Case Study_dm II New

HOLY ANGEL UNIVERSITYCOLLEGE OF NURSING

ANGELES CITY

A Case Study Presented to the College of Nursing In Partial Fulfillment of the Requirements for the subject NCM 104

Related Learning Experience:

DIABETES MELLITUS TYPE II

Ms. Jenny Rose Leynes, RN MANClinical Instructor

Submitted by:GROUP 4-A

N-303

Catap, Marjorie G.Guarin, Merry Christine B.Liwanag, Angelica Erika S.

Luntao, Aina MariePangan, Astley

January 31, 2011

TABLE OF CONTENTS

I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-4

II. NURSING HISTORYa. Personal History

a. Demographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b. Socio-economic and Cultural Factors. . . . . . . . . . . . . . . . . . . . 5-6

b. Family-Health Illness History . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6c. History of Past Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7 d. History of Present Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7e. Genogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

III. PHYSICAL ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-12

IV. DIAGNOSTIC AND LABORATORY PROCEDURES. . . . . . . . . 13-26

V. THE PATIENT AND HIS ILLNESSa. Anatomy and Physiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-31b. Pathophysiology

i. Book-Based. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-36ii. Patient-Based . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-40

VI. THE PATIENT AND HIS CAREa. Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41-42

i. Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43-52ii. Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53-54

iii. Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55b. Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56-58

VII. NURSING CARE PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59-68ACTUAL SOAPIE(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69-70

VIII. DISCHARGE PLANNING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71-72

IX. LEARNING DERIVED FROM THE STUDY. . . . . . . . . . . . . . . . 73-74

X. REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

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INTRODUCTION

Diabetes is a lifelong disease involving glucose (sugar) in the blood. It is caused by a problem in the way the body makes or uses insulin. Insulin, a hormone is necessary for glucose to move from the blood to the inside of the cells. Unless glucose gets into the cells, the body cannot use it for energy. Diabetes occurs when the body has too much blood glucose due to either the pancreas does not produce enough insulin or the body cannot effectively use the insulin produced.

In type 2 diabetes (formerly called non-insulin-dependent diabetes or adult-onset diabetes), the pancreas continues to produce insulin, sometimes even at higher-than-normal levels. However, the body develops resistance to the effects of insulin, so there is not enough insulin to meet the body's needs.

Diabetes Mellitus is a chronic health disorder; it means that the condition lasts for many years. Diabetes can cause serious health problems. It is an endocrine disorder causing various metabolic changes in the body leading to severe complications such as damage to the eyes, kidneys, nerves, heart and blood vessels. The causes of diabetes mellitus are unclear. Both heredity and environment may be involved. Studies have shown that certain genetic factors may be responsible for diabetes. Genes are chemical units found in all cells, which tell cells what functions they should perform. Genes are passed down from parents to children. If parents carry a gene for diabetes, they may pass that gene onto their children. It not treated properly, type 2 diabetes can cause kidney damage, poor circulation, and numbness in the feet. The main consequence of this condition, however, is heart disease, which claims the lives of approximately 80% of all diabetic patients (Sy, 2007).

At least 171 million people worldwide have diabetes. This figure is likely to be more than double by 2030. A diabetes epidemic is underway. An estimated 30 million people worldwide had diabetes in 1985. A decade later, the global burden of diabetes was estimated to be 135 million. The latest WHO estimate – for the number of people with diabetes, worldwide, in 2000 – is 171 million. This is likely to increase to at least 366 million by 2030 (WHO, 2003).

Diabetes Mellitus based on statistics here in the Philippines is one of the top ten leading causes of mortality and it is ranked 9th. The number of mortality of the said disease per 100,000 population is 16,552 on both sexes, 7,970 are males and 8,582 are females [The 2004 Philippine statistics updated last February 11, 2008].

According to the website Science Daily (November 29, 2010) – Medical scientists at the University of Leicester have identified for the first time a new way in which our body controls the levels of sugar in our blood following a meal. They have discovered the part played by a particular protein in helping to maintain correct blood sugar levels.

The breakthrough was made in the University of Leicester by a team led by Professor Andrew Tobin, Professor of Cell Biology, who is a Wellcome Trust Senior

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Research Fellow. The research is published online ahead of print in the international scientific journal the Proceedings of the National Academy of Sciences.

Professor Tobin said: "The work, which was done wholly at the University of Leicester, is focused on the mechanisms by which our bodies control the level of sugar in our blood following a meal.

"We found that in order to maintain the correct levels of sugar, a protein present on the cells that release insulin in the pancreas has to be active. This protein, called the M3-muscarinic receptor, is not only active but also needs to undergo a specific change. This change triggers insulin release and the control of blood sugar levels."Professor Tobin added: "Without the change in the M3-muscarinic receptor protein sugar levels go up in the same way that we see in diabetes. We are of course testing if the mechanism of controlling sugar levels we have discovered is one of the mechanisms disrupted in diabetes. If this were the case then our studies would have important implications in diabetes."

Basically, there are a significant number of Diabetes Mellitus Type II cases in the country, and this is the reason why thorough study of this case is needed. This case study has enabled the nurse to be more familiarized with the different aspects of such condition. Thus, confirming the belief that when the nurse become more knowledgeable, the more effective he/he becomes in the provision of nursing care. The nurse-researcher also thinks that the knowledge he has acquired regarding this type of disease would benefit him especially in his practice of the nursing profession.

At the same time, having large variety of information about the said topic will enable us, health care provider, to provide explanations and health teachings about the client’s condition.

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Objectives (Nurse – Centered)

After 2 days of nurse-patient interaction and data gathering, student nurses will be able to:

Cognitive Identify the underlying cause(s) or risk factors that contributed to the

condition of the patient; Enumerate the signs and symptoms of the disease and the pathologic changes

occurring during the course of the disease; Develop critical thinking abilities so as to determine appropriate interventions

and medical management of the disease condition and care indicate. Discuss thoroughly the nature of Sugar cancer and the disease process

Affective Recognize the importance of developing a practice of performing accurate and

complete assessment findings Display the proper knowledge and skills in providing effective nursing care to

the patient

Psychomotor Perform a cephalocaudal assessment on the patient Monitor and evaluate patient’s recovery during hospitalization Provide health teachings to the patient especially factors that will contribute to

the continuity of care.

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II. NURSING HISTORY1. Personal History

a. Demographic DataMr. Sugar is a 56 year old male who currently resides at a certain barrio in

Bacolor, Angeles City. He was born on the 11th day of August 1954. He is married for 19 years to Mrs. Insulin, and they were blessed with only 1 child.

b. Socio-economic and Cultural Factors

b.1 Occupational mode of expenditureAccording to Mr. Sugar, he started working as a taxi driver since he was

20 years old. Likewise, he worked as a construction worker but considered it only as a part-time job. Their monthly family income is 6, 000 pesos. A breakdown of their monthly expenses was enumerated by Mrs. Insulin: P 300.00 is allotted for their electricity; P4, 000 for their foods and other basic needs; P 1, 200 goes to the allowance of their child; P 120.00 and if ever there is money left, it goes to their savings.

b.2 Educational AttainmentMr. Sugar shared that his highest educational attainment was high school.

He belongs to a big family (according to him) – 7 members, parents and 5 siblings. According to him, he was not able to continue into college because of poverty.

b.3 Religious AffiliationMr. Sugar is a Roman Catholic. He attends masses every Sundays and

special occasions like birthdays, Christmas, etc.

b.4 Cultural factors affecting the health of the familyUnlike other Filipino residing in barrios, Mr. Sugar shared that their

family does not believe and adhere to superstitious beliefs, but they adhere to using herbal plants as alternatives. According to him, only physicians have the ability to cure and diagnose people. Whenever a member of their family gets ill, either they consult a physician or resort to self-medication. Mefenamic Acid, Biogesic are the most often used medications for pain, while Tuseran, Lagundi, and Oregano are the ones taken for cough. He usually sleeps at 11:00 pm and usually wakes up at around 7:00 am to work as a taxi driver. He also added that he does not perform routine exercises since after his work, he prefers to stay home watching television.

Mr. Sugar mentioned that he did not have any vices since he was young. He neither smoked, nor drink alcoholic beverages. He was just fond of drinking softdrinks, specifically Coke. He even added that his day will not be complete without drinking almost 3-4 bottles of softdrinks per day. He was aware that he should minimize if not totally avoid drinking softdrinks since this greatly increases his sugar level, but according to him, he can’t comply with his physician’s advice because he considers this as his favourite drink.

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With food preferences, he is also fond of eating sweets, salty, and most especially fatty foods like chicharon, and taba ng baboy. He does not like eating high fiber foods like vegetables. Their usual foods are pork, chicken, sardines, and tuyo. According to him, he wanted to limit his high-fat intake since their family has a history of hypertension and Diabetes.

2. Family-Health Illness Historya. Hereditary disease in the family

According to Mr. Sugar, the significant diseases that run in their family are Hypertension, Diabetes Mellitus Type II, and kidney problems like having kidney stones. His father died of heart attack – a complication of Diabetes at the age of 68. His mother died of unknown cause when she was 52 years old. Also, three of them inherited their father’s condition of having kidney stones and Diabetes Type II.

3. History of Past Illness

Included in the past illnesses of Mr. Sugar are the usual childhood illnesses like mumps, chickenpox, common colds and diarrheal problems. According to him, he considers himself as having weak immune system since he easily gets sick and infected.

Formerly, at the age of 46 years old (October, 2000), he was diagnosed of having kidney stones and was advised by his physician to undergo surgery (Nephrolithiasis) on that same year. In the year 2005, he shared that he started feeling some known signs and symptoms of Diabetes Type II like blurring of vision, frequent urination (polyuria), frequent feeling of thirst (polydipsia), and the like but he refused to seek medical advice because according to him, his physician would surely prescribe medications which their budget cannot afford. It took him 3 years before he went to his physician where he was diagnosed and confirmed of having Diabetes Mellitus Type II. Since then, he had no choice but to take his maintenance drugs: Metfromin and Clindamycin twice a day to maintain his blood glucose and improve the effectiveness of insulin in his body. According to him, he has been controlling his serum glucose levels to the standard range although he does not have his own CBG kit. He also shared that he often boils the leaves of ampalaya since for him, this was known to be a herbal medicine for diabetic patients.

In line with this, Mr. Sugar shared that he experienced drastic weight loss since the year 2006. His weight before was 200 lbs (2006), then in 2008, it decreased to 180, and now he is currently weighing 140 lbs. Obviously, he had lost 40 lbs. for only a period of 2 years. According to him, this seems to be impossible because ever since he was diagnosed with Diabetes, he has an intense increase in appetite. He even verbalized “balamu eku kakabsi”. (polyphagia)

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Mr. Sugar does not have allergies or even sensitivities with the food he eats. Aside from this, he did not have any serious injuries such as burns and severe bleeding.

