diabetes mellitus 2

Holy Angel University College of Nursing

Angeles City

In Partial Fulfillment ofRequirements in NCM104-RLE

Diabetes Mellitus Type 2

A CASE STUDY

Group 3/ Subgroup 2N-405

I. INTRODUCTION

1. Description

Diabetes mellitus is a group of metabolic diseases characterized by high blood

sugar (glucose) levels that result from defects in insulin secretion, or action, or both. In

patients with diabetes, the absence or insufficient production of insulin causes

hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be

controlled, it lasts a lifetime.

Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-dependent

diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder that is characterized by

high blood glucose in the context of insulin resistance and relative insulin deficiency.

Over time, diabetes can lead to blindness, kidney failure, and nerve damage.

These types of damage are the result of damage to small vessels, referred to as

microvascular disease. Diabetes is also an important factor in accelerating the hardening

and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease,

and other large blood vessel diseases.

There are an estimated 23.6 million people in the U.S. (7.8% of the population)

with diabetes with 17.9 million being diagnosed, 90% of whom are type 2. With

prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as

an epidemic.

World

Prevalence of diabetes worldwide

2000 2030

World 171,000,000 366,000,000

Philippines 2,770,000 7,798,000

http://en.wikipedia.org/wiki/Epidemic

http://en.wikipedia.org/wiki/Centers_for_Disease_Control_and_Prevention

http://www.medicinenet.com/script/main/art.asp?articlekey=87976






http://en.wikipedia.org/wiki/Insulin_resistance

http://en.wikipedia.org/wiki/Metabolic_disorder

http://en.wikipedia.org/wiki/Diabetes_mellitus

http://en.wikipedia.org/wiki/Insulin


Chan-Cua said the Philippines is still low on this score compared with

other countries, especially Scandinavian nations like Finland, Sweden, and Norway, but

we are also seeing an increase every year. Moreover, mathematical modeling on

projection yields that 380 million people are expected to develop diabetes by 2025 based

on International Diabetes Federation/World Health Organization data, a good percentage

will be coming from Southeast Asian countries, including the Philippines. This finding

is no longer astonishing considering the latest statistics on Filipinos afflicted with

diabetes and hypertension which continues to increase on the scale of medical records.

This goes to show that statistics on Diabetes Mellitus in the Philippines continues to be

unfavorable to the general population because of the continuous rise in the number of

Filipinos developing diabetes every year which adds to the number of people who

cannot enjoy life and are becoming less productive due to this disease.

Objectives

The researches have the following objectives in this case study:

Described and explained Diabetes Mellitus together with the risk factors

contributing to the occurrence of the condition.

Reviewed the anatomy and physiology of the organs involved.

Interpreted the results in the laboratory and diagnostic procedures done

with the patient including their purposes, and specific nursing

responsibilities before, during and after the procedure.

Enumerated the different medications administered for the condition, their

indications and specific nursing responsibilities.

Formulated significant nursing diagnoses, with their significantly related

nursing care plans.

II. NURSING HISTORY

1. PERSONAL HISTORY

a. Demographic data

Mr. Sugar, a 52 years old male who is not married and has no children, was born

on June 27, 1957 at Porac Pamapanga. He is pure Filipino. Mr. Sugar graduated Business

and Accountancy at the college of Holy Angel University. After graduation, he worked

for 16 years at Saver’s Bank Guagua. He presently resides at Baidbid, Porac Pampanga

with his younger brother.

b. Socio-economic and Cultural factors

Mr. Sugar used to work at the bank for 16 years. Due to a confidential incident at

work, Mr. Sugar was asked to leave the company. When he did, he decided to stay with

his brother and help at the bakery. He never smoked and used to drink. When he was

diagnosed, he stopped drinking. He regularly has a walk in the morning as a form of

exercise. He is not choosy in eating foods and loves to eat fruits regularly.

Mr. Sugar is a Roman Catholic. Last 3 years ago he made a habit of going to Apo

to visit the church there but rarely attends mass. Since he grows up at Porac, he usually

speaks the dialect Kapampangan and Tagalog.

