TYPE 2 DIABETES MELLITUS, HYPERTENSION II

University of Perpetual Help System – Dalta Calamba, Campus

Brgy. Paciano Rizal Calamba, Laguna  

A Case Study Presented to the Faculty of College of NursingIn Partial fulfillment of the requirements

In Related Learning Experience 102 for the degree ofBachelor of Science in Nursing

Submitted by:Camille Angeli M. Opis

BSN- 3A3Group 4

IntroductionDiabetes 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. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications.

Diabetes mellitus is a chronic disease that causes serious health complications including renal failure, heart disease, stroke, and blindness.

Every cell in the human body needs energy in order to function. The body's primary energy source is glucose which from the digested food that 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. 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, now the glucose stays in the blood rather entering the cells.

Type II is considered a milder form of diabetes because of its slow onset because it usually can be controlled with diet and oral medication. This form is also called non-insulin-dependent diabetes, a term that is somewhat misleading. However, insulin injections are sometimes necessary if treatment with diet and oral medication is not working. The pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may not work as effectively. 

I. DEMOGRAPHIC DATA  Name: Patient XGender: FemaleAge: 34y/o Birth date: October 7, 1975 Birth place: Eastern Samar Marital status: MarriedNationality: FilipinoAddress: Gen. Trias Cavite Educational Background: High school UndergraduateOccupation: HousekeeperUsual source of income: Security guard(husband)Admission Diagnosis: Type 2 Diabetes Mellitus, Hypertension II

II. SOURCES AND RELIABILITY OF THE INFORMATION 

The data presented in the case was collected from Gen. Emilio Aguinaldo Memorial Hospital in Trece Martires , Cavite, and dated December 10&12, 2009. The data collected are from medical records of the patient and most of the information was given by her.   III. REASON FOR SEEKING HEALTH CARE 

Based in my interview with the patient, she suffered from dizziness and difficulty of breathing from December 1-3 of 2009 even though she’s taking her usual medications so her cousin decided to take her to the hospital.   IV. HISTORY OF PRESENT ILLNESS 

3 days PTA the patient started to experience dizziness and dyspnea, no consult done, taking her usual medications, Losartan and Neobloc 50mg BID of signs and symptoms prompt to consult health care.    

V. PAST MEDICAL HISTORY  

Patient X was hospitalized a year ago due to weakness and increased BP; she was diagnosed with Diabetis Mellitus Type 2 five years ago. She had already experienced common childhood illnesses like chickenpox, diarrhea, cough and colds during her childhood years. She received complete tetanus toxoid immunization when she was pregnant. All of her five children have been given birth through normal spontaneous vaginal delivery. After giving birth to her last child she had undergone tubal ligaton. 

According to Patient X her menarche was when she is on her grade five. She has no known allergies to food and drugs.

Hypertension

(60y/o)stroke

Hypertension,peptic ulcer, alcoholic(63y/o)

Hyperten-sion,

DM(61y/o)

Husband 38y/o (CAD)

(CAD)

Daughter 10y/o

LEGEND

Male

Female

Patient

Deceased

Daughter 9y/o

Son

7y/o

Son

6y/o

Son

4 1/2 y/o

Patient 34y/o (DM

typeII)

Patient 34y/o (DM

typeII)

Brother 40y/o Brother 37y/o

Grandfather(natural death)

Grandmother(stoke)

VII. Family History

VIII. FUNCTIONAL ASSESSMENT A. Health Perception and Health Maintenance 

Patient is aware of her condition; she knows that she needs to control her diet. When someone has a chronic illness in their family she seeks the help of the doctor. Patient X is a non-smoker. She only consults to the health provider when she already tolerates the symptoms she’s experiencing. B. Self-esteem, Self Concept and Self Perception Pattern 

The patient is kind and approachable. She can described herself as a nice and kind person and she feels good about herself. She said that she have a good relationship with her family and friendly to other people. She also added that she sees equality to other people.