4. History of Present Illness

Mr. Sugar was admitted at a certain hospital in the City of San Fernando last January 13, 2011, was managed as a case of Diabetes Mellitus Type II and was discharges last January 24, 2011.

Mr. Sugar shared that he had a wound on his middle finger on the left dorsal foot. According to him, this was due to a burn which he got from accidentally staying close to a motor’s machine. When asked by the student nurses when the incident happened, Mrs. Insulin only answered last December 2010 since she cannot remember the exact date. Also since then, the wound started manifesting signs of swelling though Mr. Insulin does not report of experiencing any pain.. No medications were taken and no consultation to a physician was done.

Two weeks prior to admission, Mr. Sugar complained of feeling of numbness in his lower extremities. And because of this, he was not able to recognize that he already had a wound on his right dorsal foot. When asked by the student nurses, he really did not have any idea with the cause of his wound. Last January 2, 2011, the wound started manifesting signs of swelling. For one week, Mr. Sugar still managed to work because according to him, he does not feel any pain at all. It is also in this time when his wound (burn) on the middle finger of his left foot started to have foul smell. In cleaning the wound, they made use only of Betadine. Up to this time, no medications were taken and no consultation to a physician was done.

A week prior to admission, Mr. Sugar complained of fever and reported that his wound grew worse. He also reported signs of weakness and irritability. Mrs. Insulin added that her husband loss his appetite and has not been eating well for 2 weeks. Still, no medications were taken and no consultation to a physician was done.

One day prior to admission, the wound burst filled with blood and pus. This time, they decided to go to the hospital where he was advised to have his right foot amputated since it was already considered gangrenous. Also, the physician advised to perform debridement in his left foot. The physician’s clinical impression was: Metgangrene, plantar and dorsal aspect foot (Right) with areas of necrosis DM II.

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5. Genogram

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19 y/o

Legend:

MALE DIABETES TYPE II FEMALE KIDNEY PROBLEM

DECEASED

HYPERTENSION

Mr. Sugar-56 y/o

Father Mother

53 y/o 49y/o58 y/o60 y/o

Father Mother

50y/oMrs. Sugar-55 y/o

53y/o

III. PHYSICAL ASSESSMENT Head- EENT (Eyes, Ears, Nose, Throat) pale palpebral conjunctiva Chest: lungs: (-) crackles auscultated on both lung fields Cardiovascular: NRRR (-) murmur

Clinical Impression: Metgangrene, plantar and dorsal aspect foot (Right) with areas of necrosis DM II

Nurse-Patient Interaction (January 17, 2011)

General Appearance:Mr. Sugar was wearing white shirt. When the group arrived, he was seen lying on

bed, conscious and coherent with an ongoing IVF of # 1 PNSS 1L x 30-31 gtts/min at 600cc level infusing well on left hand.

During the nurse-patient interaction last January 17, 2011, the group obtained the following vital signs:

8:00 am BP: 120/80 mmHg PR: 70 bpmRR: 26 bpm Temp: 36 0C


Nurse-Patient Interaction (January 18, 2011)

General Appearance:Mr. Sugar was wearing white shirt. When the group arrived, he was seen lying on

bed, sleeping with an ongoing IVF of # 2 PNSS 1L x 30-31 gtts/min at 700cc level infusing well on left hand.

During the nurse-patient interaction last January 18 2011, the group obtained the following vital signs:



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Physical Examination:

SkinInspection:

Pale skin Poor skin turgor Dryness noted

Palpation: cold, clammy skin prolonged capillary refill time of 3 seconds

Head and neckInspection:

symmetrical facial movements has coordinated head movements with no difficulty

upon flexion, extension and rotation.Palpation:

no masses lymphadenopathies not noted on cervical area

EyesInspection:

hair of the eyebrows are evenly distributed symmetrically aligned eyebrows eyelids close symmetrically pale palpebral conjunctiva noted blurred vision pupils equally round and reactive to light accommodation

EarsInspection:

color same as facial skin auricle aligned with outer canthus of eye

Palpation: no masses and tenderness noted

Nose and SinusesInspection:

symmetric and straight uniform color nasal septum intact and in midline Both nares are patent

Mouth and TeethInspection:

dry pale lips pale gums

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dry mucous membranes acetone breath (fruity odor) With dentures Tongue is on central position, moves freely

ThoraxInspection:

expands bilaterally without retractions uses accessory muscles when breathing

Auscultation: no adventitious breath sounds noted

Cardiovascular Palpation:

normal rate, regular pulse rhythm capillary refill test: more than 3 seconds narrow pulse on extremities

Auscultation: no murmurs

AbdomenInspection:

Presence of diagonal scar on lower right abdominal region ap-proximately 5 inches long due to nephrolithiasis last October 2000

Auscultation: (+) borborygmy

Palpation: direct pain noted at RUQ with a pain scale of 7/10 (-) palpable mass no pain and tenderness noted

UrinaryInspection:

Amber-colored urine Consumes 3 wet and soaked diapers in an hour

MusculoskeletalInspection:

limited range of motion both lower extremities noted generalized weakness noted slowed movement difficulty turning from side to side to sitting position Patient manifested numbness and tingling sensation on lower

extremities Amputated right leg (stump limb) Debridement performed on the middle finger of left dorsal foot

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NeurologicNeurological Vital Signs (NVS) = 14

Eye Opening: 4 Verbal Response: 5 Motor Response: 5

a. Mental StatusConsciousness

Lethargic Responds slowly Restless/agitated

Posture relaxed in a supine position

Grooming/hygiene clean and short fingernails and toenails

Facial expressions grimace and guarding behavior noted

Speech/Mood responds slowly to questions

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IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/LaboratoryProcedure

Indication/PurposeDate Ordered/

Date Results were released

Results

Normal Values(units used in thehospital)

Analysisand

Interpretationof Results

Complete Blood Count

Hematocrit

White BloodCell

Hemoglobin

This test measures the amount of space (volume) red blood cells take up in the blood. The value is given as a percentage of red blood cells in a volume of blood. It closely reflects the Hgb and RBC values.Used to measure RBC number and volume to screen for anemia or polycythemia or is measured on a person to determine the extent of the said conditions.

The white blood cells also called as leukocytes, are the blood cells responsible for both immunity and the body’s response to infectious organisms. This measures the number of WBC in the blood during the process of infection in the body

The hemoglobin concentration is a measure of the total amount of Hgb in the

DO: January 13, 2011

DR: January 13, 2011 32%

37.1 x 109/L

108 g/L

40-52%

4.8-10.8 x 109/L

125-175 g/L

Mr. Sugar’s result is below the normal range which implies that Mr. Sugar has no enough RBC volume in his blood.

The result is above the normal range which may indicate that Mr. Sugar has an infection.

The result is within the normal range which reflects that Mr. Sugar is not suffering from

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Neutrophils

Lymphocytes

Monocytes

Platelet

peripheral blood which reflects the number of RBC in the blood. Hgb serves as a vehicle for oxygen and carbon dioxide transport. It is used to detect any presence of anemia. It measures the amount of oxygen-carrying protein in the blood.

Neutrophils are the most common type of WBC and this test may determine any body’s response to acute body stress, whether from infection, infarction, trauma, emotional distress, or other noxious stimuli.

This is done to check viral infection.

This test measures the amount of monocytes in blood. This test is used to evaluate and manage blood disorders, certain problems with the immune system, and cancers, including monocytic leukemia. This test may also be used to evaluate for the risk of complications after a heart attack.

This test will determine the coagulating

80 %

15 %

5.2 %

427x 109/L

45-65 %

20-35 %

3-9 %

150-400x 109/L

anemia.

The result is above the normal range, which means that Mr. Sugar’s body responds to a certain infection.

The result is within the normal range, therefore, Mr. Sugar does not have a viral infection.

The result is within normal range which implies that Mr. Sugar has normal levels of monocytes in his blood.

The result is above the normal range which implies that Mr. Sugar’s

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MCV (Mean Corpuscular Volume)

MCH (Mean Corpuscular Hemoglobin)

MCHC (Mean Corpuscular Hemoglobin Concentration)

ability of the patient.And also to detect possible bleeding.

This test is a measure of the average size of red blood cells (RBC), also called erythrocytes. Knowing your MCV is important to assure that you are in good health. It is also a good way to discover if you have an illness that may still be asymptomatic.

This test is conducted to know the average weight of hemoglobin that is present inside a red blood cell.

MCHC and MCV, or mean corpuscular volume, levels are both used to test a person for anemia. MCHC tests for the levels of hemoglobin in the blood. This identifier in a blood test can help a doctor diagnose a patient with anemia.

90.6 femtolitre

s

28.9 picograms

31.9 %

82-98 femtolitres

28-33 picograms

32-38 %

coagulating ability is increased, and may be a sign of bleeding.

The result is within the normal range which implies that Mr. Sugar’s RBC sizes are normal.

The result is within the normal range.

The result falls within the normal range which means that Mr. Sugar is not experiencing anemia.

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Results


Analysisand


Complete Blood Count

Platelet

MCV (Mean Corpuscular Volume)

MCH (Mean Corpuscular Hemoglobin)

This test will determine the coagulating ability of the patient.And also to detect possible bleeding.

This test is a measure of the average size of red blood cells (RBC), also called erythrocytes. Knowing your MCV is important to assure that you are in good health. It is also a good way to discover if you have an illness that may still be asymptomatic.

This test is conducted to know the average weight of hemoglobin that is present inside a red blood cell.

DO: January 14, 2011

DR: January 14, 2011

472x 109/L

79.4 femtolitre

s

27.2 picograms

150-400x 109/L

82-98 femtolitres

28-33 picograms

The result is highly deviated from the normal values. This is then suggestive that Mr. Sugar is having bleeding.

The result is below the normal range which implies that Mr. Sugar’s RBC sizes are deviated from normal.

The result is slightly decreased from the normal range which may imply that the RBCs of Mr. Sugar are

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MCHC (Mean Corpuscular Hemoglobin Concentration)

Reticulocyte Count

MCHC and MCV, or mean corpuscular volume, levels are both used to test a person for anemia. MCHC tests for the levels of hemoglobin in the blood. This identifier in a blood test can help a doctor diagnose a patient with anemia.

This test is used to evaluate erythropoietic activity; Increased in acute and chronic hemorrhage, hemolytic anemias; The Reticulocyte production index will decide if one is working with a hyper-proliferative or non-proliferative anemia, and thus, which tests should be subsequently ordered.

31.3 %

0.8 %

32-38 %

1-5 %

not carrying sufficient hemoglobin.

The result is below the normal range. This can then support the values gathered from the above tests performed. They all indicate that Mr. Sugar may be suffering from bleeding.

This indicates that Mr. Sugar may be suffering from bleeding.