When it comes to health practices, he usually practices self medicate when the

sickness isn’t severe and tolerable. Paracetamol is the usual medications they use for

treating colds and colds. He doesn’t use herbs or seek herbalarios or albularyo. If his

condition gets worse, medical attention is sought. He usually goes to Porac District

Hospital for check-ups and emergency cases. Aside from emergencies, he has an annual

check up with his private doctor.

2. FAMILY HEALTH ILLNESS HISTORY

Mr. Sugar is eight child of twelve children. Diabetes Mellitus runs in the family.

His grandfather and father had Diabetes 2 while his mother was diagnosed with

hypertension and died because of a stroke. Among his siblings, one has hypertension and

the two has Diabetes Mellitus while the others are almost at pre-hypertension. His brother

before him is his twin who experiences almost the same as he does.

3. HISTORY OF PAST ILLNESS

Mr. Sugar was a drinker before. When he is working, he noticed that he got really

weak and easily fatigue, so he decided to get a check up and was diagnosed to have

Diabetes Mellitus type 2 on 1985. Medications were given to control his situation such as

Metformin and a device such as Glucoplus to monitor his blood glucose.

Hypertension arised last 3 months ago and was prescribed a maintenance of Neoblock

one tab every morning and Combizar at night.

Mr. Sugar thought his medications would maintain his health but one month ago, his eyes

started to swell and the doctor said that it was diabetic retinopathy. Thus, he had

undergone laser therapy to prevent further damage.

4. HISTORY OF PRESENT ILLNESS

On November 13, 2009, Mr. Sugar started to have the feeling of fullness but

didn’t affect his appetite. He also noticed that his bowel pattern started to change because

the urge to defecate is gone.

After 2 days, he started to vomit a lot of times. He mentioned that “parang hindi

nadigest ang mga kinakain ko.” Mr. Sugar was afraid to go to the hospital but his brother

noticed him getting weak and pale. He went to Porac District Hospital on November 17,

2009 at 7:30pm with a chief complaint of body weakness and abdominal pain.

Diagnostics exams were done and his tentative diagnoses were constipation, Diabetes

Mellitus type 2 and Pre-renal disease.

He was then admitted for observation and treatment. A stool softener, Senokot 2

tabs was prescribed so that he can eliminate and to lessen the abdominal pain. On

November 18, 2009 when the student nurses had their nurse-patient interaction, the

patient stated he defecated twice and the pain eased.

5. PHYSICAL EXAMINATION

November 17, 2009 (Admission)

Vital Signs: Bp- 160/110 mmHg; PR- 90bpm; RR- 19bpm; T- 36.4 ºC\

Chief complaint: Constipation and body weakness

General Appearance:

SKIN: Pale No lesions observed Dry skin

HEENT: Head

Hair is thin and quite moist, black with minimal white hair strands Even distribution of hair

No dandruff observedEyes

Pale palpebral conjunctiva Anicteric sclera Patient has blurred vision

Ears External canal is clean No discharge noted

Nose No discharge seen

Tongue and mouth Incomplete set teeth Pale lips Dry lips No breath odor

LUNGS: Chest expands during inhalation

ABDOMEN: Rigid upon palpation

MUSCULOSKELETAL: No edema

November 18, 2009 Vital Signs: Bp- 170/90 mmHg; PR- 80bpm; RR- 20bpm; T- 36 ºC

General Appearance:

Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair

disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left

hand.

Assessment:

SKIN: No lesions observed

Skin is moist and warm

HEENT:

Head

Hair is black with minimal white hair strands

Even distribution of hair

No dandruff observed

Eyes

Pale palpebral conjunctiva

Anicteric sclera

Patient has a blurred vision

Pupils are constrict when in light and dilates when the light is removed

Ears

External canal is clean

No discharge noted

Pinna recoils after it is folded (<2secs)

Nose

No discharge seen

Can breath with one nostril occluded

Tongue and mouth

Dry lips

Incomplete set of teeth

No breath odor

NECK:

Lymph nodes are palpable

LUNGS:

chest expands during inhalation

ABDOMEN:

Non-tender upon palpation

Flabby

With bowel movement (twice in one day as stated by patient)

GENITO-URINARY:

With urinary frequency

UPPER AND LOWER EXTREMITIES

With dry cracking fissures on the soles of the feet.

