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Case Study - Niddm

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Republic of the Philippines University of Northern Philippines Tamag, Vigan City College of Nursing A Case Study on Non-Insulin Dependent Diabetes Mellitus In partial fulfilment Of the requirements Of the course Nursing Care Management: Curative and Rehabilitative Nursing Care Related learning Experience Hospital Duty Presented to: Madeline C. Villanueva, R.N. Clinical Instructor Presented by: Kimberly Ruth Ramos BSN-III Bromeliads JANUARY 2012 1
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Page 1: Case Study - Niddm

Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City

College of Nursing

A Case Study on Non-Insulin Dependent Diabetes Mellitus

In partial fulfilment

Of the requirements

Of the course

Nursing Care Management:

Curative and Rehabilitative Nursing Care

Related learning Experience

Hospital Duty

Presented to:

Madeline C. Villanueva, R.N.

Clinical Instructor

Presented by:

Kimberly Ruth Ramos

BSN-III Bromeliads

JANUARY 2012

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TABLE OF CONTENTS

PAGE

FRONTPAGE i

TABLE OF CONTENTS ii

I. INTRODUCTION AND OBJECTIVES

II. PATIENT’S PERSONAL DATA

(NURSING HISTORY OF PAST AND PRESENT ILLNESS)

III. PEA/RSON ASSESSMENT

IV. DIAGNOSTIC PROCEDURE

V. ANATOMY AND PHYSIOLOGY

VI. PATHOPHYSIOLOGY

A. ALGORITHM

B. EXPLANATION

VII. MANAGEMENT

A. MEDICAL-SURGICAL

B. NURSING CARE PLAN

C. PROMOTIVE AND PREVENTIVE

VIII. DRUG STUDY

IX. DISCHARGE PLAN

X. UPDATES

XI. ORGANIZATION

XII. BIBLIOGRAPHY

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I. INTRODUCTION AND OBJECTIVES

According to Department of Health as derived from its book, Public Health Nursing, Diabetes is one of the leading causes of disability in persons older than 45 years old. In this statement, it is evident that Type 2 diabetes mellitus is more common than its counterpart.

Diabetes mellitus is a metabolic disorder characterized by hyperglycemia in more than one blood sugar measurement at different visits. It is a disorder in which the primary problem is uncontrolled blood sugar level secondary to impaired insulin production or insulin resistance, thus, classifying diabetes mellitus into Type 1 and Type 2 DM, formerly Insulin-Dependent (IDDM) and Non-

Insulin Dependent diabetes mellitus (NIDDM) respectively. The latter nomenclature is no longer used today to avoid confusion because the former name signifies literally the treatment not the cause. This has led to confusion because type 2 DM also adds insulin in its pharmacologic therapy.

This disorder is a major health threat since it causes macrovascular problems (CAD, CVA, PVD, etc.), microvascular problems (retinopathy and nephropathy) and neuropathy or the loss of sensation. These complications basically resulted from poor circulation s/t increased blood coagulation.

Meanwhile, in type 1 DM, the beta cells of the pancreas are destroyed by autoimmunity thus there is little or no insulin production at all. On the other hand, in type 2 DM, the pancreas produces enough insulin but the body has resistance to its effects secondary to increased fat deposits. That’s why obesity is the most common cause of type 2 DM.

In line with this, this case study focuses on Type 2 Diabetes Mellitus. It commonly occurs after the age of 30 thus, calling it as “adult-onset DM”. It is assumed by many as mild because of its slow and gradual occurrence of signs and symptoms and its degree of treatment, but the complications are as dangerous as type 1 DM. It’s like transforming your disease into a riskier type if left unguarded and untreated. Persons at risks are the following:

obese

has familial history

has previous gestational diabetes

The hallmark of type 2 DM is fasting hyperglycemia (high levels of blood sugar even without eating) characterized by the 3 P’s (Polyuria, Polydypsia and Polyphagia), blurred vision, drowsiness, fatigue, glucosuria, UTI and poor healing wound. Its major complication is Hyperglycemic Hyperosmotic

Non-Ketotic Syndrome (HHNK). It is non-ketotic because the body still produce insulin thus glucose is still utilize though not all. However, type 2 DM can complicate into type 1 if the pancreas cannot accommodate the insulin needs of the body. The tendency is when the body creates resistance to insulin, it also tries to compensate by increasing the release of the hormone. If more glucose is absorbed in the intestine and produced by the liver, the pancreas tends to wear out.

Type 2 DM is reversible as long as diet is modified and exercise is incorporated in the daily lifestyle because the main problem here is insulin resistance. Fat deposits cause insulin resistance and fat comes from dietary intake. However, it really takes time.

This study was under the consent of the said patient, thus all of the data used in this study are under legal circumstances. The data were gathered through an assessment conducted on the dates of duty at the said hospital. Nursing interventions were also rendered limitedly within the shift.