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Nursing Responsibilities for Complete Blood Count:Before the procedure:

Check the Doctor's Order. Identify the patient. Check the Vital signs. Reduce the patient's anxiety by explaining the procedure and why it has to be performed. Acknowledge questions regarding the safety of the procedure.

During the procedure: Stay with the patient. Assist with the collection of the specimen if allowed. Observe sterile technique.

After the procedure: Check the site for bleeding, cyanosis or swelling. Apply pressure and warm compress for five to ten minutes. Check vital signs for any changes. In case of hematoma formation, instruct the patient to apply warm compress. Document the data (attach result on the chart)

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Results


Analysisand


Blood Chemistry

Random Blood Sugar

Creatinine

Blood Urea Nitrogen

Random blood sugar testing checks glucose levels randomly throughout the day, regardless of meal times. Reasons for testing glucose levels are to check for diabetes, to monitor treatment of diabetes, and to check for hypoglycemia.

The creatinine test is used to diagnose impaired kidney function and to determine renal (kidney) damage.

It measures the amount of urea nitrogen (urea is a chemical waste product cleared by the kidney) in the blood. It is done to help diagnose a number of other conditions, such as liver failure, urinary

Date Ordered: January 13, 2011

Date Released: January 13, 2011

30.89mmol/

L

165.2 mmol/

L

16.6mmol/

L

3.85-9.0 mmol/L

60-120 umol/L

1.7-8.3mmol/L

The result is highly increased from the normal range. This clearly indicates that Mr. Sugar has diabetes.

The result is highly deviated from the normal. An elevated serum creatinine levels generally indicate that Mr. Sugar has an impaired kidney function.

The result is above the normal range. This then supports the result of the Creatinine level which is also increased. Both

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Electrolytes:Sodium

Potassium

Chloride

tract obstruction, congestive heart failure or gastrointestinal bleeding.

The sodium levels are measured to detect whether there is the right balance of sodium and liquid in the blood to carry out functions like regulating the amount of water in the body and transmitting electrical signals in the brain and in the muscles.

This test is made to diagnose or monitor kidney disease. It is also measured to check people with high blood pressure.

Chloride levels are measured to detect acid-base imbalance (acidosis or alkalosis) and to aid evaluation of fluid status and extra cellular cation anion balance.

111.3 mEq/L

5.6mEq/L

83.2mEq/L

136-145 mEq/L

3.5-5.0mEq/L

101-111mEq/L

indicates that Mr. Sugar has an impaired kidney function – which is known to be one of the complications of his diabetes.

The result implies that Mr. Sugar’s low total body water and sodium levels may be due to dehydration since he reports of urinating frequently.

The result indicates that Mr. Sugar experiences kidney impairment or is suffering from loss of potassium.

The result denotes that Mr. Sugar has an acid-base imbalance (acidosis).

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http://www.webmd.com/hw-popup/high-blood-pressure-hypertension




Results


Analysisand


Blood Chemistry

Random Blood Sugar

Electrolytes:Sodium

Potassium






21.97mmol/

L

113.0 mEq/L

5.03mEq/L

3.85-9.0 mmol/L

136-145 mEq/L

3.5-5.0mEq/L


The result implies that Mr. Sugar’s low total body water and sodium levels may be due to dehydration.


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Results


Analysisand


Blood Chemistry

Random Blood Sugar

Electrolytes:Sodium

Albumin



An albumin test may be ordered as part of a liver panel to evaluate liver function, along with a creatinine and BUN (Blood Urea Nitrogen) and to evaluate a person's nutritional status.



14.18mmol/

L

116.5 mEq/L

33.0g/L

3.85-9.0 mmol/L

136-145 mEq/L

34-50g/L



The results depict that Mr. Sugar has a decreased nutritional status.

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http://www.labtestsonline.org/understanding/analytes/bun/glance.html

http://www.labtestsonline.org/understanding/analytes/bun/glance.html

http://www.labtestsonline.org/understanding/analytes/creatinine/glance.html

http://www.labtestsonline.org/understanding/analytes/liver_panel/glance.html




Results


Analysisand


Blood Chemistry

Random Blood Sugar

Electrolytes:Sodium

Potassium






18.75mmol/

L

117.6 mEq/L

5.53mEq/L

3.85-9.0 mmol/L

136-145 mEq/L

3.5-5.0mEq/L




Nursing Responsibilities:

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Before the procedure: Check the doctor’s order Explain procedure to the patient Review client’s record for medication that may prolong bleeding such as anti-coagulants Assess the client’s skin at the puncture site to determine if it is intact and the circulation is not compressed. If the patient will undergo blood chemistry that will need fasting, NPO for at least 8-10 hours is required.

During the procedure: Direct the patient to breathe normally and to avoid unnecessary movement. Label the specimen, and promptly transport it to the laboratory.

After the procedure: Observe venipuncture site for bleeding or hematoma formation. Apply pressure bandage. Evaluate test results in relation to the patient’s symptoms and other tests performed.

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Indication/PurposeDate Ordered/Date Results were released

Results

Normal Values(units used

in thehospital)

Analysisand


Urinalysis Urinalysis can reveal diseases that have gone unnoticed because they do not produce striking signs or symptoms. Examples include diabetes mellitus, various forms of glomerulonephritis, and chronic urinary tract infections.



Color: Amber

Transparency: Turbid

Glucose and Albumin: 3+

pH: Acidic

Specific Gravity: 1.020

Color: Light Yellow to Dark amber

Transparency: Transparent

Glucose and Albumin: 3+

pH: Acidic

Specific Gravity:1.006-1.025

Turbid or cloudy urine may be due to excessive cellular debris or proteins.

Positive sugar and albumin is due to the DM of Mr. Sugar which is concerned for the excretion of glucose in the urine (glucosuria).

The acidity of Mr. Sugar will prevent his from acquiring infections.

This result indicates that Mr. Sugar has a good-functioning kidney and is able to concentrate the urine.

Page | 26

Pus Cells: 0-1/HPF (high power field)

Epithelial Cells: few

Red Cells: 1-2 RBC/HPF

Pus Cells: Negative

Epithelial Cells: few

Red Cells: <4 RBC/HPF

The presence of pus cells is indicative of an infection.

Some epithelial cells from the skin surface or from the outer urethra can appear in the urine. Some forms of crystals appear in the urine of healthy individuals.

A high count of red blood cells in the urine can indicate infection, trauma, tumors, or kidney stones.

Nursing Responsibilities for Urinalysis:Before the procedure:

Check the doctor’s order Explain procedure to the patient Tell the SO of the patient and/or that no fasting is required.

During the procedure: Instruct patient to get the midstream of his urine.

After the procedure: Label the specimen, and promptly transport it to the laboratory. Urine should be delivered to the laboratory within 30 minutes for the accuracy of results.

Page | 27

V. THE PATIENT AND HIS ILLNESS 1. Anatomy and Physiology

THE PANCREAS

The function of the pancreas is to make digestive enzymes which digest food materials in the small intestines. In addition, the pancreas also makes insulin which controls the blood glucose levels.

As chyme floods into the small intestine from the stomach, two things must happen: acid must be quickly and efficiently neutralized to prevent damage to the

duodenal mucosa macromolecular nutrients - proteins, fats and starch - must be broken down

muinterestinglych furthis before their constituents can be absorbed through the mucosa into blood

The pancreas plays a vital role in accomplishing both of these objectives, so vital in fact that insufficient exocrine secretion by the pancreas leads to starvation, even if the animal is consuming adequate quantities of high quality food.

In addition to its role as an exocrine organ, the pancreas is also an endocrine organ and the major hormones it secretes - insulin and glucagon - play a vital role in carbohydrate and lipid metabolism. They are, for example, absolutely necessary for maintaining normal blood concentrations of glucose.

Page | 28

http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/pancreas/index.html

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 rathis entering the cells.

Exocrine Function of the PancreasThe bulk of the pancreas is composed of pancreatic exocrine cells and their

associated ducts. Embedded within this exocrine tissue are roughly one million small clusters of cells called the Islets of Langerhans, which are the endocrine cells of the pancreas and secrete insulin, glucagon and several other hormones.

Pancreatic exocrine cells are arranged in grape-like clusters called acini. The exocrine cells are packed with membrane-bound secretory granules which contain digestive enzymes that are exocytosed into the lumen of the acinus. From there, these secretions flow into larger intralobular ducts, which eventually combine into the main pancreatic duct which drains directly into the duodenum.

Endocrine Function of the PancreasThe endocrine pancreas refers to those cells within the pancreas that synthesize

and secrete hormones. The endocrine part of the pancreas takes the form of many small clusters of cells called Islets of Langerhans.

Pancreatic islets house three major cell types, each of which produces a different endocrine product:

Alpha Cells (A cells) secrete the hormone glucagon Beta Cells (B cells) produce insulin which are the most abundant of the islet

cells Delta Cells (D cells) secrete the hormone somatostatin, which is also pro-

duced by a number of other endocrine cells in the body

Page | 29

http://nursingcrib.com/wp-content/uploads/ana-physio-diabetes.png

The different cell types within an islet are not randomly distributed – beta cells occupy the central portion of the islet and are surrounded by a rind of alpha and delta cells.

Islets are highly vascularized, allowing their secreted hormones’ ready access to the circulation. Although islets comprise only 1 to 2% of the mass of the pancreas, they receive about 10 to 15% of the pancreatic blood flow. Additionally, they are innervated by parasympathetic and sympathetic neurons, and nervous signals clearly modulate secretion of insulin and glucagon.

Control of Insulin SecretionInsulin is secreted in primarily in response to elevated blood concentrations of

glucose. This makes sense because insulin is "in charge" of facilitating glucose entry into cells. Some neural stimuli (e.g. sight and taste of food) and increased blood concentrations of other fuel molecules, including amino acids and fatty acids, also promote insulin secretion.

Our understanding of the mechanisms behind insulin secretion remain somewhat fragmentary. Nonetheless, certain features of this process have been clearly and repeatedly demonstrated, yielding the following model:

Glucose is transported into the beta cell by facilitated diffusion through a glucose transporter; elevated concentrations of glucose in extracellular fluid lead to elevated concentrations of glucose within the beta cell.

Elevated concentrations of glucose within the beta cell ultimately leads to membrane depolarization and an influx of extracellular calcium. The resulting increase in intracellular calcium is thought to be one of the primary triggers for exocytosis of insulin-containing secretory granules. The mechanisms by which elevated glucose levels within the beta cell cause depolarization is not clearly established, but seems to result from metabolism of glucose and other fuel molecules within the cell, perhaps sensed as an alteration of ATP:ADP ratio and transduced into alterations in membrane conductance.

Increased levels of glucose within beta cells also appears to activate calcium-independent pathways that participate in insulin secretion.