With non-pitting edema on both lower extremities

Capillary refill: 1-2 secs.

6. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostic/ Laboratory Procedures

Date OrderedDate results IN

Indication orPurpose

Results Normal Values

Analysis and Interpretation of results

Complete Blood Count (CBC)

WBC count

11/17/09

-Measures the number of WBCs in a cubic mm of blood.-It is used to detect infection or inflammation and to monitor client’s response to or adverse effects of chemotherapy or radiation therapy.

11.7 x 10g/L

5-10 x 10 g/L

The result is slightly above the normal range which may signify infection.

Lymphocytes -To determine immune function, provides a gross measure in nutritional status.

0.21 0.20 - 0.40 The result is within the normal range.

Eosinophils -To fight infection and control mechanism associated with allergies and asthma.

0.01 0.01 - 0.06 The result is within the normal range.

Hemoglobin -To evaluate the hemoglobin content (iron status and O2 carrying capacity) of erythrocytes by measuring the no. of grams of

107g/L 140 - 180 g/L

The result is below the normal range which indicates anemia.

hemoglobin /dl of blood.

Hematocrit - Measures the volume of RBCs in whole blood expressed as a percentage.- It is also a useful in the diagnosis of anemia, polycythemia, and abnormal hydration states.-Value is roughly three times the hemoglobin concentration.

0.32 0.40 – 0.54 The result is below the normal range which indicates anemia.

Nursing Responsibilities:

Prior to the procedure:

Explain the procedure to the pt. and why it is indicated

Inform the patient that fluid and food restriction is not required

Inform the patient that a blood sample will be taken.

Tell the patient that he may experience transient discomfort from the needle

pincture

Fill up laboratory request form properly and send it to the laboratory technician

during the collection of sample/specimen.

During the procedure:

Inform the patient that pain may be felt through prick in the needle

Instruct the patient to calm down to avoid uneasiness.

After the procedure:

Apply brief pressure to prevent bleeding

Apply warm compress if Hematoma will develop at the venipuncture site.






Random Blood Sugar

11/17/09 To measure blood glucose regardless of when you last ate.

145.3 mg/dl

< 140 mg/dl

The result is above the normal range which indicates too little insulin/ diabetes mellitus.



Inform patient that there are no food restrictions.

Wash your hands thoroughly before beginning procedure.

Ready your meter according to on-screen instructions or owner's manual (every

meter is slightly different).


Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry

or dry with gauze.

Wipe away the first drop of blood

Squeeze slowly and rhythmically, gripping the digit firmly between the base of

thumb and first finger.


Check for sample acceptance and allow time for the machine to work. Apply firm

pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.

Record your glucose level and follow your physician's guidelines pertaining to

necessary actions for low or high glucose levels.






Kidney Function Test

Createnine

11/17/09

To monitor renal function, specifically the ability of the kidney to excrete waste products

3.7 mg/dl

0.4-1.4 mg/dl

Creatinine level is above the normal range which indicates kidney impairment.



Explain to the patient the purpose of the procedure.

Inform the patient that he need not restrict food or fluids before the test, NPO

post midnight

Check the patient’s history for use of drugs that may influence test results.

Inform the patient that the test requires blood sample. Explain whom will perform

the venipuncture and when it will be done


Explain to the patient that may experience slight discomfort from the needle

puncture and the tourniquet but that collecting the sample usually takes less than 3

minutes



Apply warm compress if Hematoma develops at the venipuncture site.

Apply pressure on the site to avoid bleeding.


Date OrderedDate results




INSerum Electrolytes

Sodium (Na)

11/17/09

To reflect water balance.

135.2 mmol/L

137 – 145 mmol/L

The result is below the normal range which indicates that there is a relative increase in the amount of body water relative to sodium.

Potassium (K)

To evaluate fluid and electrolyte balances and identify renal dysfunction. Potassium is critical to neuromuscular function, specifically skeletal and cardiac muscle activity.

3.6 mmol/L

3.6 – 5.0 mmol/L

The result is within the normal level which indicates normal osmotic pressure and cardiac and neuromuscular electrical conduction.