This case study was organized having the following objectives:

To expand knowledge regarding NIDDM. To gather appropriate and sufficient data to trace the history of the present illness. Describe the symptoms of type 2 diabetes mellitus. State the criteria for diagnosis of diabetes mellitus. State the management goals for a patient with diabetes mellitus. List the target goals for blood glucose, blood pressure and lipids. Discuss the role of medical nutrition therapy and the benefit of increased activity. List the types of oral medications for type 2 diabetes and their mechanisms of action. Describe the short-term and long-term complications of diabetes mellitus. Discuss the role of diabetes self-management education in assisting patients with type 2

diabetes to make the necessary behavioural changes to manage their disease. Describe the routine primary care follow-up for a patient with type 2 diabetes. To be aware of the new advances, researches, studies and updates regarding the condition. To evaluate effectiveness of the treatment regime

II. PATIENT’S PERSONAL DATA

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NAME: Maxima Fenol Quiba

GENDER: Female

CIVIL STATUS: Widowed

AGE: 90y/o

ADDRESS: Anonang Mayor, Caoayan, Ilocos Sur

DATE OF BIRTH: Setember 22, 1921

NATIONALITY: Filipino

RELIGION: Roman Catholic

OCCUPATION: Unemployed

ADMITTED AT: Ilocos Sur Medical Mission Group and Hospital

ATTENDING PHYSICIAN: Dr. Manuel Cajigal

DATE AND TIME OF ADMISSION: November 21, 2011 @ 9:30 AM

DATE AND TIME OF DISHARGE: November 27, 2011 @ 12:00 NOON

CHIEF COMPLAINT: Body Weakness

ADMITTING DIAGNOSIS: DM Type 2, Diaper rash

FINAL DIAGNOSIS: Type 2 DM

HISTORY OF PAST ILLNESS:

According to the patient, her common illness was cough and colds. No home treatment was provided. It will just subside if time comes as she said. She couldn’t remember her immunizations. Her family has histories of hypertension and diabetes. According to her laboratory results, she has dyslipidemia, and often experiences positional vertigo but manages it with prescribed medications. She has non-healing diaper rashes on her perineal area since January 2011 and recurrent body weakness that had brought her to seek medical attention.

HISTORY OF PRESENT ILLNESS:

Prior to admission, she complains of body weakness for 2 days. She had difficulties of sleeping at night, and complains of irritating pain on her perineal area due to rashes. On admission, her vital signs were as follows: BP: 120/70, T: 36.5, RR: 24cpm, and PR: 72 bpm. PLRS 1L plus B-Complex was infused to her as ordered, and instructed to have complete bed rest. Laboratory tests were ordered: HGT result reflected initially as 129 mg/dl, and Glimeperide 1mg 1 tab OD before breakfast was ordered. Antibiotics were also ordered ANST, as well as multivitamins and prescribed diet.

III. PEA/RSON ASSESSMENT

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1ST DAY (November 27, 2011)

2nd DAY (November 28, 2011)

P(personal)

(psychosocial)

(psychosexual)

(physical)

hospitable and talkative at times conscious and coherent appears weak and sleepy with noted non-healing diaper rash on

perineal area noted presence of redness and

swelling on perineal area complaints of tolerable pain upon

initial contact

conscious and coherent appears weak and sleepy still with noted non-healing diaper

rash on perineal area still with redness and swelling on

perineal area still with bearable pain initially

E has (-) bowel movement on Bisacodyl suppository OD after

breakfast as ordered voided twice, yellowish and aromatic

odor as claimed, during the 8-hour shift

no IFC inserted

has (+) bowel movement voided twice with same

characteristics

A/R lies in bed most of the time goes to comfort room with assistance,

ambulatory cannot sleep well as complained

lies in bed most of the time goes to comfort room with assistance,

ambulatory cannot sleep well as complained

S the bed has no side rails the ward is not that congested wears clean clothes that fit her size wears slippers upon ambulation

the bed has no side rails the ward is not that congested wears clean clothes that fit her size wears slippers upon ambulation

O has initial respiratory rate of 20 cpm, shallow and regular

no dyspnea observed initial BP = 120/70 mmHg the ward is not well ventilated with poor skin turgor afebrile with an initial temperature of

36.9⁰ C

initial RR = 20 mmHg initial BP = 130/80 mmHg ward is still poorly ventilated still with poor skin turgor afebrile initially

N received on bed with PLRS 1L plus B-Complex @ 20-22 gtts/min

on diabetic diet with fair appetite with no sweet beverages nor food

were seen in the bedside table

same assessment as yesterday

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IV. DIAGNOSTIC PROCEDURE

IDEAL EXAMINATION

A. Urine Glucose Testing

urine is checked for the presence of glucose

due to the excessive amount of blood sugar, the kidney is not able to filter all the glucose

thus glucosuria is present in a diabetic pt.

not an accurate tool because the result does not reflect the exact amount of glucose in the

blood.