Insulin and Carbohydrate MetabolismGlucose enters the blood stream after the small intestine hydrolyzes carbohydrates

such as starch and sucrose to form glucose. High concentrations of glucose in the blood stimulate insulin secretion. This insulin then acts on various cells throughout the body to stimulate uptake, utilization and storage of glucose. Two important effects are:

1. Insulin facilitates entry of glucose into muscle, adipose and several other tissues. The only mechanism by which cells can take up glucose is by facilitated diffusion through a family of hexose transporters. In many tissues, such as muscle, the major transporter used for uptake of glucose (called GLUT4) is made available in the plasma membrane through the action of insulin.

Page | 30

In the absence of insulin, GLUT4 glucose transporters are present in cytoplasmic vesicles, where they are useless for transporting glucose. Binding of insulin to receptors on such cells leads rapidly to fusion of those vesicles with the plasma membrane and insertion of the glucose transporters, thereby giving the cell an ability to efficiently take up glucose. When blood levels of insulin decrease and insulin receptors are no longer occupied, the glucose transporters are recycled back into the cytoplasm.

Please note that some tissues, such as the brain and liver, do not need insulin for efficient uptake of glucose. This is because they use a glucose transporter that is not insulin dependent.

2. Insulin stimulates the liver to store glucose in the form of glycogen. A large fraction of glucose absorbed from the small intestine is immediately taken up by hepatocytes, which convert it into the storage polymer glycogen.

Insulin has several effects in liver which stimulate glycogen synthesis. First, it activates the enzyme hexokinase, which phosphorylates glucose, trapping it within the cell. Coincidently, insulin acts to inhibit the activity of glucose-6-phosphatase. Insulin also activates several of the enzymes that are directly involved in glycogen synthesis, including phosphofructokinase and glycogen synthase. The net effect is clear: when the supply of glucose is abundant, insulin "tells" the liver to store as much of it as possible for use later.

A well-known effect of insulin is to decrease the concentration of glucose in blood , which should make sense considering the mechanisms described above. Another important consideration is that, as blood glucose concentrations fall, insulin secretion ceases. In the absence of insulin, a majority of the cells in the body become unable to take up glucose, and begin a switch to using alternative fuels like fatty acids for energy. Neurons, however, require a constant supply of glucose, which in the short term, is provided from glycogen reserves.

In the absence of insulin, glycogen synthesis in the liver ceases and enzymes responsible for breakdown of glycogen become active. Glycogen breakdown is stimulated not only by the absence of insulin but by the presence of glucagon, which is secreted when blood glucose levels fall below the normal range.

Insulin and Lipid MetabolismThe metabolic pathways for utilization of fats and carbohydrates are deeply and

intricately intertwined. Considering insulin's profound effects on carbohydrate metabolism, it stands to reason that insulin also has important effects on lipid metabolism. Important effects of insulin on lipid metabolism include the following:

Page | 31

Insulin promotes synthesis of fatty acids in the liver. As discussed above, insulin is stimulatory to synthesis of glycogen in the liver. However, as glycogen accumulates to high levels (roughly 5% of liver mass), further synthesis is strongly suppressed.

When the liver is saturated with glycogen, any additional glucose taken up by hepatocytes is shunted into pathways leading to synthesis of fatty acids, which are exported from the liver as lipoproteins. The lipoproteins are ripped apart in the circulation, providing free fatty acids for use in other tissues, including adipocytes, which use them to synthesize triglyceride.

Insulin inhibits breakdown of fat in adipose tissue by inhibiting the intracellular lipase that hydrolyzes triglycerides to release fatty acids. Insulin also facilitates entry of glucose into adipocytes, and within those cells, glucose can be used to synthesize glycerol. This glycerol, along with the fatty acids delivered from the liver, is used to synthesize triglyceride within the adipocyte. By these mechanisms, insulin is involved in further accumulation of triglyceride in fat cells.

From a whole body perspective, insulin has a fat-sparing effect. Not only does it drive most cells to preferentially oxidize carbohydrates instead of fatty acids for energy, insulin indirectly stimulates accumulation of fat in adipose tissue.

Page | 32

2. Pathophysiology A. Book-Based a. Schematic Diagram (Flow Chart)

Non – Modifiable Modifiable

Page | 33

Causes decreased insulin secretion

(chronic exposure)

Reduces muscle glucose uptake and promotes hepatic glucose output

(consistent w/ insulin resistance)

Insulin secretory failure / insulin resistance

Decreased cellular glucose uptake Increased hepatic glucose production

Hyperglycemia Increase blood osmolarity

Cellular dehydration

POLYDIPSIA

POLYURIA

No glucose would enter the cell

Cell demand for glucose source

Cellular starvation

POLYPHAGIA

Production of glucose from proteins and fats

Wasting of lean body mass

WEIGHT LOSS

Increased ketones

ACETONE BREATH

Family History of DM

Identical twin

80% chance of developing

DM

Parents

40% chance of acquiring the disease

Age

35 and above(degenerative)

Children/Adolescents/Young

adults

Puberty

Growth hormone

Physical Inactivity

Decreased sensitivity to

insulin

Hypertension

Metabolic Syndrome (together

with obesity)

Obesity

Increased number of adipose tissue cells

(adipocytes)

Releases NEFA into the

circulation

Acidosis 1

Page | 34Stage IV – cancer has spread to other organs in the body such as the lungs/liver surrounds the colon

1

Chronic elevations in blood glucose

Glycoprotein cell wall deposits

Small vessel disease Atherosclerosis Impaired immune function

Coronary Artery Disease

FREQUENT INFECTIONS

DELAYED WOUND HEALING

Diabetic Neuropathy Diabetic Nephropathy

Diabetic Retinopathy

BLURRING OF VISION /

BLINDNESS

End Stage Renal Failure

SYMMETRICAL LOSS OF

PROTECTIVE SENSATION

NUMBNESS AND TINGLING

SENSATION IN THE LOWER

EXTREMITITES

CHARCOT FOOT

DIABETIC FOOT ULCERATION

b. Synthesis of the disease b.1 Definition of the disease

Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar (specifically, glucose) in the blood. Glucose in the blood gives you energy to perform daily activities, walk briskly, run for a bus, ride your bike, take an aerobic exercise class, and perform your day-to-day chores.

Diabetes is due to one of two mechanisms:

1. Inadequate production of insulin (which is made by the pancreas and lowers blood glucose)

2. Inadequate sensitivity of cells to the action of insulin.

The pancreas secretes insulin, but the body is partially or completely unable to use the insulin. This is sometimes referred to as insulin resistance. The body tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they do not continue to secrete enough insulin to cope with the higher demands.

The signs and symptoms of both types of diabetes include increased urine output and decreased appetite as well as fatigue. Diabetes is diagnosed by blood glucose testing, the glucose tolerance test, and testing of the level of glycosylated hemoglobin (glycohemoglobin or hemoglobin A1C). The mode of treatment depends on the type of the diabetes.

The major complications of diabetes include dangerously elevated blood sugar, abnormally low blood sugar due to diabetes medications, and disease of the blood vessels which can damage the eye, kidneys, nerves, and heart.

b.2 Predisposing and Precipitating factors Predisposing Factors:

a. Age.i. 35 years old and above (degenerative). As people gets older, they tend to exercise less and also gain weight

because their metabolism gets slower than normal.

i. Children/adolescents/young adults. Individuals falling in this category are expected to undergo the

puberty stage. Puberty is associated with an increase secretion of growth hormone, which in turn promotes a transient state of physiologic insulin resistance.

b. Family History of Diabetes. i. Parents.

Page | 35

http://www.medterms.com/script/main/art.asp?articlekey=3668







http://www.emedicinehealth.com/script/main/art.asp?articlekey=103861



http://www.emedicinehealth.com/script/main/art.asp?articlekey=80952

Genetic components has a stronger basis for type 2 DM than type 1 DM. Although no definite and consistent genes have been identified, multifactorial inheritance is the most important factor in the development of type 2 DM. A person with one parent having type 2 DM is at an increased risk of getting diabetes, but if both parents have type 2 DM, the risk in the offspring rises to 40%.

i. Identical Twin. There is approximately 80% chance of developing diabetes in the

other identical twin if the other twin has the disease.

Precipitating Factors:a. Physical Inactivity.

Physical activity helps in controlling weight, uses up glucose as energy and makes cells more sensitive to insulin.

b. Hypertension. Hypertension, together with obesity, is known to be under “Insulin

Resistance Syndrome” which basics are glucose tolerance and insulin resistance. Hypertension attempts the body to compensate for insulin resistance but later, this compensatory mechanism fails and elevated blood glucose levels result.

c. Obesity. In obesity, there are increased number of adipose tissue cells

(adipocytes) which are known to release non-esterified fatty acids (NEFA) into the circulation. These NEFAs affect cells causing decreased insulin secretion in chronically exposed patients. Likewise, NEFA reduces muscle glucose uptake promoting hepatic glucose output, known to be consistent with insulin resistance.

b.3 Signs and symptoms with rationale Polyphagia (increased hunger). If cells have no glucose intake, there will

be cellular starvation which then stimulates the satiety center of the hypothalamus to increase the urge of the person to eat excessive amounts of food.

Polydipsia (increased thirst). If cells are not able to absorb the glucose, there will be intracellular and extracellular dehydration. As a compensatory mechanism of the body, the person will have the urge to drink more water.

Polyuria (increased urination). The excessive drinking of water leads to increased blood volume, wherein the kidneys consequently functions to excrete large volumes of urine in an attempt to regulate excess vascular volume.

Weight loss. Despite eating more than usual to relieve hunger, you may lose weight. Without the ability to use glucose, the body uses alternative fuels

Page | 36

stored in muscle and fat. Calories are lost as excess glucose is released in the urine.

Acetone breath. This is due to the acidosis caused by the presence of ketones and is characterized by a fruity-odor breath. Ketones lead to acidosis because these interfere with the body’s acid-base balance by producing hydrogen ions resulting to decrease in pH. In addition, when ketones are excreted, sodium is also eliminated resulting in sodium depletion and further acidosis.

Blurring of vision/blindness. This is primarily due to Diabetic Retinopathy – one of the known complications of DM Type 2. Increasing levels of blood glucose causes blood to become viscous. Viscous blood tends to put high pressures on the minute blood vessels in the eyes, which may cause rupture of the blood vessels overtime.

Delayed wound healing. This is due to the sluggishness of blood and distance of wound because lesser blood supply reaches the extremities.

Frequent infections. When hyperglycemia exceeds 200 mg/dl, leukocyte and granulocyte function – substances which are known to defend the body against foreign materials and infectious diseases, becomes impaired. Poorly controlled DM is likened to a starved state, and malnutrition is closely linked to depressed immune function.

Symmetrical loss of protective sensation and Numbness/Tingling Sensation. This is one of the effects of Diabetic Neuropathy, a complication of Type 2 DM. This is due to the progressive loss of nerve fibers leading to nerve damage which then results to loss of sensation.