Chloride (Cl) It reflects a change in the dilution or concentration of the ECF and does so in direct proportion to sodium concentration.

97 mmol/L

96 – 110 mmol/L

The result is within the normal range which indicates normal balance of fluids.

Before the procedure:

Explain to the patient that the test is used to evaluate the electrolytes content of

blood.

Inform the patient that he need not restrict food or fluids before the test, NPO

post midnight

Check the patient’s history for use of drugs that may influence test results.

Inform the patient that the test requires blood sample. Explain whom will perform

the venipuncture and when


Explain to the patient that may experience slight discomfort from the needle

puncture and the tourniquet but that collecting the sample usually takes less than 3

minutes



Apply warm compress if Hematoma develops at the venipuncture site.

Apply pressure on the site to avoid bleeding.






Fasting Blood Sugar (FBS)

11/18/09 To measure blood glucose after you have not eaten for at least 8 hours. It often is the first test done to check and monitor treatment of diabetes.

146 mg/dl

70 – 110 mg/dl

The result is above normal range which indicates too little insulin/ diabetes mellitus.



Ask patient if he/she had not eaten at least 8 hours.

Wash your hands thoroughly before beginning procedure.

Ready your meter according to on-screen instructions or owner's manual (every

meter is slightly different).


Swab your finger tip (or arm if your meter allows) with alcohol and allow to dry

or dry with gauze.

Wipe away the first drop of blood

Squeeze slowly and rhythmically, gripping the digit firmly between the base of

thumb and first finger.


Check for sample acceptance and allow time for the machine to work. Apply firm

pressure to puncture with an alcohol wipe, gauze or a bandage while you wait.

Record your glucose level and follow your physician's guidelines pertaining to

necessary actions for low or high glucose levels.

III.ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The body’s

primary energy source is glucose, a simple sugar resulting from the digestion of foods

containing carbohydrates (sugars and starches). Glucose from the digested food circulates

in the blood as a ready energy source for any cells that need it. Insulin is a hormone or

chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin

bonds to a receptor site on the outside of cell and acts like a key to open a doorway into

the cell through which glucose can enter. Some of the glucose can be converted to

concentrated energy sources like glycogen or fatty acids and saved for later use. When

there is not enough insulin produced or when the doorway no longer recognizes the

insulin key, glucose stays in the blood rather entering the cells.

Anatomy of the pancreas:

The pancreas is an elongated, tapered organ located across the back of the

abdomen, behind the stomach. The right side of the organ (called the head) is the widest

part of the organ and lies in the curve of the duodenum (the first section of the small

intestine). The tapered left side extends slightly upward (called the body of the pancreas)

and ends near the spleen (called the tail).

The pancreas is made up of two types of tissue:

Exocrine tissue

The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a

network of ducts that join the main pancreatic duct, which runs the length of the

pancreas.

Endocrine tissue

The endocrine tissue, which consists of the islets of Langerhans, secretes

hormones into the bloodstream.

Functions of the pancreas:

The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine tissue in the pancreas help break down

carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel

down the pancreatic duct into the bile duct in an inactive form. When they enter

the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate

to neutralize stomach acid in the duodenum.

The hormones secreted by the endocrine tissue in the pancreas are insulin and

glucagon (which regulate the level of glucose in the blood), and somatostatin

(which prevents the release of the other two hormones.

Anatomy of kidney

The kidneys play key roles in body function, not

only by filtering the blood and getting rid of waste

products, but also by balancing levels of electrolytes in the

body, controlling blood pressure, and stimulating the

production of red blood cells.


The kidneys are located in the abdomen toward the back, normally one of each

side of the spine. They get their blood supply through the renal arteries directly from the

aorta and send blood back to the heart via the renal veins to the vena cava. (The term

"renal" is derived from the Latin name for kidney.)

The kidneys have the ability to monitor the amount of body fluid, the

concentrations of electrolytes like sodium and potassium, and the acid-base balance of

the body. They filter waste products of body metabolism, like urea from protein

metabolism and uric acid from DNA breakdown. Two waste products in the blood can be

measured: blood urea nitrogen (BUN) and creatinine (Cr).