PROCEDURE:

a. Apply urine over the surface of the reagent strip.

b. Wait till color changes.

c. Match the color with the standard color chart.

B. Blood Glucose level Measurement

1. Random Human Glucose Test

uses a glucometer

blood can be drawn at any time throughout the day, regardless of when the

person last ate.

PROCEDURE:

a. Ask patient what finger he wishes to use. Finger must be intact.

b. Massage fingertip in an upward motion.

c. Wipe the lateral side of the fingertip with an alcohol-wet cotton ball.

d. While waiting for skin to dry, insert the testing strip into the

glucometer. Make sure the codes are matched.

e. Inform patient when you are about to prick because it causes a little

sudden pain.

f. Wipe the first drop of blood with a dry cotton ball.

g. Massage fingertip upward till a drop of blood is seen.

h. Gently touch the tip of the strip on the blood. Small amount may do.

i. Wait for the glucometer to process the blood.

j. Read the measurement.

CRITERIA:

80-120 mg/Dl = Normal

> 120 mg/dL = (+) DM in more than 1 reading at different days of

visits.

2. Fasting Blood Sugar

can also be done after meals.

PROCEDURE:

a. have pt not eat 8 to 12 hours (usually overnight). Water is allowed as

long as it is not mineralized.

b. Blood sample is taken from a vein or fingertip.

CRITERIA:

≤109 mg/dL = Normal

110 - 125 mg/dL = (+) Impaired Glucose Tolerance (IGT)

≥ 126 mg/dL if fasting = (+)DM

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≥ 200 mg/dL if after meals = (+) DM

usually repeated on another day to confirm diagnosis.

3. Oral Glucose Test

the most sensitive test for diagnosing diabetes.

not routinely recommended because it is inconvenient compared to a fasting

blood glucose test.

PROCEDURE:

a. Perform FBS Test.

b. Obtain FBS measurement.

c. Have patient drink 75 g of liquid glucose solution (which tastes very

sweet, and is usually cola or orange-flavoured).

d. 2 hours later, a second blood glucose level is measured.

CRITERIA:

≤150 mg/dl after 2 hours = normal

> 150 mg/dl = DM in more than 1 reading at different days of visits

C. Complete Blood Count

done to assess the general status of the bone marrow cells

to determine the degree of infection since the patient has non-healing wound.

PROCEDURE:

a. Blood is drawn either from a vein or fingertip.

b. Blood is processed in a machine.

c. Blood components are measured and compared with the normal values.

ACTUAL EXAMINATION

A. Complete Blood Count

Date: 11/25/11

PARAMETER RESULT NORMAL VALUE

WBC H 15.4 x 10⁹/L 5.0 – 10.0

LYMPH # L 1.8 x 10⁹/L 3.0 – 3.4

MID # H 1.8 x 10⁹/L 0.1 – 0.9

GRAN H 11.8 x 10⁹/L 5.0 – 7.0

LYMPH % L 11.7 % 30 – 40 %

MID % H 11.5 % 1– 9 %

GRAN % H 76.8 % 50 – 70 %

INTERPRETATION:

The blood components that have increased greatly were those responsible for the immunity. So far

WBC and granulocytes are trying to fight the infection. However, the lymphocytes are seriously low

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which means the body has not produced antibody yet and has not attracted much macrophages and

other cells to combat the invading microorganism.

Thus, making the patient still susceptible for spread of the infection because WBC and granulocytes

will definitely wear out if antibodies and other defense cells are not in action.

B. Routine HGT q6º

DATE RESULTS INTERPRETATION11/23/11 6 am 129 mg/dL H 11 am 120 mg/dL H11/24/11 6 am 130 mg/dL H 11 am 190 mg/dL H 6 pm 145 mg/dL H 12 mn 137 mg/dL H11/25/11 6 am 130 mg/dL H 12 nn 190mg/dL H 6 pm 175mg/dL H 12 mn 140 mg/dL H11/26/11 6 am 121 mg/dL H

RESULT: There is significant rise in glucose levels which suggest the occurrence of hyperglycaemic reactions as manifested in type 2 DM. Moreover, in adjunct to these levels, medications were given as prescribed.

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V. 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 primarily comes from the diet and the liver. Once the food is ingested, glucose is absorbed into the

bloodstream. This stimulates the pancreas, a small gland located behind the stomach, to secrete insulin which is

produced by the beta cells of the said organ. The functions of insulin then are as follows:

transports glucose into the cell

signals the liver to stop releasing glucose

stores glucose in the liver thru the form of glycogen as a reserved energy source

stores dietary fat in the adipose tissues

During fasting periods (between meals and midnight), the pancreas continuously releases basal insulin and

another hormone called glucagon which is responsible in stimulating the liver to break down glycogen into glucose

to be used by the body (basal metabolic rate). The basal insulin assists the transport of glucose then.

Blood sugar normally is high early in the morning because of the normal increase in growth hormone and

corticosteroids (DAWN PHENOMENON). The blood sugar also increases excessively if there is a sudden drop in

the blood glucose level as a compensatory mechanism (SOMOGYI EFFECT).