Charcot Foot. Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). This causes bones to be fractured easily because the ability to sense pain is diminished.

Diabetic foot ulceration. As diabetic patients lose their ability to sense pain or hot/cold, the risk of acquiring feet injuries increases.

Page | 37

B. Pathophysiology (PATIENT-BASED) Non – Modifiable Modifiable

Page | 38

Causes decreased insulin secretion

(chronic exposure)

Reduces muscle glucose uptake and promotes hepatic glucose output

(consistent w/ insulin resistance)

Family History of DM

Parents

40% chance of acquiring the disease

Age (54 years old when he was diagnosed)

35 and above(degenerative)

Physical Inactivity

Decreased sensitivity to

insulin

Obesity (wt: 200lbs/90.91kg; ht: 5’8’’/2.98m2)(BMI: 30.51 kg/m2)

Increased number of adipose tissue cells

(adipocytes)

Releases NEFA into the

circulation

Insulin secretory failure / insulin resistance

Decreased cellular glucose uptake Increased hepatic glucose production

Hyperglycemia Increase blood osmolarity

Cellular dehydration

POLYDIPSIA (HPI)

POLYURIA (HPI; PA – 3 wet and soaked diapers in

1 hour)

No glucose would enter the cell

Cell demand for glucose source

Cellular starvation

POLYPHAGIA (HPI)

Production of glucose from proteins and fats

Increased ketones

ACETONE BREATH (PA)

Acidosis

1

Signs of dehydration:(PA)

cold, clammy skinprolonged capillary refill of 3 seconds

Poor skin turgorPale skinDryness notedpale palpebral conjunctiva

dry pale lipspale gumsdry mucous membranes

Lab results: (Jan. 15, 2011)Sodium: 117.6 mEq/L

Page | 39

Diabetic Retinopathy

BLURRING OF VISION /

BLINDNESS(HPI; PA)

1

Chronic elevations in blood glucose

Glycoprotein cell wall deposits

Small vessel disease Impaired immune function

DELAYED WOUND HEALING

(1 WEEK PTA)

Diabetic Neuropathy

SYMMETRICAL LOSS OF PROTECTIVE

SENSATION(2 WEEKS PTA)

NUMBNESS AND TINGLING SENSATION

IN THE LOWER EXTREMITITES

(2 WEEKS PTA; PA)

DIABETIC FOOT ULCERATION(1 WEEK PTA)

Diabetic Nephropathy

Amputated right leg (stump limb):

Jan. 16, 2011(PA)

Narrow pulse on extremities (PA)

KIDNEY AFFECTATION

Lab results: (Jan. 13, 2011)Creatinine: 165.2 mmol/L

Blood Urea Nitrogen: 16.6mmol/L

Debridement of middle finger on left dorsal footJan. 16, 2011

(PA)

b.2 Predisposing and Precipitating factors Predisposing Factors:

a. Age (62 years old)i. 35 years old and above (degenerative). When Mr. Sugar was diagnosed, he was 54 years old, therefore he is

already in the degenerative phase. And as we all know, as people gets older, they tend to exercise less and also gain weight because their metabolism gets slower than normal.

b. Family History of Diabetes. i. Parents. Mr. Sugar’s father died of Diabetes, therefore, the said disease runs

in their family. Genetic components has a stronger basis for type 2 DM than type 1 DM. Although no definite and consistent genes have been identified, multifactorial inheritance is the most important factor in the development of type 2 DM. A person with one parent having type 2 DM is at an increased risk of getting diabetes, but if both parents have type 2 DM, the risk in the offspring rises to 40%.

Precipitating Factors:a. Physical Inactivity.

Mr. Sugar shared that he is not active in exercising. Likewise, he does not do household chores since he finds himself weak and irritable most of the time. Physical activity helps in controlling weight, uses up glucose as energy and makes cells more sensitive to insulin.

b. Obesity. Mr. Sugar is said to be obese since his body mass index is 30.51-

falling on the 30.0-34.9 obese I range. In obesity, there are increased number of adipose tissue cells (adipocytes) which are known to release non-esterified fatty acids (NEFA) into the circulation. These NEFAs affect cells causing decreased insulin secretion in chronically exposed patients. Likewise, NEFA reduces muscle glucose uptake promoting hepatic glucose output, known to be consistent with insulin resistance.

b.3 Signs and symptoms with rationale Polyphagia (increased hunger). If cells have no glucose intake, there will

be cellular starvation which then stimulates the satiety center of the hypothalamus to increase the urge of the person to eat excessive amounts of food. Also, because of inability to produce insulin, the hormone necessary for glucose to enter cells and fuel their functions — leaves your muscles and organs energy depleted. A symptom of hunger makes you feel like eating more until your stomach is full, but the hunger persists because, without insulin, the glucose produced from dietary carbohydrates never reaches your body's energy-starved tissues.

Page | 40

Polydipsia (increased thirst). If cells are not able to absorb the glucose, there will be intracellular and extracellular dehydration. As a compensatory mechanism of the body, the person will have the urge to drink more water. Likewise, a high level of blood glucose pulls water from the body's tissues, making the patient thirsty.

Polyuria (increased urination). The excessive drinking of water leads to increased blood volume, wherein the kidneys consequently functions to excrete large volumes of urine in an attempt to regulate excess vascular volume.

Acetone breath. This is due to the acidosis caused by the presence of ketones and is characterized by a fruity-odor breath. Ketones lead to acidosis because these interfere with the body’s acid-base balance by producing hydrogen ions resulting to decrease in pH. In addition, when ketones are excreted, sodium is also eliminated resulting in sodium depletion and further acidosis.

Delayed wound healing. This is due to the sluggishness of blood and distance of wound because lesser blood supply reaches the extremities.

Symmetrical loss of protective sensation and Numbness/Tingling Sensation. This is one of the effects of Diabetic Neuropathy, a complication of Type 2 DM. This is due to the progressive loss of nerve fibers leading to nerve damage which then results to loss of sensation.

Diabetic foot ulceration. As diabetic patients lose their ability to sense pain or hot/cold, the risk of acquiring feet injuries increases.

Page | 41

VI. THE PATIENT AND HIS CARE

1. Medical ManagementA. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Thisapy, etc.

Medical Management

General Description Indication or Purpose

Date Ordered, Date Performed,

Date Changed /discontinued

Client’s Response to Treatment

Plain Normal Saline Solution/ 0.9% Sodium Chloride

Regulation:30-31 gtts/min

0.9% Sodium Chloride is an isotonic Solution which has the same concentration as blood and plasma. It is used to restore vascular volumes.

0.9% Sodium Chloride is indicated for use in adults and children as sources of electrolytes and water for hydration. It is also indicated for extracellular fluid replacement, treatment of metabolic alkalosis in the presence of fluid loss and mild sodium depletion, and may be used to initiate and terminate blood transfusions without hemolyzing red blood cells.

Date Ordered:January 14, 2011

Date Started:January 14, 2011

Mr. Sugar tolerated the said management.

Page | 42

Nursing Responsibilities:Before the Procedure:

Check the physician’s order for IV solution and explain to the client the procedure. Check the patency of the IV and the needle. Check the type of infusion, condition of the vein and medical condition of the patient.

During the procedure: Maintain aseptic technique and proper procedure and steps in infusion of IV solution

After the procedure: Monitor IV infusion at least every 2 hours. Inspect site for pain, swelling, coolness or pallor at site of insertion, which may indicate infiltration of IV Inspect site for redness, swelling, heat and pain which may indicate phlebitis. Monitor client for fluid overload.

Page | 43

B. Drugs Generic Name/

Brand Name/ Dosage/ Route/ Frequency of

Administration

General Action Indication or Purpose

Date orderedDate performed/Date Changed/ discontinued

Client’s Response to Treatment

Generic Name:Ranitidine

Brand Name:Aceptin

50 mg/ IV every 8 hours

Ranitidine inhibits the action of histamine H2-receptors of the parietal cells in the stomach and prevents histamine-mediated gastric acid secretion. It does not affect pepsin secretion, pentagastrin-stimulated factor secretion or serum gastrin.

Prophylaxis of acid aspiration during general anesthesia.

Date ordered:January 16, 2011

Date Performed:January 16, 2011

Mr. Sugar experienced adverse reactions like headache, and dizziness.

Generic Name:Tramadol Hydrochloride

Brand Name:Ultram

50 mg IV every 8 hours

A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

Management of moderate to severe pain



Mr. Sugar did not experience any side effects such as N/V diarrhea, dizziness, or headache

Generic Name:Paracetamol

Brand Name:Biogesic, Tempra


Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever

It is given to treat Mr. Sugar’s fever.



Mr. Sugar’s temperature decreased from 380C to 37.40C

Page | 44

x T > 37.80C through central action in the hypothalamic heat-regulating center.

Generic Name: Promethazine Hydrochloride

Brand Name:Phenergan

50 mg/ IM on call

Promethazine is a phenothiazine derivative that competitively blocks histamine H1 receptors without blocking the secretion of histamine. It also is a very weak dopamine antagonist. It has sedative, anti-motion-sickness, anti-emetic, and anti-cholinergic effects.

For preoperative sedation and to counteract postnarcotic nausea. As antiallergic medication to combat hay fever, allergic rhinitis, etc. To treat allergic reactions it can be given alone or in combination with oral decongestants like pseudoephedrine.



Mr. Sugar experienced a feeling of fatigue and drowsiness.

Generic Name: Atropine Sulfate

Brand Name:Sal-Tropine

0.5 g IM on call

An anticholinergic that inhibits acetylcholine at the parasympathetic neuroeffector junction, blocking vagal reflects on the SA and AV nodes, enhancing conduction.

Given preoperatively to diminish secretions and block cardiac vagal reflexes.



Mr. Sugar experienced dryness of mouth as one of the side effects of the drug.

Generic Name: Clindamycin Hydrochloride

Brand Name:

Inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome.

Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. It is also



Mr. Sugar did not experience any side effects of the said drug.

Page | 45

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

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

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

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

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

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

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

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

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

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

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

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

Cleocin HCl


indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci. Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate.

Generic Name:Ceftazidime

Brand Name:Ceptaz, Fortaz, Tazicef

1g IV every 8 hours

Third-generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usually bactericidal.

It is indicated for Lower Respiratory Tract Infections, Skin and Skin-Structure Infections, Urinary Tract Infections, Bacterial Septicemia, and Bone and Joint Infections.



Mr. Sugar did not experience any side effects of the said drug.

Generic Name:Ferrous sulfateFeSO4

Brand Name:Feosol

200mg/tab once on DAT

Provides elemental iron, an essential component in the formation of hemoglobin.

The patient was given Iron supplements to prevent Iron-deficiency anemia.



Mr. Sugar experienced side effects such as light headedness and loss of appetite.