C. Activity and Exercise Pattern 

The client reports that she has a sedentary lifestyle. She walks for 30 minutes once a week and considers this as her form of exercise. She exercise once a week only because she often gets tired easily. She drinks alcohol occasionally.  

D. Sleep/Rest Pattern 

Patient X sleeps for at least seven hours in the evening from 10:30pm-5:30am. She frequently naps after meals. During days when she’s exhausted she has difficulty sleeping and difficulty staying asleep.  E. Nutrition and Elimination 

The patient eats any kind of food. Even though she knows she needs to avoid foods high in sugar and fats sometimes she cannot help herself in indulging to this kinds of foods. She also loves to drink lots of water because she always feels thirsty. Her favorite food is siomai. She frequently urinates and she defecates every other day. There are days that she has feels burning sensation when urinating.  F. Sexuality/Reproductive 

The patient has harmonious relationship with her family and her relatives. She is not sexually active because her husband is away always because of his work. She had her menarche when she was in grade five. She has five children (G5P5). Now she’s already ligated. She doesn’t practice monthly BSE.

G. Interpersonal RelationshipAccording to Erik Erickson’s stages of psychosocial development

patient X is in the Intimacy vs. Isolation stage where in she is afraid of rejections such as being turned down by her partner. She is capable of forming intimate reciprocal relationships and willing to make sacrifices and compromises that such relationships require. H. Coping and Stress Management Tolerance Pattern When problems are present, patient tends to be quiet; if her closest cousin is with her she seeks help to her cousin. I. Personal Habits According to the client, she is fond of eating lots of foods not knowingly if it’s healthy or not and drinking alcohol occasionally. She also stated that she is fond of watching T.V. and chatting with her friends.

J. Environment Hazards   The patient stated that their house is a apartment type located in sunny brook subdivision, it is clean and quiet environment, far from noise and air pollution. People there have a harmonious relationship with each other. 

System December ,2009 December , 2009General Conscious and coherent

Height: 5’4 Weight = 58kgs. Afrebrile (T=36.2˚C)

Conscious and coherent Height: 5’4 Weight= 58kgs. Afrebrile (T=36˚C)

Skin Brown skin complexion Good skin turgor Smooth and warm to touch

Brown skin complexion Good skin turgor Sweaty and warm to touch

HEENT H: Normocephalic scalp has no dandruff black hair round face without edema and

disproportionate structuresE: PERRLA Pale conjunctivaE: Symmetrical Sound is heard on both ears Same color with facial skinN: Midline and straight Pink mucosa No dischargeT: Smooth, pink lips Pink gums

H: Normocephalic scalp has no dandruff black hair round face without edema and

disproportionate structures dizziness(HGT=62mg/dl)E: PERRLA Pale conjunctivaE: Symmetrical Sound is heard on both ears Same color with facial skinN: Midline and straight Pink mucosa No dischargeT: Smooth ,pale lips Pink gums

IX. REVIEW OF SYSTEMS

Respiratory Symmetrical chest wall Clear breath sounds No cough eupnea

Symmetrical chest wall Clear breath sounds No cough eupnea

Cardiovascular Pulse rate= 76bpm BP=110/80mmHg Grade 2 peripheral and apical

pulses Veins not visible Regular rhythm Absent palpitations Cold extremities

Pulse rate= 77bpm BP=100/70mmHg Grade 2 peripheral and apical

pulses Veins not visible Regular rhythm Absent palpitations Cold extremities

Gastrointestinal Good appetite Distended abdomen Absence of masses and tenderness

in the abdomen Hypoactive bowel sounds Did not defecate during the shift

Good appetite Distended abdomen Absence of masses and tenderness

in the abdomen hypoactive bowel sounds Defecated once within the shift Stool color: yellow Consistency: soft