Kidneys are also the source of erythropoietin in the body, a hormone that

stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor

the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the

body starts to manufacture more red blood cells.




IV. THE PATIENT AND HIS ILLNESSa. Schematic diagram

Pathophysiology (book–based)

b.1. Definition of the disease

Diabetes Mellitus

Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly

known as adult-onset diabetes, it usually affects people aged over 40 and

progresses gradually. In this type the pancreas has not ceased to produce insulin,

but the quantity is insufficient, or the hormone is not stimulating the glucose

uptake in muscles and tissues required for energy. The result is a build-up of

glucose in blood and urine.

Although the cause of this malfunctioning is unclear, non-insulin

dependent diabetes mellitus tends to run in families. Other risk factors, such as

increasing age, obesity, and a sedentary lifestyle, probably contribute to its

increased incidence in developed countries.

Non-insulin dependent diabetes mellitus can often be controlled initially

by diet alone, or in combination with tablets that reduce the amount of blood

glucose. There are two main types of blood glucose-reducing drugs:

sulphonylureas work mainly by stimulating the pancreas’s islet cells (known as

the islets of Langerhans) to produce more insulin and biguanides increase the

effectiveness of insulin on cells. Eventually, however, patients may need insulin

injections.

Prerenal Acute Renal Failure

It is categorized as an acute renal failure which is characterized by inadequate

blood circulation (perfusion) to the kidneys, which leaves them unable to clean

the blood properly. Many patients with prerenal ARF are critically ill and

experience shock (very low blood pressure).There often is poor perfusion within

many organs, which may lead to multiple organ failure.

Prerenal ARF is associated with a number of preexisting medical

conditions, such as atherosclerosis ("hardening" of the arteries with fatty

deposits), which reduces blood flow. Dehydration caused by drastically reduced

fluid intake or excessive use of diuretics (water pills) is a major cause of prerenal

ARF. Many people with severe heart conditions are kept slightly dehydrated by

the diuretics they take to prevent fluid buildup in their lungs, and they often have

reduced blood flow (underperfusion) to the kidneys

b.2. Predisposing Factors

Age - Type 2 DM usually occurs at the age 40 years old and above. Type 2 DM

occurs most commonly in people older than 30 years who are obese.

Family history of DM - Type 2 DM has a strong genetic component. Although the

major gene that places the patient at risk is not yet identified, it is clear that the

disease is polygenic and multifactorial. Individuals with a parent with type 2 DM

have an increased risk for diabetes. Genetic factors are thought to play a role in

insulin résistance and impaired insulin secretion in type 2 DM.

Race (African-Americans, Hispanic-Americans) - The risk for type 2 diabetes

varies among population groups. Diabetes also seems to pose higher or lower

risks for specific complications among racial groups.

Precipitating Factors

Obesity - Elevated levels of free fatty acids, a common feature of obesity, may

contribute to the pathogenesis of type 2 DM. It can impair glucose utilization in

skeletal muscles, promote glucose production by the liver and impair beta cell

function.

Environmental Factors/Stress – An increase in stress hormone triggers the release

of epinephrine and norepinephrine which will promote the secretion of glucose

leading to hyperglycemia.

Inactive Lifestyle – A risk factor that had contributed in the occurrence of DM

due to the fact that lack of muscle activities decreases the need for the body to

utilize glucose as a form of energy.

Diet – Foods rich in carbohydrates can easily promote the increasing level of

glucose along the bloodstream.

Prerenal Risk Factors

Atherosclerosis cause obstruction to the flow of blood reaching the kidneys

Blood loss can lead to the constriction of the arteries carrying blood throughout

the body, reducing the volume of blood reaching various organs including the

kidney

Heart disease can lead to a reduction in the pumping effect of the heart, reducing

the amount of blood reaching the kidneys and other organs.

b.3. Signs and Symptoms with Rationale

Diabetes Mellitus

HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)

May be due to lack of physiologically active insulin that transports

glucose from extracellular to intracellular leading to accumulation of

glucose in the intravascular space. The glucose is not utilized by the body

and it remains in the blood streams.