Page | 46

Generic Name:Insulin

Brand Name:Humulin R

Sliding Scale:CBG140-160 2 “u” IV 161-180 4 “u” IV 181-200 6 “u” IV 201-250 8 “u” IV 251-300 10 “u” IV>301 10 “u” IV + 5 “u” SQ

Insulin is a polypeptide hormone that controls the storage and metabolism of carbohydrates, proteins, and fats. This activity occurs primarily in the liver, in muscle, and in adipose tissues after binding of the insulin molecules to receptor sites on cellular plasma membranes. insulin increases active glucose transport through muscle and adipose cellular membranes, and promotes conversion of intracellular glucose and free fatty acid to the appropriate storage forms (glycogen and triglyceride, respectively).

It is used to treat Mr. Sugar’s diabetes mellitus. Like other insulin products, it works by helping sugar (glucose) get into cells. It is a short-acting insulin.



Mr. Sugar did not experience any side effects like nausea and vomiting, and hypotension.

Page | 47

CBG MONITORING SHEETDate/Time CBG Result Type of Insulin Administered Dosage

1-14-11 6 pm 12 mn

No strip availableNo strip available

--

--

1-15-11 6 am 8 am 12 mn 6 pm

No strip availableNo strip available

300 mg/dl200 mg/dl

--

Rapid Acting InsulinRapid Acting Insulin

--

10 “u”8 “u”

1-16-11 12 mn 6 am 7 am 12 nn

No strip availableNo strip availableNo strip availableNo strip available

----

----

1-17-11 12 mn 6 am 12 nn 6 pm 8 pm

251 mg/dl120 mg/dl120 mg/dl

No strip available160 md/dl

Rapid Acting InsulinRapid Acting InsulinRapid Acting Insulin

-Rapid Acting Insulin

10 “u”----

Page | 48

Nursing Responsibilities: Ranitidine Before:

Assess the patient accordingly. Check doctor’s order. Perform skin test. Wash hands properly.

During: Check patient’s name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication.

After: Wash hands properly. Document the administration. Assess for potential problems related to the medication administered like diarrheas, nausea and vomiting, enlargement of

breasts and decrease in libido.

Tramadol HydrochlorideBefore:

Check doctor’s order. Explain the purpose of each medication. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.

During: Check patient’s name and medication, including medication name, dose, route of administration, time and drug indication. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended

doses.After:

Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects.

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Monitor patient for seizures. May occur within recommended dose range. Document the administration.

ParacetamolBefore:

Check doctor’s order. Explain to the patient the importance of taking the medication. Tell the patient that the medication may be taken with or without meals.

During: Check patient’s name and medication, including medication name, dose, route of administration, time and drug indication. Take it with a full glass of water.

After: Monitor changes in patient’s temperature or a change in pain that causes discomfort. Emphasize to the patient that he/he might feel dizzy when taking the medication. Document the administration.

Promethazine HydrochlorideBefore:

Assess the patient accordingly. Check doctor’s order. Wash hands properly.

During: Check patient’s name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. Tell patient to take oral form with food or milk.

After: Wash hands properly. Document the administration.

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Atropine SulfateBefore:

Assess the patient accordingly. Check doctor’s order. Perform skin test. Wash hands properly.


After: Wash hands properly. Instruct patient to report serious or persistent adverse reactions promptly. Document the administration.

Clindamycin Hydrochloride Before:



After: Wash hands properly. Tell patient to report discomfort at IV insertion site. Instruct patient to notify prescriber of adverse reactions (especially diarrhea). Warn him not to treat such diarrhea himself be-

cause drug may cause life threatening colitis. Document the administration.

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CeftazidimeBefore:

Assess the patient accordingly. Ask if he is allergic to penicillins or cephalosporins. Check doctor’s order. Wash hands properly.


After: Wash hands properly. Tell patient to report discomfort at IV insertion site. Advise patient to notify prescriber about loose stools or diarrhea. Document the administration.

Ferrous SulfateBefore:


During: Check patient’s name and medication, including medication name, dose, route of administration, time and drug indication. Explain the purpose of each medication. Assist patient in sitting position in administering oral medication then offer liquids. Administer before meals and at bed time.

After: Wash hands properly. Document the administration.

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Assess for potential problems related to the medication administered like loss of appetite, GI upset, fast heart rate, mouth sores, drop in BP and light headedness.

Humulin RBefore:

Check doctor’s order. Read it before you start using this insulin and each time you get a refill, if you have any questions, consult your doctor or

pharmacist. Before using, inspect this product visually for particles or discoloration. If either is present, do not use the insulin. Before injecting each dose, clean the injection site with rubbing alcohol it is important to change the location of the injection

site to avoid developing problem areas under the skin. Explain the purpose of each medication.

During: Check patient’s name and medication, including medication name, dose, route of administration, time and drug indication. Inject this medication under the skin within 30-60 minutes before eating a meal or immediately after the meal is directed by

your doctor. To reduce discomfort to the injection site, do not inject cold insulin. Insulin may be injected at the abdominal wall, the thigh or the back of the upper arm.

After: Store and discard needles and medial supplies safely. Tell patient about possible side effects. After pulling out the needle, apply gentle pressure on the injection site. Do not rub the area. Tell patient to use this medication regularly to get the most benefit from it, to help the patient remember; use it at the same

time(s) each day. Document the procedure done.

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C. Diet

Type of Diet General Description Indication or Purpose

Date orderedDate performed/Date Changed/ discontinued

Client’s Response and/or Reaction to the

Diet

Nothing Per Orem(NPO)

No food, beverage, or even medicine is passed through the mouth. The major purpose of withholding food and fluid before surgery is to prevent aspiration. Fluid and foods are restricted preoperatively overnight.

Patient was ordered to go on NPO before surgery for stomach emptying and after surgery to prevent aspiration.

Date Ordered:January 13, 2011 January 14, 2011 post-midnightJanuary 16, 2011

Mr. Sugar followed the said diet instructed by the physician. Also, emptying of the stomach before operation was achieved.

Low Salt Diet A low sodium diet is a diet that includes no more than 1,500 to 2,400 mgs of sodium per day.

Intended for patients with CRF, declining renal function and hypertension. Likewise, it is advised to decrease sodium concentration in the body and prevent uremia because kidneys cannot normally concentrate or dilute the urine if there is declining renal function, as these may cause edema and heart failure in the patient.

Date Ordered:December 05, 2010

Mr. Sugar followed the said diet instructed by the physician.

Nursing responsibilities for Nothing Per Orem (NPO):

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

Before: Verify doctor’s order. Discuss the importance of the ordered diet. Identify the type of diet.

During: Explain to the significant others the reason including the health precaution for the diet given Update patient significant others of the patient diet change Monitor if the patient complies with the diet given

After: Monitor client’s reaction. Assess for patient’s condition, how he respond to the diet.

Nursing responsibilities for Low Salt Diet:Before:

Verify doctor’s order. Discuss the importance of the ordered diet. Identify the type of diet.

During: Explain to the significant others the reason including the health precaution for the diet given. Update patient significant others of the patient diet change. Monitor if the patient complies with the diet given

After: Monitor client’s reaction. Assess for patient’s condition, how he respond to the diet.

D. Activity

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Type of Activity/ Exercise

General Description Indication or PurposeClient’s Response and/or

Reaction to the Diet

Bed Rest An activity wherein the patient is not allowed to do any strenuous activity. This is a pursuit where the patient stays on bed.

General weakness was noted to Mr. Sugar and so bed rest is indicated to conserve energy and regain optimum strength.

Mr. Sugar complied with the treatment regimen as ordered. He maintained rested on his bed and limits physical activity.

Nursing Responsibilities:Before:

Checked doctor’s order Explained the importance of the procedure to the patient and S.O.

During: Teached the patient SO proper position of the activity to prevent complication Assisted the SO in changing position of the client at least every 2 hours

After: Checked for any complications like bed sores, muscle atrophy Removed all unnecessary objects to the patient’s bed to provide comfort Documented response of the patient and the procedure done.

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2. Surgical Management“E” Below the Knee Amputation (BKA) of Right Foot, Debridement of Left Foota. Brief Description

Below the knee amputation (BKA) is a common procedure performed in diabetic patients for foot gangrene or uncontrolled foot infections. Amputations can be either planned or emergency procedures. Injury and arterial embolisms are the main reasons for emergency amputations. The operation is performed under regional or general anesthesia by a general or orthopedic surgeon in a hospital operating room.

Details of the operation vary slightly depending on what part is to be removed. The goal of all amputations is twofold: to remove diseased tissue so that the wound will heal cleanly, and to construct a stump that will allow the attachment of a prosthesis or artificial replacement part.

The surgeon makes an incision around the part to be amputated. The part is removed, and the bone is smoothed. A flap is constructed of muscle, connective tissue, and skin to cover the raw end of the bone. The flap is closed over the bone with sutures (surgical stitches) that remain in place for about one month. Often, a rigid dressing or cast is applied that stays in place for about two weeks.

On the other hand, debridement may be considered one of the most important aspects of diabetic foot ulcer care, along with offloading and infection control. ADA guidelines recommend debridement of abscessed tissue along with incision and drainage.

Debridement is the removal of necrotic tissue to decrease the risk of infection and to promote wound closure. Debridement should remove all necrotic tissue, callus, and foreign bodies down to the level of viable bleeding tissue. Wounds should be thoroughly flushed with sterile saline or a noncytotoxic cleanser following debridement. Hydrotherapy is not recommended for diabetic patients. Debridement is essential for the removal of nonviable cells and for healing. Periwound callus must also be removed, as it may contribute to periwound pressure and incomplete wound contraction. Ulcers may also be obscured by the presence of callus.

Vascular status must always be determined prior to sharp surgical debridement. This may be accomplished through techniques described earlier in this manuscript. Determining local perfusion is of particular importance when debriding ulcers on the distal aspect of the foot.

b. Client’s response to operationMr. Sugar had reports of pain but felt relieved of the wounds he had on both of his lower extremities.