Genitourinary Urine color: yellow Voided 2x the shift

Urine color: yellow Voided 3x the shift

Peripheral vascular No cyanosis 2 seconds capillary refill

No cyanosis 2 seconds capillary refill

Musculoskeletal Moves in full range of without tenderness

Moves in full range of without tenderness

Neurologic Oriented to time, person and place Appears relax

Oriented to time, person and place Appears quiet

X. ANATOMY AND PHYSIOLOGY

Predisposing factors:

Age

genetics

Etiology

unknown

Receptor defect

Destruction of Beta cells

Delayed / insufficient insulin production

Receptor defect

Decrease # of insulin specific receptors

Decrease binding of insulin to insulin specific receptors

Precipitating factors:

Sedentary lifestyle Diet Obesity(wt=58kgs)

Altered beta-cell function

XI. PATHOPHYSIOLOGY

Increase insulin demand Insulin resistance

Beta cells exhaustion and dysfunction

Cells starvation

Cellular hypoglycemiaGluconeogenesis, glycogenolysis Vascular hyperglycemia

polyphagia

FATSPROTEIN

Free fatty acids

Deposition to vessel walls

Atherosclerosis

Blood glucose reaches renal thresholds

Hypersmolar diuresis

polyuria Glucosuria[+3]S/sx: good appetite

Decreased GFR

S/sx:(CBG=62mg/dl CBG= 203 mg/dl

Increase LDL

Increase BP(160/100 during admission)

Excretion of Na+, K, Cl-

↓Na in the blood(133.8mmol/L)

,↑Cl in the blood(106 .5mmol/L)

Water loss

polydipsia

S/sx: excessive thirst

Procedure Results Normal Values

Significance Nursing Implications

HematologyDate: December 4, 2009

MCHC 37.2 33-37 g/dL increase Spherocytosis(hereditary)

Eosinophils 8.4 1-4% increase Allergic disorder,par

asitic infestation, eosinophilic

leukemia

XII. LABORATORY RESULTS

Procedure Results Normal Values

Significance Nursing Implication

Blood ChemistryDate: December 5, 2009

FBS 15.3 3.8-6.06mmol/L increase Hyperglycemia

Triglycerides 2.7 .40-1.86 mmol/L increase Poorly controlled diabetis mellitus

HDL 11.9 30-75mg/dL decrease Poorly controlled diabetis mellitus, lipoproteinemia

LDL 131.4 <130mg/dL(desirable)

140-159(borderline

high-risk)160 mg/dl(high-

risk)

increase Hyperlipidemia, hypercholesterolemia

Sodium 133.8 135-145 mmol/L decrease Hyponatremia,excessive fluid loss

Chloride 106.5 96-106 mmol/L increase Dehydration

Results Normal Values Significance Nursing Implications

UrinalysisDate: December 5, 2009

Transparency Slightly cloudy Clear-slightly hazy

abnormal This can be due to the

presence of glucose,pus

cells and RBC in the urine

Glucose +3 (-) increased Diabetis mellitus

Pus cells 5-7/hpf <5hpf increased infection

RBC 1-3/hpf <5hpf increased Indicates bleeding

Date Result Significance Nursing Implications

12-8-095am 196 mg/dl abnormal Somogyi effect

11pm 203mg/dl abnormal hyperglycemia12-9-09

5am 161 mg/dl abnormal hyperglycemia11pm 159mg/dl abnormal hyperglycemia

12-10-095am 68mg/dl normal

11pm 70mg/dl normal12-12-09

5am 62mg/dl abnormal hypoglycemia

Capillary Blood Glucose

Humulin RXIII. DRUG STUDY

Ciprofloxacin

Simvastatin

Amlodipine

Problem No. Problem Date Identified Date resolved

1 Dizziness December 12, 2009

On going

2 The patient is requesting for

information

December 10, 2009

December 12, 2009

Problem No. Problem Date Identified Date Resolved

1 Risk for deficient fluid volume

December 10, 2009

XIV. PROBLEM LIST