Reference: Smeltzer, S., et. al., Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Vol. 2, 10th ed.

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VI. PATHOPHYSIOLOGY OF TYPE 2 DIABETES MELLITUS

A. ALGORITHM

Insulin resistance

Excessive accumulation of glucose in the blood (hyperglycemia)

osmotic diuresis (polyuria) blood becomes more viscous

polydipsia poor circulation

cells become hungry

gluconeogenesis

polyphagia

↑ production of insulin

beta cells are worn out

↓ / no insulin production

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Obesity Family history Previous gestational

diabetes

blurred vision fatigue tingling sensationpoor wound healing drowsiness

COMPLICATIONS:

Type 1 DM Retinopathy Nephropathy Neuropathy CVA CAD HHNK

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A. EXPLANATION

The primary problem in type 2 DM is insulin resistance, not destruction of the beta cells. The latter is actually a complication. That’s why obesity is the main cause of type 2 DM merely because fat deposits resist insulin. Other causes include genetic factor and previous gestational diabetes.Since there is resistance, glucose is not utilized thereby accumulated in the blood. Signs and symptoms of hyperglycemia occur. As a compensatory mechanism, the body excretes glucose via urine leading to glucosuria. This is called osmotic diuresis wherein some electrolytes are also excreted with the glucose.

To compensate the electrolyte loss, the patient experiences polydipsia. However, the cells become hungry without transport of glucose, thus the body breaks down proteins and other substances into glucose (gluconeogenesis). Due to this catabolic effect of the body, the patient tends to hunger much, a condition called polyphagia.

On the other hand, the blood becomes viscous leading to poor circulation. Signs and symptoms like blurred vision, tingling sensation, fatigue and drowsiness are experienced. The body then is alarmed and signals the pancreas to secrete more insulin in an attempt to counteract insulin resistance. If resistance continues and glucose uncontrollably increases in the blood, the pancreatic cells become worn out, thus little or eventually no insulin is produced. This complication is called Type 1 DM. Other complications like retinopathy, nephropathy and neuropathy are due to poor circulation while CAD and CVA are due to increased blood coagulation secondary to increased blood viscosity. Hyperglycemic Hyperosmolar non-Ketotic Syndrome is the most common complication.

Meanwhile, on this case study, obesity, family history and previous gestational diabetes predisposed the patient to type 2 DM. Signs and symptoms of hyperglycemia were claimed as stated in the history of present illness. All other signs and symptoms included in the algorithm are negative so far.

REFERENCE:

Smeltzer, S., et. al., Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th ed., Vol. 2 (2004)

The Merck Manual of Medical Information, 2nd home edition (2003)

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VII. MANAGEMENT

IDEAL MEDICAL MANAGEMENT

GOAL: to enhance activity of insulin and maintain blood glucose level within normal range

The primary management of type 2 DM is a combination of diet, exercise and weight loss program. If these

are ineffective, medicines are prescribed but still lifestyle modification must be adopted for a long time.

A. PHARMACOTHERAPY1. Oral Hypoglycemic Agents

used to decrease blood glucose level by either stimulating the pancreas to release insulin

or decrease absorption of glucose in the intestines.

Types:

CLASS/EXAMPLES ACTION SIDE EFFECTS SPECIAL CONSIDERATIONSSulfonylureas

Glyburide (DiaBeta, Glynase PresTab, Micronase)

Glipizide (Glucotrol, Glucotrol XL)

Glimepiride (Amaryl)Chlorpropamide

Stimulate pancreas to secrete insulin

GI symptoms and dermatologic problems = most common

hypoglycemia

Drug-to-drug interactions:**↑ hypoglycemic effect

o Sulfonamideso Chloramphenicolo Clofibrateo Phenylbutazoneo Bishydroxycoumarin

**↑ hyperglymic effecto K+ sparing diureticso Corticosteroidso Estrogeno Diphenylhydantoin

(Dilantin)Drug-food interactions:

o Chlorpropamide + alcohol = disulfiram effect

MeglitinidesRepaglinide (Prandin)Naglitinide (Starlix)

Stimulate pancreas to secrete insulin

hypoglycemia fast and short-actingDrug-to-drug interactions:

o Meglitinides + Metformin = synergistic effect

must always be taken right before meals to avoid hypoglycaemia except Naglitinide which is very rapid in action. It must be taken with meals

BiguanidesMetformin (Glucophage,

Glucophage XR)

Facilitates insulin action on peripheral receptors

metallic tasten/vabdominal bloatingpaindiarrhealactic acidosis =

most dangeroushypoglycemia

Drug-to-drug interactions:o Biguanides + Sulfonylureas

= synergistic effect of ↓ing blood glucose level

o anticoagulantso diureticso contraceptiveso corticosteroids

must not be given 2 days before any diagnostic test using contrast agent bec. it inc. lactic acidosis tendency.