POLYURIA

Increased frequency of urination. This may be due to the osmotic diuretic

effect of the glucose, wherein it attracts water during urination.

POLYDIPSIA

Increased thirst and fluid intake. This may be due to the activation of the

thirst center in the hypothalamus resulting form the intracellular

dehydration or volume depletion.

POLYPHAGIA

Increased hunger and food intake. This may be due to the decrease glucose

uptake by the cells leading the stimulation of the satiety center in the

hypothalamus resulting to the ‘hunger sensation.”

WEAKNESS/ FATIGUE

This is due to the decreased glucose uptake by the cells leading to

decreased energy production.

http://healthinfo.healthcommunities.com/heartdisease/index.shtml

GLYCOSURIA

The kidney filters the blood, making it to its normal state. Glucose was

filtered out and excreted in the urine.

Due to the excess glucose ad compared to the kidney threshold, which

results to the excretion of glucose in the urine.

GASTROPARESIS (Stomach fullness) ,CONSTIPATION and BLOATING

This is due to changes in nerves and damages the blood vessels that carry

oxygen and nutrients to the nerves. Over time, high blood glucose can

damage the vagus nerve. The stomach fails to empty properly and is likely

due to the generalized neuropathy.

NAUSEA/ VOMITING

Due to stomach fullness, there will be an involuntary emptying of

stomach contents that are forcefully expelled by the mouth.

A compensatory mechanism due to acidity of body because of decrease

excretion of metabolic waste.

PALE

Due to decreased production of erythropoietin.

a. Schematic diagram of the disease

PATHOPHYSIOLOGY(client-centered)

b.1. Predisposing/ Precipitating Factors

Predisposing Factors

Age- 52 years old.

Heredity- patient’s grandfather and father has DM

Precipitating Factors

Sedentary lifestyle

b.2. Signs and Symptoms

Gastroparesis( Stomach fullness) and Constipation

o November 13, 2009

o This is due to changes in nerves and damages the blood vessels

that carry oxygen and nutrients to the nerves. Over time, high

blood glucose can damage the vagus nerve. The stomach fails to

empty properly and is likely due to the generalized neuropathy.

Nausea/vomiting

o November 15, 2009

o Due to stomach fullness, there is a involuntary emptying of

stomach contents that are forcefully expelled by the mouth.

o A compensatory mechanism due to acidity of body because of

decrease excretion of metabolic waste.

Hyperglycemia

o November 17, 2009

o Due to lack of physiologically active insulin that transports

glucose from extracellular to intracellular will lead to

accumulation of glucose in the intravascular space. The glucose is

not utilized by the body and it remains in the blood streams.

Hypertension

o November 17, 2009 160/110 mmHg

o Due to increase in osmotic pressure, fluid goes to the vascular

space increasing the blood volume.

Weakness/fatigue

o November 17, 2009

o Due to decreased glucose uptake by the cells leading to decreased

energy production.

Pale

o November 17, 2009

o Due to decreased production of erythropoietin.

V. PATIENT AND HIS CARE

1. Medical Management

a. IVF

Medical Management

Treatment

Date Ordered/ Date

Performed/Date

Changed/ D/C

General Description

Indication or Purpose

Client’s response to the

treatment

Plain Normal

Saline

Solution

(PNSS)

1L x

40gtts/min.

11/17/09 An aqueous

solution of 0.9

percent sodium

chloride,

isotonic with the

blood and tissue

fluid, used in

medicine chiefly

for bathing

tissue and, in

sterile form.

It can be used for

hydration, and,

as a solvent for

drugs that are to

be administered

parenterally.

The drug was

administered

properly, with

expected effects

achieved, and

the patient did

not experience

dehydration.


Prior the procedure:

Read the doctor’s order

Check IV label


Check for patency of tubing

Regulate as ordered


Check IV infusion and amount every 2 hours

b. Drugs

Name of Drug

Date Ordered/

Date Taken/Date

Changed/ D/C

Route of administration,

Dosage and Frequency of administration

General Action, ClassificationMechanism of

Action


medication

Generic Name:

metoclopramide

Brand Name:

Plasil

11/17/09 1 amp, IV

STAT then q 8

An anti-emetic

drug that blocks

dopamine, but also

stimulates

acetylcholine to

increase gastric

emptying. It

increases the force

of gastric

contraction, relaxes

pyloric sphincter,

and increases

peristalsis in the

duodenum and

jejunum without

affecting the

motility of the

large intestine.

