diabetes mellitus 2
TRANSCRIPT
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
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.
Diagnostic/ Laboratory Procedures
Date OrderedDate results IN
Indication orPurpose
Results Normal Values
Analysis and Interpretation of results
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.
Nursing Responsibilities:
Prior to the procedure:
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).
During the procedure:
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.
After the procedure:
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.
Diagnostic/ Laboratory Procedures
Date OrderedDate results IN
Indication orPurpose
Results Normal Values
Analysis and Interpretation of results
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.
Nursing Responsibilities:
Prior to the procedure:
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
During the procedure:
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
Instruct the patient to calm down to avoid uneasiness.
After the procedure:
Apply warm compress if Hematoma develops at the venipuncture site.
Apply pressure on the site to avoid bleeding.
Diagnostic/ Laboratory Procedures
Date OrderedDate results
Indication orPurpose
Results Normal Values
Analysis and Interpretation of 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
During the procedure:
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
Instruct the patient to calm down to avoid uneasiness.
After the procedure:
Apply warm compress if Hematoma develops at the venipuncture site.
Apply pressure on the site to avoid bleeding.
Diagnostic/ Laboratory Procedures
Date OrderedDate results IN
Indication orPurpose
Results Normal Values
Analysis and Interpretation of results
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.
Nursing Responsibilities:
Prior to the procedure:
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).
During the procedure:
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.
After the procedure:
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.
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.
Nursing Responsibilities:
Prior the procedure:
Read the doctor’s order
Check IV label
During the procedure:
Check for patency of tubing
Regulate as ordered
After the procedure:
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
Client’s response to the
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.
Nursing Responsibilities:
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
Route of administration,
Dosage and Frequency of administration
General Action, ClassificationMechanism of
Action
Client’s response to the
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.
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
Route of administration,
Dosage and Frequency of administration
General Action, ClassificationMechanism of
Action
Client’s response to the
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.
Nursing Responsibilities:
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 for signs of tachycardia, palpitations and especially blood pressure
-Instruct patient to sit before standing
Name of Drug
Date Ordered/
Date Taken/Date
Route of administration,
Dosage and Frequency of
General Action, ClassificationMechanism of
Action
Client’s response to the
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.
Nursing Responsibilities:
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 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
Route of administration,
Dosage and Frequency of administration
General Action, ClassificationMechanism of
Action
Client’s response to the
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)
Nursing Responsibilities:
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.
During Administration
-Instruct the patient to calm down to avoid uneasiness.
After Administration
-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.