Alpha-glucosidase inhibitorsAcarbose (Precose) Miglitol (Glyset)

Slow down glucose absorption in the SI

painflatulencediarrheahypglycemia

Drug-to-drug interactions:o AGI +

Sulfonylureas/Meglitinides = significant hypoglycaemia

If hypoglycaemia occurs, sucrose absorption is useless because its

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absorption is blocked, rather take glucose tablets.

take immediately before meals because food interferes its action.

HbA1c ↓esThiazolidinediones

Rosiglitazone (Avandia) Pioglitazone hydrochloride

(Actos)

Make body tissues more sensitive to insulin without ↑ing insulin secretion

liver damage = most serious

hypoglycemia

indicated for patients taking INS injections and cannot control blood glucose adequately

first-line agents in combination with diet to treat type 2 DM

2. Insulin used if OHA cannot control blood sugar level in the shortest period of time used for sudden hyperglycemia dependence to drug depends on the ability of the pancreatic beta cells

TIME COURSE AGENT ONSET PEAK DURATION INDICATIONSRapid-acting Lispro (Humalog)

Aspart (Novolog)10-15 min10-15 min

1 h40-50 min

3 h4-6 h

used for rapid reduction of glucose level

to treat postprandial hyperglycemia

to prevent nocturnal hyperglycemia

Short-acting Regular (Humalog R, Novolin R, Iletin II Regular)

½ - 1 h 2-3 h 4-6 h usually administered 20-30 minutes before a meal

may be taken with long-acting INS

Intermediate-acting

NPH (neural protamine Hagedorn)Humulin N (Lente, NPH)

2-4 h

3-4 h

6-12 h

6-12 h

16-20 h

16-20 h

usually taken after meals

Long-acting Ultralente (“UL”) 6-8 h 12-16 h 20-30 h used primarily to control fasting glucose level

Very long-acting Glargine (Lantus) 1 h continuous 24 h used for basal dose

Administration Consideration:

1. Main areas of injection site: abdomen, arms, thigh, buttocks

2. Systemic rotation of anatomical sites every day.

3. Injection site must be 1 ½ inches apart within the anatomical area.

4. Insulin syringe needles are G27-G29 that is ½ inch long.

5. Usually prefilled but can be prepared. Roll the container first before withdrawing.

6. Only regular INS may be mixed with other INS.

7. When mixing, withdraw Regular INS first.

8. Administer mixed dose within 5-15 minutes after preparation.

9. Administer 45-90º angle in fat persons and 45-60º in thin persons.

10. Regular INS is the only INS given IV.

11. Place the needle upright or flat to prevent clogging.

Complications:

Hypoglycemia

Lipodystrophy

Dermatologic allergic reactions

B. DIET1. Diabetic Diet

diet with exercise is the primary key or first line in treating type 2 DM.

must be low in calorie

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all food groups have caloric value, it’s just that carbohydrates have the highest value.

must be referred to a dietician.

a. Meal Plan

50-60% Carbohydrates

20-30% Fats

10-20% Proteins

b. Food Guide Pyramid

represents the base as with the lowest in calories and fats and the highest

in fiber.

C. OTHERS1. Hemoglobin A1C

also known as Glycosylated Hemoglobin

represents the blood glucose level changes over a prolonged period of time usually 2-3

months.

used as a monitoring tool of the effectiveness of OHA and INS, not a diagnostic tool.

when blood glucose level is elevated, glucose molecules attach to haemoglobin in the

RBC. The longer the amount of glucose in the blood remains high, the more glucose

binds to RBC an the higher the HbA1c which is permanent and lasts for the life of RBC

usually up to 120 days.

2. Daily Wound Care of the affected leg

involves bed rest, proper hygiene, antibiotic and debridement

safety precaution against potential injuries.

IDEAL SURGICAL MANAGEMENT

A. Possible Amputation done if treatment is long enough to prevent the spread of infection.

done if wound is poorly healing due to poor circulation without improvement despite

interventions.

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bread, rice, cereals, pastafruit

meat, poultry, fish, dry beans, eggs, nutsvegetables

milk, yogurt and cheese

fats, oils and sweets

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ACTUAL MEDICAL MANAGEMENT

Upon admission, the patient received an initial treatment of PLRSS plus B-Complex 1L regulated to 21-22

gtts/min. Her initial blood glucose level was 129 mg/dL and Metformin was administered as ordered. The physician

also prescribed her an antibiotic, Ceftriaxone, and was administered accordingly. The patient was on diabetic diet

and has fair appetite within the 2 consecutive shifts. During the course of hospitalization, the patient’s blood glucose

level was monitored every 6 hours.

Upon discharge, the physician prescribed home medications and advised the patient for follow-up one week

after discharge.

