Phoebe E. Kionisala Ajerson M.

Gargar CASE PRESENTATION

January 24-27, 2012 ZCMC-ER (3-11) CI: MR. JONATHAN AGTUCA, RN

I. INTRODUCTION Diabetes is a kind of metabolic disease that is brought about by either the insufficient production of insulin or theinablitiy of the body to respond to the insulin formed within the system. There are 3 types of diabetes which are Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. This type 1 affects approximately 5%-10% of people with the disease; it is characterized by an acute onset, usually before the age of 30 (CDC,2008). Type 2 diabetes was also referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for their bodys needs, particularly in the face of insulin resistance. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle cells). Gestational diabetes can occur temporarily during pregnancy. Significant hormonal changes during pregnancy can lead to blood sugar elevation in genetically predisposed individuals.

II. ETIOLOGY OF THE DISEASE

High blood pressure High blood triglyceride (fat) levels Gestational diabetes or giving birth to a baby weighing more than 9 pounds High-fat diet High alcohol intake Sedentary lifestyle Obesity or being overweight Ethnicity, particularly when a close relative had type 2 diabetes or gestational diabetes; certain groups, such as African Americans, Native Americans, Hispanic Americans, and Japanese Americans, have a greater risk of developing type 2 diabetes than non-Hispanic whites.

Aging: increasing age is a significant risk factor for the type 2 diabetes. Risk begins to rise significantly at about age 45 ages, and rises considerably after age 65 ages.

IV. GENERAL INFORMATION Name: Verigilio Parojinog Address: Alicia, Zamboanga Sibugay Age: 47 years old Religion: Roman Chatholic Date of Birth: September 26, 1964 Place of Birth: Alicia, Zamboanga Sibugay Marital Status: Married Educational Attainment: College Graduate Course: Engineering

III. PATHOPHYSIOLOGY

Diabetes Mellitus Type 1

Diabetes Mellitus Type 2

PHYSICAL EXAMINATION General Appearance Height and Weight Norms Height and weight should be equal within normal range of BMI (18-25) BP: systolic (<120), diastolic (<80) mmHg T: 36.6C- 37.3C P: 60-80 beats/min R:12-20 breaths/min O2 Sat.: >95% Actual Finding Height: 165cm Weight: 48kg BMI: 17 BP: 130/90 mmHg T: 36.9C P: 97 beats/min R: 25 breaths/min O2 Sat.: 98% Analysis/Interpretation BMI of 17 indicates underweight. BP is in upper limit, temperature and O2 sat. are within normal range , pulse is higher, respiratory rate is increase (tachypnea). Sympathetic Nervous system is triggered causing some body systems to increase their function than usual, i.e. respiratory system is increasing together with cardiovascular system that the hearts pumps faster causing elevated in BP Normal findings

Vital Signs

Eye

Eyes clear and bright; positive blink reflex; no lid lag, ectropion, or entropion, lesions on lids; sclera white; conjunctivae clear and glossy External ear canals clear without redness, swelling, lesions,or discharge. Lungs clear; no adventitious breath sounds. R:12-20 breaths/min, unlabored breathing, trachea midline Pulses +2, no bruits or thrills, no varicose veins. P: 60-80 beats/min Bowel movement < 3 times/day, presence of bowel sounds in all quadrants. +2 pulses, Full ROM of upper extremities, +5 muscle strength

Ear

Respiratory System

Cardiovascular System Gastrointestinal

Eyes clear and bright; positive blink reflex; no lid lag, ectropion, or entropion, lesions on lids; sclera white; conjunctivae clear and glossy External ear canals clear without redness, swelling, lesions,or discharge. Lungs clear; no adventitious breath sounds. R:25 breaths/min, labored breathing, trachea midline Pulses +3, no bruits or thrills, no varicose veins. P: 97 beats/min Bowel movement: once a day, presence of bowel sounds in all quadrants +3 pulses, Full ROM of upper extremities, +4 muscle strength

Normal findings

respiratory rate is increase (tachypnea). O2 supply administered at 2L/min. Due to SNS stimulation, respiratory rate is increase. Bounding pulse

Normal findings

Extremities

Integumentary System

Skin even in color, warm, dry, positive turgor, no suspicious lesions. Nails pink, brisk capillary refill, no clubbing.

Genito-Urinary System Immunization if any

Normal urine output >30ml/hr or >720ml/day

Skin even in color, slightly warm, dry, positive turgor, no suspicious lesions. Nails pink, brisk capillary refill, no clubbing. Hair clean, coarse, slightly graying, evenly distributed. Urine output: Approximately 950/day not noted

Bounding pulse, full ROM against gravity and moderate amount of resistance (+4). Arterial resistance is increasing because the vasoconstriction occurs leading to bounding pulse. Hair gray due to age, skin slightly warm (impaired circulation)

Normal findings

Activity of Daily Living Self-care activities

Before hospitalization Patient is a government employee, going to work by jeep/tricycle. Able to perform ADL (bath, change attire, eat) independently.

