationale

10-21-2008 Evaluation

Subjective: Hindi ko matugunan ang aking mga pangangailanganas verbalized by the patient Objective: -inability to bring food from receptacle to the mouth. -inability to wash body. -inability to maintain appearance at satisfactory level. -inability to carry out proper toilet hygiene. Physiological

Self care deficit related to weakness and fatigue as evidence by: Inability to manage activities at daily living.

Within 2-3 days of effective nursing intervention the patient will demonstrate techniques/life style changes to meet self care needs.

-monitor v/s,neuro v/s -determine age/developmental issues affecting ability of individual participate in own care. -determine individual strengths and skills at the client. allow sufficient time for accomplish task to fullest extent of ability. assist with medication regimen as necessary, encouraging timely use of medication. encouraging keeping a journal progress and participating of independent living skills to foster self care and self determination

-base line data

After 2-3 days of effective nursing g intervention the -to identify causative/contributing goal was met as evidence by patient factors demonstrating techniques/lifestyle changes to meet self care needs. -to assess degree of disability -to assist in correcting/dealing with situation

-To promote wellness

10-21-2008

Assessment Subjective: paano ko nakuha ang sakit ko?as verbalized by the patient. Objective: -request for information -statement of concern/misconceptions -inadequate follow through of instruction -inappropriate behaviors -verbalized of the problems

Nursing diagnosis Deficient knowledge related to unfamiliarity with information /lack of recall as evidence by: Request for information, inadequate follow through of instruction.

Nursing goal Within 1-2 hours of effective nursing intervention the patient will verbalized understanding of condition/disease process and treatment.

Nursing intervention -create an environment of trust by listening to concerns, being available.

Rationale - Support and respect need to be established before client will be willing to take part in learning process. -use of different means of assessing information promotes learner retention. -provide encourage with client can make informed lifestyle choices.

Evaluation After 1-2 hours of effective nursing intervention the patient verbalized understanding of condition/disease process and treatment.

-select a variety of technique strategies(demonstrate needed skills and have client do return demonstration) -discuss essential elements. -provide information relevant only to the situation to prevent topic overload. -discuss at a time avoid giving too much information in one session.

-to assess the clients motivation to facilitate learning.

Brand name Esomepraz ol

Generic name Nexi um

MOA Impaired renal function, gastric ulcer malignancy should be excluded, as may delay diagnosis and mask symptoms .pregnancy lactation children and elderly.

Dos ages 2mg

R/F 1cap once a day ac breakfast Per Orem

Adverse reaction Headache, abdominal pain, diarrhea .flatulence, nausea, vomiting and constipation. Nausea ,headache, rashes and GI disturbances

NURSING CONSIDERATION Treatment of GERD as an alternative to oral therapy in patients when may therapy is most appropriate. History: allergy to any thiazolidinedione type I diabetis,keto acidosis,serious hepatic impairment,advance d heart disease,pregnancy lactation. Physical: orientation reflexes,peripheral sensation,R,adventiti ous sounds liver evaluation,liver function tests,blood glucose and CBC.

Gliclazide

Diamicr on

-hepatitis and renal 30mg impairment,a small starting dose should be used w/ careful patient monitoring.as with other sulfonylureas,hypoglyce mia may occur of the patients dietary intake is reduced or if they are receiving a longer dose of diamicron than is required.

1tab once a day Per orem

Isordril

Relaxes vascular smooth Isosorbid muscle with a resultant 60mg decrease in venous e return and decrease in arterial BP,w/c reduce le

tab once a day at bed time Cns: headache,confusion,disor ientation,dizziness ,light headedness,syncope;

Brand name Xorymax

Generic NAME Cefuroxime

MOA Bactericidal inhibits systhesis of bacterial cell wall, causing cell death.

DOSAGE 500mg

R/F 1 tab 2x a day

ADVERSE REACTION Cns; headache, dizziness, lethargy, paresthesias GI; nausea, vomiting, diarrhea, anorexia, abdominal pain.

NURSING CONSIDERATION History liver and kidney dysfunction, actation pregnancy. Physical; skin status liver and kidney function test, culture if affected area, sensitivity test.

Actos

Pioglitazone

Resensitives tissue to insulin, stimulates 30 mg improve to the action of insulin receptor sites to lower blood glucose and improve the action of insulin, decreases hepaticgluconeogenisis and increases insulin dependent muscles glucose uptake

1 tab once a day after meal

Headache, pain ,myalgia

History ; allergy to any thiazilidinedione type 1 diabetis sketoacidosis serious hepatic impairment advanced heart disease, pregnancy lactation.