SURGICAL MANAGEMENT

**None so far.

REFERENCE:

Smeltzer, S., et. al., Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th ed., Vol. 2 (2004)

The Merck Manual of Medical Information, 2nd home edition (2003)

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NURSING CARE PLAN

CUES NURSING DIAGNOSIS

SCIENTIFIC BACKGROUND GOAL/OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:“Nag-ut-ot unay toy sugat ko.”

OBJECTIVE:presence of frequent

facial grimacediaphoresiswith pain scale of

7/10wound appears red

and warmV/S taken as follows:

T – 38.6⁰ CP – 108 bpmR – 24 cpmBP – 130/80 mmHg

P - Acute pain

E - r/t progression of non-healing wound s/t poor circulation

S – as evidenced by the presence of facial grimace, diaphoresis, pain scale of 7/10, elevated vital signs and pt’s verbalization

Local tissue damage from injury

Initiation of nociceptors to respond to noxious

stimulus

Transmission of nerve impulses to the brain

Pain sensation is experienced

Increased metabolic rate

Diaphoresis, ↑ V/SRedness and warmth

REFERENCE:Smeltzer, et. al., Brunner

and Suddharth’s textbook of Medical-Surgical Nursing, 10th Edition, Vol 1, pg. 256

Date:11/20/11Shift: 7-3Time: 1:30 PM

GOAL: After rendering nsg ix,

the pt will verbalize pain relief and demonstrate relaxation and diversional activities.

OBJECTIVES:After 30 minutes,

facial grimace will decrease from frequent to moderate

diaphoresis will stoppain scale will decrease

to 6/10V/S will normalizept will demonstrate 2/2

relaxation/ diversional activities

INDEPENDENT:Obtained V/S

Asked patient the degree of pain

Noted characteristics of wound

Provided TSB and increased hydration

Opened the windows

Instructed and encouraged diversional activities such as sleeping, listening to radio or chatting with students and other patients/ SO.

Monitored V/S q 15 minutes especially temperature and asked patient about the pain status.

DEPENDENT:Administered Diclofenac

to have a baseline data and to verify pain because it alters V/S.

to intervene appropriately. Severe pain already needs pain reliever rather than simple diversional activities.

to assess progress of wound focusing on discharges that might have initiated pain or another infection.

to normalize temperature. increased in V/S was affected by the ↑ed temp. So if temp normalizes, other V/S follow.

to provide better ventilation which will help normalize temperature and respiration. Pain can also be eased by good ventilation.

Done if and only if analgesic was administered in order to refocus attention. Diversion activities are useless in severe pain

to evaluate effectivity of care and medications

to rapidly relieve pain

Date: 11/20/11Shift: 7-3Time: 1:30 PM

GOAL PARTIALLY MET as evidenced by:

facial grimace decreased

diaphoresis stoppedpain scale decreased to

5/10V/S stabilized within

normal range and taken as follows:

T- 37.2 ⁰ CP- 94 bpmR- 20 cpmBP- 120/80 mmHg

pt demonstrated 2/2 relaxation/ diversion activities

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75 mg IV q8º PRN.Administered Paracetamol

500 mg IV q4º PRN

COLLABORATIVE:Monitored laboratory

results

to normalize temperature

To determine progress of condition and obtain cues related to pt’s diagnosis.

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CUES NURSING DIAGNOSIS

SCIENTIFIC BACKGROUND GOAL/OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:“Nabayag atoy sugat kon. Objective:poorly healing rahes

on perineal area (+) redness (+) swellingwound site is warm

to touch (+) pain, rated as

5/10

P- Impaired tissue integrity

E- r/t mechanical trauma of of skin and subcutaneous tissue s/t injury

S- as evidenced by presence of poorly healing wound with redness and swelling as well as pt’s verbalization

Injury

Destruction of skin layers

Initiation of wound healing as a compensatory

mechanism (but here, there is slow

wound healing)

Occurrence of the cardinal signs

Presence of redness(rubor) in the incision site

Sensation of heat(calor) in the incision site

Swelling(dolor) is observed

Pain(tumor) sensation

REFERENCE:Elaine Marieb, Anatomy and Physiology 9th Edition, pg. 463

Date: 11/21/11Shift: 7-3Time: 8:00 am

GOAL: After rendering nursing

interventions, the pt will display behaviour and lifestyle changes to promote healing and prevent complications

OBJECTIVES:The patient will:

enumerate and observe 2/2 lifestyle changes

enumerate and display 3/3 safety precautions against injury

INDEPENDENT:Noted evidence of tissue

involvement

Obtained history of condition including color, smell, location and consistency

Reinforced knowledge about wound care as observed during doctor’s round

Emphasized the importance of proper food intake especially food rich in fiber and protein such as vegetables and meat

Encouraged skin hygiene

Instructed to avoid injury as much as possible especially in the lower extremities. Activities involved wearing closed slippers, cutting nail into square-tipped and avoiding pedicure and abrasions.