During hospitalization Patient is totally dependent to watchers in all activities.

Sleep & rest

Habits/exercises

Patient is usually sleeps 6-7 hours a day, and occasionally having outings with family during weekends. Patient smokes, and drinks occasionally. Seldom exercise. Fond drinking soft drinks

Patient is having difficulty in sleeping, frequent awakenings at night.

Analysis/Interpretation Muscle coordination weakness to perform ADL independently due to most of the energy is used in autonomic nervous system rather than somatic causing muscle weakness. Adjustment to hospitalization and loss of appetite.

Patient drinks water several times and eats small frequent feedings.

Active ROM applied for exercise. Frequent feeding to compensate nutritional status.

V. CULTURE AND LIFESTYLE His physical activity includes doing house holed chores. He doesnt want to do any strenuous activity because he easily gets tired. His diet is mostly carbohydrates, some fibers and lots of soft drinks as beverages. VI. SOCIOECONOMIC He wasnt able to support his family or even to pursue his career due to his illnesses preventing him to be active and independent. His wife supports him and the family financially and for the medication as well. VII . INTRAPERSONAL He views himself as a strong person. His family is his source of hope and strength to continue his life. He has good faith and thinks positively for his fast recovery. VIII. INTERPERSONAL Patient has a good relationship with his family, friends and relatives. Though he suffers in his condition, but they have a mutual relationship among families. IX. EXTRAPERSONAL FACTORS He has been admitted in the hospital for the past four years due to UTI, Kidney stones, HPN, gastric ulcer, and Diabetes mellitus. He has an insulin injection for daily usage. The expenses are shouldered by the relatives. SUMMARY/CONCLUSION 1. Physiological, appearance during admission, chief complaint, diagnosis. Patient came in to ER, with a chief complaint of fever, loss of appetite and claimed to have Diabetes Mellitus. Patient came in with watchers, oriented with time, date and place, diaphoretic, pale and cool to touch skin. Patient was weak. IV line was started. 2. Phsyco-social cultural factor Patient has a good relationship with his family and good working relationship with workmates. Patient is updated with current issues, and fond to read newspapers everyday. 3. Developmental factor Patient is categorized in Middle Adulthood (Erik Erikson); Generativity vs. Stagnation. Patient has a family, a career and goals in life, responsible to be a husband and a father of four children. 4. Spiritual, belief system Patient is a Catholic and believes that God has the power to take over ones life.

Ajerson M. Gargar BSN IVA, 2008200851

January 24-27, 2012 ZCMC-ER (3-11) CI: MR. JONATHAN AGTUCA, RN

LEARNING FEEDBACK DIARY

My first time exposure in Emergency room was really challenging, tiring but worth it. Theres really a need to prepare oneself with sufficient background, knowledge, skills and attitude in dealing with patients especially ER patients. The nurse should move faster, efficient and creative enough to minimize the time consume for one patient while entertaining other patients. Theoretical knowledge would not be enough without hands-on or practical interventions. Some nursing procedures that have been taught or demonstrated at school are realistically being applied here and a nurse should always be ready. Aseptic technique and sterility of instruments and in any nursing interventions should always be observed and maintain. Self-precaution is the nurse responsibility by wearing gloves, hand-washing before and after and mask to prevent contamination. ER personnel should be trained to start on IV line efficiently. Vital signs taking is the most important intervention should a nurse should a nurse need to observe especially with a critically ill patients. Due to lack of resources, a nurse should have simple instruments with her at all times, i.e. scissors, tourniquet, stethoscope, alcohol, thermometer, 4-color ball pen, small notebook and gloves. Cooperation among ER personnel is really necessary to meet the high number of patients. A four-day exposure in ER, I have learned many procedures to name, urinary catheterization, assisting in minor surgery and minor suturing, vital signs taking efficiently, starting an IV line, IVF calculation, different instruments in ER, taking ECG tracing, ECG 2 and 12-lead, administer medications via IV port, endotracheal tubing placement, nasogastric tube placement, emergency drugs, different color coded waste, some common OR instruments, different IV fluids, the many types of sickness and diseases, flowing of ER procedures, post-mortem care, ER F-DAR, BLS and CPR, proper documentations/charting, different units in ER i.e. Ob-gyn, Pediatrics, Medical, Surgical and Triage units. In a nutshell, to work in ER surroundings is to work faster and anticipating smartly and personally I think, I myself lacking more experiences and needs more exposure in the future.