The patient did

not vomit the

day after the

medication was

given and has

bowel

movement.


Prior to Administration

-Check patient’s name before administration

-Check the doctor’s order

-Prepare the medication as ordered.

-Explain the purpose, indication and possible adverse effects of the medication.

After Administration

-Monitor bowel movement.

-Instruct patient not to drink alcohol during therapy.

Name of Drug

Date Ordered/

Date Taken/Date

Changed/ D/C




Action


medication

Generic

Name:

Senna

Brand Name:

Senokot

11/17/09 2 tabs, It is laxative that is

used as a short-term

treatment of

constipation and to

evacuate the colon

for bowel or rectal

examinations.

The patient had

defecated.







-Monitor bowel movement.

-Instruct patient not to drink alcohol during therapy.

Name of Drug

Date Ordered/

Date Taken/Date

Changed/ D/C




Action


medication

Generic

Name:

metoprolol

Brand Name:

Neobloc

11/17/09 1 tab, PO, OD Metoprolol is in a

group of drugs

called beta-

blockers. It is a

selective inhibitor

of beta1-adrenergic

receptors affecting

the heart and

circulation. It is

used to treat angina

and hypertension.

Patient’s blood

pressure is still

high. From

160/110 mmHg

upon admission

rises to 170/ 90

mmHg.








-Monitor for signs of tachycardia, palpitations and especially blood pressure

-Instruct patient to sit before standing

Name of Drug

Date Ordered/

Date Taken/Date


Dosage and Frequency of


Action


medication

Changed/ D/C

administration

Generic

Name:

losartan

Brand Name:

Combizar

11/17/09 1 tab, PO, OD Losartan is in a

group of drugs

called angiotensin II

receptor

antagonists.

Losartan keeps

blood vessels from

narrowing, which

lowers blood

pressure and

improves blood

flow. It is also used

to slow long-term

kidney damage in

people with type 2

diabetes who also

have high blood

pressure

Patient’s blood

pressure is still

high. From

160/110 mmHg

upon admission

rises to 170/ 90

mmHg.








-Monitor for signs of tachycardia, palpitations and especially blood pressure

-Instruct patient to sit before standing

Name of Drug

Date Ordered/

Date Taken/Date

Changed/ D/C




Action


medication

Generic

Name:

metformin

Brand Name:

Glucophage

11/17/09 1 tab, PO, OD It decreases hepatic

glucose production,

decreasing

intestinal absorption

of glucose and

improves insulin

sensitivity

Glucose level of

the patient may

decrease. ( No

available data)







During Administration

-Instruct the patient to calm down to avoid uneasiness.


-Monitor glucose level closely in this patient because severe hypoglycemia may result

before the patient develops symptoms.

-Advice patient to avoid vigorous exercise immediately after dose.

-Inform patient to avoid alcohol, which lowers glucose level.

c. Diet

Type of dietDate started/ Date changed

General description

Indication or purpose.

Client’s response and/or reaction to the

dietNothing per

orem (NPO)

11/17/19 It is a type of

diet that

withholds oral

fluids and

foods.

Indicated for patients unable to consume a regular diet and patients wild mild G.I. problems.

Since the patient

was oriented

and understands

needed

interventions, he

followed with

the doctors

prescriptions.

Nursing ResponsibilitiesPrior Verify doctor’s order. Explain the diet prescribed to the patient. Instruct patient to withhold oral fluids and foods.

During Ensure that the patient strictly follow the diet.

After Assess for patient’s condition; how he responds to the diet.

d. Exercise/ Activity

Type of exercise

General description

Indication or Purpose

Date Ordered,

Date Started,

Date Changed or

D/C

Client’s Response and/or reaction to

activity

Keep rested An activity where strenuous activities should be avoided. Bed rest should be implemented

Indicated to avoid fatigue.