DEPENDENT:Administered Ceftriaxone

1 gram IV q12º

COLLABORATIVE:

to determine which tissue is affected which will serve as baseline data for your health teachings.

to know the progress of the condition and have a baseline data to plan for nursing interventions

to motivate the pt for self-care upon discharge

fiber promotes tissue healing and decreases blood sugar level. Iron enhances clotting factors.

Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.

to enhance patients knowledge and self-care.

antibiotic helps prevent spread of infection

Date:11/21/11Shift: 7-3Time: 8:00 am

GOAL MET as evidenced by:

the patient enumerated and observed 2/2 lifestyle changes

the patient enumerated and displayed 3/3 safety precautions against injury

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Monitor laboratory results to determine changes

indicative of healing; to gain data as a basis for interventions.

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PROMOTIVE AND PREVENTIVE INTERVENTION FOR TYPE 2 DM

Since the patient is diabetic, she is more likely experiencing poor wound healing accompanied with pain.

Wound can be an entry of infection especially that there is poor circulation. Moreover, if blood glucose level cannot

be controlled, complications stated earlier are more likely to happen.

The goals of promotive-preventive interventions are to:

Promote optimal blood glucose level

Proper wound care and prevent infection

Prevent complications

Interventions are as follows:

To promote optimal blood glucose level, the patient has to:

Eat proper diet which is low in calories and lose weight. Foods high in fiber are

recommended to decrease elevated blood glucose level. These include vegetables and

fruits.

Exercise regularly as tolerated to burn calories. Be sure that she had taken meals and

medications before doing so to prevent hypoglycaemia and hyperglycaemia respectively.

Take medications religiously and with precautions. OHA must always be taken before

meals so that there will be insulin needed for the food to be digested and utilized into

energy.

Avoid food and medications that may alter the actions of her medications. Better consult

the doctor first before taking anything.

To facilitate proper wound care and prevent infection, the patient has to:

Take antibiotics religiously.

clean wound with antibacterial soap and wrap it with gauze to prevent exposure to debris.

wear protective shoes and observe safety precautions on the affected leg.

practice proper hygiene.

eat foods high in protein to facilitate wound healing. But this still depends on lowering

the blood glucose level in order to improve circulation.

To prevent complications, the patient has to:

avoid injury as much as possible because of slow wound healing which might lead to

infection and eventually to amputation.

take medications religiously to control blood glucose level. All she has to do is to

maintain the blood sugar within normal level so that the blood will circulate properly.

report unusual signs and symptoms such as loss of sensation, spread of infection,

and the like to intervene immediately and prevent progress.

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VIII. DRUG STUDY

NAME/CLASS DOSAGE/ROUTE MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING

RESPONSIBILITY1. Ceftriaxone

(Antibiotic)1 gram IV q12º Bactericidal and

bacteriostatic.Inhibits bacterial cell wall synthesis.

Treatment of moderate to severe infections of soft tissues and wounds

Hypersensitivity GI symptomsheadachevertigopruritus

Drug-to-drug interaction: Aminoglycosides and diuretics

Ensure safetyEncourage to drink lots of

water to counteract SE

2. Metformin 500mg 1 tab OD Decreases hepatic glucose production and intestinal absorption of glucose.

Adjunct to patients with type 2 DM

Hypersensitivity GI symptoms Hypoglycemia Megaloblastic anemia

Give with meals.Monitor glucose levels

regularly.3.Glimepiride

(Oral Hypoglycemic Agents)

1 mg/tab 1 TAB OD Stimulate pancreas to secrete more insulin

Adjunct with diet for the management of type 2 DM

Hypersensitivity Hypoglycemia headache dizziness n/v GI pain and diarrhea pruritus

Drug-to-drug interaction: diuretics, corticosteroids, some NSAID

Administer right before mealsMonitor blood glucose level

4. Simvastatin 10 mg 1 tab TID Inhibits HMG-CoA reductase an early stage in biosynthesis.

To reduce total LDL cholesterol levels

Hypersensitivity abdominal pain nausea vomiting, constipation diarrhea

patient should follow a low cholesterol diet during treatment.

5. VCO Cogel 1 tab OD Unknown action Believed to have numerous indications such as vitamins, or reducing risks of CVA’s and cancer.

Hypersensitivity No known side effects Regularly take the drug for better results.

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IX. DISCHARGE PLAN

M(Medications)

Glimepiride 1 mg/tab 1 tab OD; taken before meals

Metfrormin 500 mg 1x a day after lunch

Simvastatin 10 mg tab HS

Diazepam 5mg ½ tab OD at bedtime

Buclizine with Fe 1 cap 1 hr before bedtime

Erceflora 2x a day for 5 days

E(Exercise)

Can walk around for 30 minutes when tolerated and assistance.

can do household chores as tolerated

T(Therapeutic)

can talk to healthcare team about worries on present condition upon follow-up

can ask assistance from SO when activities or needs are not possible for the patient to do

H(Health Teachings)

proper hygiene and cleaning of the perineal area.

report to healthcare team any unusual signs and symptoms which can be indicative of

complications. These includes:

o loss of sensation

o progressive loss of vision

o acetone-smelled urine (progressed into Type 1 DM)

o chest pain (CAD)

o slowly healing wound

importance of compliance to drug regimen.

monitor blood glucose level by going to a health center since the patient claimed she can’t

afford to buy a glucometer and its testing strips.