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c. Nursing responsibilities prior, during and after the operationPRE-OPERATIVE PHASEPreadmission Testing1. Initiates initial preoperative assessment2. Initiates teaching appropriate to patient’s needs3. Involves family in interview4. Verifies completion of preoperative testing5. Verifies understanding of surgeon-specific preoperative orders6. Assesses patient’s need for postoperative transportation and care

Admission to Surgical Center or Unit1. Completes preoperative assessment2. Assesses for risks for postoperative complications3. Reports unexpected findings or any deviations from normal4. Verifies that operative consent has been signed5. Coordinates patient teaching with other nursing staff6. Reinforces previous teaching7. Explains phases in perioperative period and expectations8. Answers patient’s and family’s questions9. Develops a plan of care

In the Holding Area1. Assesses patient’s status, baseline pain and nutritional status2. Reviews chart3. Identifies patient4. Verifies surgical site and marks site per institutional policy5. Establishes intravenous line6. Administers medications if prescribed7. Takes measures to ensure patient’s discomfort8. Provides psychological support9. Communicates patient’s emotional status to other appropriate

members of the health care team

INTRAOPERATIVE PHASEMaintenance of Safety1. Maintain aseptic, controlled environment2. Effectively manages human resources, equipment, and supplies for

individualized patient care3. Transfers patient to operating room bed or table4. Positions the patient5. Applies grounding device to patient6. Ensures that the sponge, needle, and instrument counts are correct7. Completes intraoperative documentation

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Physiologic Monitoring1. Calculates effects on patient of excessive fluid loss or gain2. Distinguishes normal from abnormal cardio-pulmonary data3. Reports changes in patient’s vital signs4. Institutes measures to promote normothermia

POSTOPERATIVE PHASETransfer of Patient in Postanesthesia Care Unit1. Communicates intraoperative information

a. Identifies patient by nameb. States type of surgery performedc. Identifies type of anesthetic usedd. Reports patient’s response to surgical procedure and anesthesiae. Describes intraoperative factors (eg, insertion of drains or

catheters; administration of blood, analgesic agents, or other medications during surgery; occurrence of unexpected events)

f. Describes physical limitationsg. Reports patient’s preoperative level of consciousnessh. Communicates necessary equipment needsi. Communicates presence of family and/or significant others

Postoperative Assessment Recovery Area1. Determines patient’s immediate response to surgical intervention2. Monitors patient’s physiologic status3. Assesses patient’s pain level and administers appropriate pain relief

measures4. Maintains patient’s safety (airway, circulation, prevention of injury)5. Administers medications, fluid, and blood component therapy, if

prescribed6. Provides oral fluids if prescribed for ambulatory surgery patient7. Assesses patient’s readiness for transfer to in-hospital unit or discharge

home based on institutional policy.

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VII. NURSING CARE PLAN1. ACUTE PAIN

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONOBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:> “Ang sakit sakit ng paa ko.”

Objective:> pain scale of 8/10

> cold clammySkin

> grimace noted

> guarding behaviour

> restlessness and irritability noted

> Amputated right leg (stump limb)

Acute pain r/t physical and surgical procedure AEB amputated right leg (stump limb)

Acute pain is described as anunpleasantsensory oremotionalexperienceassociated withactual orpotentialtissue damageor injury aslasting fromseconds to 6months. Incases ofamputation of limb, painis continuous until tissues are properly healed by the continuous flow of blood through the tissues.

After 1 hour of nursing interventions the patient will be able to demonstrate the use of relaxation skills and diversional activities to control pain and pain scale decrease from 8/10 to controllable level

> Provide comfort measures such as repositioning, warm packs and therapeutic touch.

> Instruct use of relaxation techniques such as focused breathing or imaging.

> Provide diversional activities such as chatting to the patient or listening to music.

> Create a quiet, non-disruptive environment with dim lights and comfortable temperature when possible.

> The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

> This may help to distract attention and reduce tension.

> Focusing attention and enhancing coping with limitations can relieve pain.

> Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation

After 1 hour of nursing interventions Mr. Sugar demonstrated the use of relaxation skills and diversional activities to control pain and pain scale decrease from 8/10 to controllable level

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> Encourage to change position side to side every 2 hours and sit-up on bed

> Encourage adequate rest periods.

technique rather than external distraction.

> To promote optimum level of function and prevent further complications

> To prevent fatigue that can be caused by too much pain.

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2. DEFICIENT FLUID VOLUME R/T ACTIVE FLUID LOSSES SECONDARY TO DM II AEB DRY MUCOUS MEMBRANES AND POOR SKIN TURGOR

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC


NURSING INTERVENTIONS


Subjective:> “Pane kung mangapali uling inum nakung inum”

Objective:> poor skin turgor

> appears pale

> pale palpebral conjunctiva

> dry mucous membranes

> dryness of the skin noted

> dry pale lips

> pale gums

Deficient Fluid Volume R/T active fluid losses AEB dry mucous membranes and poor skin turgor

In DM type 2, If cells are not able to absorb the glucose, there will be intracellular and extracellular dehydration. As a compensatory mechanism of the body, the person will have the urge to drink more water. The excessive drinking of water then leads to increased blood volume, wherein the kidneys consequently functions to excrete large volumes of urine in an attempt to regulate excess vascular volume.

After 1-2 hours of nursing interventions, the patient will be able to verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications.

> Administer/ Regulate fluids and electrolytes.

> Advise patient to limit intake of alcohol/caffeinated beverages.

> Encourage the SO to bathe less frequently using mild cleanser/soap, and provide optimal skin care with suitable emollients.

> Note change in mentation/behaviour/ functional abilities such as confusion, lethargy, dizziness

> To rehydrate the patient.

> These tend to exert a diuretic effect.

> To maintain skin integrity and prevent excessive dryness.

> These signs indicate sufficient dehydration to cause poor cerebral perfusion and/or electrolyte imbalance.

After 1-2 hours, Mr. Sugar verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.

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> prolonged capillary refill time of 3 seconds

> Consumes 3 wet and soaked diapers in an hour

> Discuss factors related to occurrence of deficit, as individually appropriate..

> Early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia.

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3. IMPAIRED SKIN INTEGRITY RELATED TO SURGICAL POCEDURE SECONDARY TO DIABETIC FOOT ULCERATION AS EVIDENCED BY INTACT AND BLOOD-TINGED DRESSING OVER THE AMPUTATED RIGHT LEG (STUMP LIMB)

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC


NURSING INTERVENTION


Subjective:> Ø

Objective:> Appears weak

> Poor skin tur-gor

> Patient mani-fested numbness and tingling sensation on lower extremi-ties

> Pale skin

> Poor skin turgor

> Dryness noted

> Prolonged capillary refill time of 3

Impaired skin integrity R/T surgical procedure 20 diabetic foot ulceration AEB intact and blood-tinged dressing over the amputated right leg (stump limb)

Disruption of dermis and epidermis layers of the skin caused by underlying disease condition resulting to amputation of the affected part.

After 2-3 hours of nursing interventions, patient will be able to verbalize understanding of causative factors and necessary interventions.

> Place the client in a comfortable position

> Assess skin, note color, turgor, and sensation, describe and measure irregularities and observed changes.

> Demonstrate good skin hygiene, like washing thoroughly and pat dry carefully.

> Instruct family to maintain clean, dry clothes, preferably cotton fabric, emphasize

> To prevent backaches or muscle aches

> Establishes comparative baseline providing opportunity for timely intervention.

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

> Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and

After 2 hours, Mr. Sugar verbalized understanding of causative factors and necessary interventions.

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seconds > Debridement performed on the middle finger of left dorsal foot

> intact and blood-tinged dressing over the amputated right leg (stump limb)

importance of adequate nutrition and fluid intake.

> Encourage adequate rest periods, especially before meals and other ADLs.

> Encourage active ROM exercises 3x a day

> Reinforce strict DM diet as ordered

> Perform wound care

increases risk for infection.

> Rest between activities provides time for energy conservation and recovery.

> Exercises maintain muscle strength and joint ROM.

> To provide a positive nitrogen balance to aid in skin/tissue healing and to maintain general good health.

> Keeps wound clean/ minimizes cross contamination and to prevent spread of infection.

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4. IMPAIRED PHYSICAL MOBILITY RELATED TO DECREASED MUSCLE STRENGTH SECONDARY TO POST BELOW THE KNEE AMPUTATION AS EVIDENCED BY LIMITED RANGE OF MOTION ON BOTH LOWER EXTREMITIES

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC




Subjective:> “Magkasakit kupang mag-galo galo, ane kasing kasakit ing bitis ku”

Objective:> limited range of motion on both lower extremities noted

> generalized weakness noted

> slowed movement

> difficulty turning from side to side to sitting position

> Patient

Impaired Physical Mobility related to decreased muscle strength secondary to post below the knee amputation as evidenced by limited range of motion on both lower extremities

Due to decreased sensitivity to insulin hyperglycemia occurs which cause symmetrical loss of sensation on lower extremities which is a sign of diabetic foot ulceration therefore perform BKA, after which causes immobility.

After 2-3 hours of nursing interventions, the patient will demonstrate techniques/behaviours that enable resumption of activities

> Observe movement when client is unaware of observation.

> Support the affected body part with pillows.

> Encourage frequent position changes.

> Instruct the SO to have the pt an adequate food and fluid intake.

> Assist in scheduling activities with adequate rest periods during the day.

> Provide adequate rest periods.

> To note any incongruencies with reports of abilities.

> To position of function and reduce the risk of pressure ulcers.

> To reduce the risk of pressure ulcers.

> To promote well-being and maximized energy production.

> To reduce fatigue.

> To maximize energy production.

After 2 hours of nursing interventions, Mr. Sugar demonstrated techniques/behaviours that enable resumption of activities such as frequent changing of positions from side to side

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manifested numbness and tingling sensation on lower extremities

> Amputated right leg (stump limb)

> Debridement performed on the middle finger of the left dorsal foot

> Identify energy-conserving techniques for ADLs.

> Encourage participation in self-care, diversional and recreational activities.

> Encourage client and SO’s involvement in decision making as much as possible.

> Limits fatigue, maximizing participation.

> To enhance self-concept and sense of independence.

> Enhances commitment to plan, optimizing outcomes.

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5. ACTIVITY INTOLERANCE R/T DECREASED TISSUE GLUCOSE UPTAKE SECONDARY TO DECREASED INSULIN PRODUCTION AEB GENERALIZED WEAKNESS

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC




Subjective:> “Eku bisang gagalo. Pag gagalo ku o kahit makakera mu sasakit ku banda bitis”

Objective:> slowed movement

> difficulty turning

> limited range of motion

> amputated right leg (stump limb)

> tenderness on amputated knee

> generalized weakness

Activity intolerance R/T decreased tissue glucose uptake secondary to decreased insulin production AEB generalized weakness

Destruction of liver beta cells

Production of insulin is greatly decreased

Pooling of glucose on blood stream, decreased tissue perfusion on distal parts of the body

Generalized weakness due to decreased oxygen supply to tissues such as muscles

Activity intolerance

After 2-3 hours of nursing interventions, patient will be able to identify negative factors affecting activity tolerance and demonstrate ways to reduce their effects as tolerated.

> Ascertain understanding of individual needs.

> Teach methods to conserve energy such as stopping to rest for 3 minutes

> Increase activity levels gradually

> Assist with activities such as positioning

> Adjust activities to tolerable level

> Teach patient regarding relaxation techniques

> Caution client to avoid strenuous activities

> To determine what information to provide client.