11/17/09 Patient responded to doctor’s order and stated decreased body weakness.

but with assisted bathroom privilege to avoid further aggravation of the gangrene and to reduce pain as well.

Nursing Responsibilities

Prior

Check doctor’s order for any other considerations needed.

Explain the activity to the patient.

Explain why it is important and what it could improve in her condition.

During

Assess patient’s present condition.

Reinforce information as appropriate.

After

Note patient’s response to activity.

VI. NURSING CARE PLAN

VII. DISCHARGE PLANNING1. General Condition of the Client

Mr. Sugar was seen lying on her bed wearing a shirt and pants, with hair

disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left

hand. He reported that he had already two bowel movements.

2. METHODS

M-edication

Metoprolol 1tab PO,OD

Losartan 1tab PO,OD

Metformin 1tab PO,OD

E-xercise

Instruct to exercise at least 3 days a week and avoid strenuous activity.

>Regular exercise, even of moderate intensity (such as brisk walking),

improves insulin sensitivity and may play a significant role in preventing

type 2 diabetes

T-reatment

Follow-up check up on his private doctor.

H-

Instruct pt. to comply with the given diet.

Explain the importance of exercise in maintaining or losing weight.

Advise patient to check blood glucose level before doing any activities and to eat

carbohydrate snack before exercising to avoid hypoglycemia.

>Blood glucose levels should be monitored before and after exercise to

establish blood glucose response patterns to the exercise regimen. If blood

glucose is >250 mg/dl, the patient should delay the exercise session.

O-PD follow-up

D-iet

Diabetic Diet

>Carbohydrates should provide 45 - 65% of total daily calories. Best choices are

vegetables, fruits, beans, and whole grains. These foods are also high in fiber.

Carbohydrate counting or meal planning exchange lists.

>Fats should provide 25 - 35% of daily calories. Limit saturated fat.

>Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient individual health requirements

Avoid eating too much sweet foods.

Eat foods rich in fiber such as banana.

VIII. CONCLUSION

In this study, the student nurses’ aim is to understand the disease more,

manifestations, risk factors and complications. Diabetes mellitus is a condition in which

the pancreas no longer produces enough insulin or cells stop responding to the insulin

that is produced, so that glucose in the blood cannot be absorbed into the cells of the

body.

Mr. Sugar’s diabetes mellitus was caused mainly by his sedentary lifestyle, his

food preference and due to hereditary factor since his grandfather and his father both had

diabetes. Diabetic retinopathy, a complication of diabetes mellitus, also occurred and Mr.

Sugar opted to undergo laser therapy a month ago.

It is best managed with a team approach to empower the client to successfully

manage the disease. As part of the team the, the nurse plans, organizes, and coordinates

care among the various health disciplines involved; provides care and education and

promotes the client’s health and well being. Diabetes is a major public health worldwide.

Its complications cause many devastating health problems.

Through this case study, we should be able to learn and understand the disease

Diabetes Mellitus type 2 and therefore give us knowledge in proper management,

prevention and treatment. As a student nurse, it is very important to know many things

including the said disease condition. After the hardships of completing our case study, a

reward of self-fulfillment and credential to our knowledge and skills has been added to us

being student nurses as well as professionals in the near future.

IX. RECOMMENDATION

The researchers would recommend the further study of this case as this is a

disease that is interesting. It would be better if another causative factor would be studied

to be able to provide diverse information about this disease and to be able to compare to

spot similarities and differences in the manifestations of this disease if there is a different

causative factor. To be able to appreciate the physical manifestations of this disease, we

advise future researchers to investigate this case on the onset of the disease to be able to

assess and note more overt manifestations both for educational and documentation

purposes.

X. BIBLIOGRAPHY

http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes

http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm

http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-

philippines-and-worldwide/

http://nursingcrib.com/diabetes-mellitus-case-study/

Brunner&Suddarth.Textbook of medical-surgical nursing.2008.Lippincott Williams

& Wilkins.

http://nursingcrib.com/diabetes-mellitus-case-study/

http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-philippines-and-worldwide/

http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-philippines-and-worldwide/

http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm

http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes

diabetes mellitus 2

Documents

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