O(OPD)

follow-up 1 week after discharge .

D(Diet)

Diabetic diet

low caloric diet. Carbohydrates can be eaten in moderation as well as other food groups.

high fiber diet which includes vegetables and fruits.

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X. UPDATES RELATED TO TYPE 2 DM

Study: Lung cancer patients with diabetes mellitus tend to live longer

Published on October 18, 2011 at 1:31 AM 

Lung cancer patients with diabetes tend to live longer than patients without diabetes, according to a Norwegian study published in the November issue of the Journal of Thoracic Oncology, the official publication of the International Association for the Study of Lung Cancer.Researchers did not speculate on the reason for the effect, but said that the survival benefit warranted more study and that diabetes should not be considered a reason to withhold standard cancer treatment.

"Standard therapy should not be withheld from patients with diabetes mellitus provided they are otherwise fit, even if it may be considered a significant comorbidity," researchers wrote in the study. "The survival benefit may be of clinical importance and should be focused on in future studies."Researchers at the Norwegian University of Science and Technology and Trondheim University analyzed 1,677 lung cancer cases from the Nord-Tr-ndelag Health study (HUNT), the pemetrexed gemcitabine (PEG) study and the Norwegian Lung Cancer Biobank study. It was the first cohort study from a well-defined geographical area, with a stable and large number of inhabitants, investigating lung cancer, diabetes and survival.

They found that the 1-, 2-, and 3-year survival in patients with lung cancer with and without diabetes mellitus were 43% versus 28%, 19% versus 11%, and 3% versus 1%, respectively.The fact that patients with diabetes mellitus showed a lower frequency of metastatic diseases may partly explain the survival benefit in patients with diabetes mellitus, because the majority of the patients with lung cancer die of metastasis and not of the primary tumor," researchers wrote. "However, as we adjusted for stage of disease in our analyses this potential advantage can hardly explain the observed increased survival in patients with diabetes mellitus. In addition, increased survival in patients with diabetes mellitus was clearly demonstrated in the PEG study where all patients had advanced lung cancer."Source: International Association for the Study of Lung Cancer

Reaction:It’s quite strange at first because most would expect that death rate is higher in patients with lung cancer and diabetes at the same time because these are fatal diseases than in patients without diabetes. Out of the blue, since metastasis occurs through the blood, the increased coagulation and poor circulation in patients with diabetes might have slowed the spread of cancer compared to those who don’t. It’s one of the possibilitie

TRPM2 in pancreatic beta-cells may control insulin secretion levelsPublished on January 4, 2011 at 11:25 PM

The research group led by professor Makoto Tominaga and Dr. Kunitoshi Uchida, National institute for Physiological Sciences (NIPS), found TRPM2 ion channel in pancreatic beta-cells is important for insulin secretion stimulated by glucose and gastrointestinal hormone (incretin) secreted after food intake. Their finding was reported in Diabetes.

Diabetes mellitus is a disease caused by lack of insulin secretion from pancreatic cells, or less response to the secreted insulin, which raises the blood glucose levels, and as a result, causes serious disorders. It is said that at least 171 million people worldwide suffer from diabetes mellitus, and its incidence is increasing rapidly. Clarify the mechanisms of insulin secretion is important for the development of diabetes therapy. Here, this research group focused on TRPM2 acting as a body temperature sensor.

TRPM2 is a temperature-sensitive Ca2+-permeable channel and expressed in pancreatic beta-cells. They found that TRPM2-deficient mice have shown the higher blood glucose levels with impaired insulin secretion compared with wild-type mice. Furthermore, TRPM2-deficient pancreatic beta-cells showed smaller intracellular Ca2+ increase and lesser insulin secretion stimulated by glucose and incretin.

Professor Makoto Tominaga and Dr. Kunitoshi Uchida said,"TRPM2 may control insulin secretion levels mainly by modulating intracellular Ca2+ concentrations. Finding the substance which stimulates TRPM2 effectively could lead to the development of a new therapy for diabetes mellitus."Source: National Institute for Physiological Sciences

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BIBLIOGRAPHY

BOOKS:

Merck Medical Manual of Medical Information, 2nd home ed., (2003).

Smeltzer, S., et. al., Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Vol. 2, 10th ed. (2004).

Philippine Pharmaceutical Directory, 14th annual ed., (2007-2008).

Grodner, et. al., Foundations and Clinical Applications of Nutrition, 4th Edition (2009).

Karch, A., Focus on Nursing Pharmacology, 4th ed., (2008).

ONLINE:

www. news-medical.net

www.nursing-crib.com

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