> To conserve energy

> To increase patient’s independence

> To protect client from injury

> To prevent overexertion

> To conserve energy and promoter rest

> To avoid further physiologic stress and to decrease

After 2 hours, Mr. Sugar identified negative factors affecting activity tolerance and demonstrated ways to reduce their effect such as frequent repositioning and adjusting activities to a tolerable level.

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> Encourage patient to undergo dietary program that is appropriate for situation such as diabetic diet

> Advise to elevate right hip

>Provide access to needed articles within reach and aid in assisting or performing ADL as indicated.

cardiac workload

> To avoid further accumulation of blood glucose

> To enhance ability to participate with activities

>To reduce energy expenditure and preserves energy which improves endurance.

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ACTUAL SOAPIE(s)Date: January 17, 2011

S: ØO: > received lying on bed with an ongoing IVF of PNSS 1L regulated @ 31gtts/min infusing well on left hand @600cc level > weak in appearance, missing body part, not looking body part > with right below the knee stump with blood-tinged dressing > Vital signs taken and recorded as follows:

BP: 120/80mmHg PR: 70 bpmT: 36°C RR: 26 bpm

A: Disturbed Body Image r/t loss of a body part AEB unwillingness to look at stump

P: After 4° of nursing interventions, pt. will verbalize understanding of body changes and demonstrate ways to improve condition.

I: > Monitored VS and recorded > Provided adequate bed rest

> Maintained affected leg elevated > Encouraged to look affected body part > Provided comfort measure such as touch therapy > Provided assistance with self-care needs > Encouraged family members to treat patient normally > Encouraged S.O. to communicate frequently to the pt > Provided information to client’s level of acceptance > Advised gradual ambulation with the use of crutches > Encouraged to sit-up in bed as tolerated

E: After 4° of nursing interventions, pt. verbalized understanding of body changes and demonstrated ways to improve condition such as maintaining leg elevated.

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Date: January 18, 2011

S: “Masakit ‘yung paa ko.”

O: > Received lying on bed with an ongoing IVF of 0.9% NaCl 1L regulated @ 31gtts/min, infusing well on left hand @ 700cc level. > weak in appearance > guarding behavior > dependent > limited ROM > with right below the knee stump with blood tinged on dressing > with vital signs taken and recorded as follows:

BP: 120/80mmHg PR: 73bpmT: 36°C RR: 22bpm

A: Acute pain r/t tissue and nerve trauma 2° to post below the knee amputation AEB pain scale of 7/10.

P: After 4° of nursing interventions, pt. will verbalize reduction of pain from pain scale of 7/10 to 5/10 and demonstrate non-pharmacological pain management.

I: > Monitored VS and recorded > Provided adequate bed rest > Encouraged frequent changing of position > Provided comfort measures such as touch therapy > Encouraged used of relaxation techniques such as deep breathing > Maintained affected leg elevated > Stretched bed linens > Observed nonverbal cues/pain behaviors > Advised diversional activities such as reading newspaper or chatting with S.O. > Advised proper wound care and stump care > Seen on rounds by Dr. Pena with orders made and carried out: 7:15am

*For wound care*elevated affected limb

E: Patient was able to sleep and verbalized reduction of pain from 7/10 to 5/10.

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VIII. DISCHARGE PLANNING

General Condition of Client upon DischargeThe condition of Mr. Sugar after confinement is progressive. He is recovering from the weakness, and his energy is gradually

coming back but cannot do strenuous tasks yet. The patient is still under observation by the physician.

Topic: Health Teachings on Diabetes Mellitus type 2Time Allotment: 1 hour and 30 minutes (Lecture on post-operative care)Venue: Hospital in City of San Fernando

Objective ContentTime

AllotmentTeaching Strategy Evaluation

After 1 hour and 30 minutes of nursing interventions, Mr. Sugar will be able to verbalize full understanding of the health teachings on DM type 2.

Advice the patient to continue the medications that are prescribed/ordered by the physician for the continuous recovery.

Advice the patient to modify his lifestyle that would suit his current condition.

Advice the client to have slow walk and do breathing exercises.

Monitor nutritional support therapies as ordered for the recovery.

The significant other should give assistance to the patient with regards to his household chores to prevent fatigue.

1 hour and 30 minutes

Lecture/ Discussion

Use of manila papers as a visual aid

After 1 hour and 30 minutes of health teachings, Mr. Sugar understood the discussion and the respective rationale of the said health teachings on DM type 2.

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Educate the patient about the proper hygiene and health maintenance.

Instruct patient to increase fluid intake.

Discuss the importance of proper nutrition.

Have a regular check up to the physician in charge to assess the recovery or condition of the patient. Coping situation in positive manner and planning for the future.

Encourage to follow diet prescribed by physician: DM diet.

Assess the client’s food preferences and discuss appropriate interventions with dietary department.

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IX. LEARNING DERIVED FROM THE STUDYIn accomplishing our case study, we have only little time to do it, because, we

didn’t get patient early for our case study. Each member was assigned their task, and I was assigned to do the physical assessment and interview with the patient together with one of my group mates. With the assigned task to me I think was able to enhanced my confidence and the ability to used my therapeutic communication in able to get those needed information in our study. Though our chosen patient, don’t want student nurses, but with the use of our therapeutic communication, we are able to talk to his. And with the cooperation of each member we are able to finish it on time.

-Catap, Marjorie G.

Upon the pursuance of our case study about Diabetes Mellitus type 2, we had the same routine of works just like how we did with our previous case studies. Although this case was not, at all, tackled in our classroom discussions, it did not stop us from exploring more of it. I got to know more about Sugar Cancer, as well as the proliferation of different kind of cancers to several parts of the body.

Personally, I felt bad for our patient they don’t have enough money to sustain all his medical treatments. I wonder why people like his still remain to continue their sedentary lifestyle even after knowing about their current disease.

Just like any other group projects, I’ve learned to be patient and determined enough in finishing our case study. Tasks have been distributed, shared, and successfully done. I’m looking forward to have more challenging case studies some time soon.

-Guarin, Merry Christine B.

Our case study is about Diabetes Mellitus type 2 with HPN. I was able to really appreciate the said case, and also I was able to apply the knowledge I have attained last semester about DM type 2. Me and my other group mate was in charged to do the physical assessment and I was able to assess the patient cephalocaudal. It was my first time to saw a gangrenous foot that’s why I really appreciate it. This case study taught me on how to be responsible and to do my assigned task in time and with minimal mistake. A group won’t be successful without coordination and trust with each other.

-Liwanag, Angelica Erika S.

Doing this case study was not that easy knowing that it is my first time to make a study in line with this case. It’s quite hard to make a study specially that we haven’t had time to converse with the patient. We have to give extra time and effort. In doing this requirement I learned the disease process of Diabetes. I had better understanding about this case. Also this made me conclude that working as a group will make the work faster, as we all know two heads are better than one. We practiced our cooperation and compiled our knowledge base on what we experienced. Aside from that, the patient that we choose in our case study gave us knowledge and learning experience in doing this study. I could say that we exerted all our efforts and gave our time to conceptualize this requirement.

-Luntao, Aina Mae

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“People grow through experience if they meet life honestly and courageously. This is how character is built.”

-- Eleanor RooseveltExperience is the best teacher. Not everything taught within the four corners of

the usual classroom are retained. The best way to see improvements on skills and concepts learned is through practice, in which through the RLE duty is done.

It is my first time to handle patient having diabetes type 1 accompanied by hypertension and to complicate things out, he is a bit irritated to student nurses as well which served as a bit of a hindrance during our assessment. Case study, a deep studying and exploration about the patient’s disease condition, related factors on how this disease is acquired and its complications which as I stated earlier, led to hypertension and palliative and curative interventions on symptoms existing. We were able to understand more the situation the patient is undergoing and the different responsibilities nurses have.

To sum everything up, the whole duty, in main ward was a great experience, dealing and caring with patients is not an easy job, but it is fun! I learned a lot, especially in terms of SOAPIE making which I was not so used to, drug responsibilities and interaction and the likes. Together with our CI and my fellow group mates we were able to have a job well done each day and an enjoyable means of learning.

-Pangan, Astley

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http://www.brainyquote.com/quotes/quotes/e/eleanorroo387278.html

X. REFERENCES A. Books

Karch,A.M.(2010). Nursing Drug Guide. Williams and Wilkins: PhilippinesSeeley,et al.(2007). Essentials of Anatomy and Physiology Sixth Edition. McGraw-Hill International Edition: PhilippinesWeber,J.R.(2008). Nursing Health Assessment Sixth Edition. Williams and Wilkins: PhilippinesHuether, S. and Mccance, K. (2003). Understanding Pathophysiology.Smeltzer, S. and Bare, B. (2005). Medical Surgical Nursing.Black, J. (2008). Medical-Surgical Nursing 8th edition. Elsevier: Singapore

B. Website http://www.news-medical.net/health/Diabetes-Mellitus-Type-2-Pathophysiology.aspxhttp://www.mayoclinic.com/health/diabetes/DS01121/DSECTION=risk-factorshttp://www.medicinenet.com/diabetes_mellitus/article.htm#tocdhttp://emedicine.medscape.com/article/766143-overviewhttp://pediatrics.aappublications.org/cgi/content/full/116/2/473http://content.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_86/_40/fdiab19_02.pdfhttp://highbloodpressure.about.com/od/highbloodpressure101/a/feedbackloop.htmhttp://www.touchcardiology.com/articles/hypertension-and-diabetes-mellitushttp://www.healingdaily.com/detoxification-diet/insulin.htmhttp://www.medscape.org/viewarticle/513877http://www.kidneyatlas.org/book3/adk3-05.QXD.pdfhttp://emedicine.medscape.com/article/1170337-overviewhttp://www.uptodate.com/patients/content/topic.do?topicKey=~Wx7Wc9T9hSgGihttp://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.htmlhttp://www.nlm.nih.gov/medlineplus/ency/article/000494.htmhttp://www.epodiatry.com/charcot-foot.htmhttp://www.epodiatry.com/charcot-foot.htmhttp://ph.answers.yahoo.com/question/index?qid=20100903004907AAjS6i6http://books.google.com.ph/books?id=zJyZfvinJ9cC&pg=PA603&lpg=PA603&dq=impaired+immune+function+in+diabetes&source=bl&ots=c2HaCOU1zR&sig=a0JJNOULAbUhYNac8JOi6ffd0vM&hl=en&ei=BD0DTbegLMO8rAfoyZyRDw&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCoQ6AEwAg#v=onepage&q=impaired%20immune%20function%20in%20diabetes&f=falsehttp://www.mayoclinic.com/health/type-2-diabetes/DS00585/DSECTION=symptomshttp://www.merckmanuals.com/home/sec13/ch165/ch165a.htmlhttp://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.htmlhttp://globalnation.inquirer.net/cebudailynews/opinion/view/20080728-151202/Diabetes-warning

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http://globalnation.inquirer.net/cebudailynews/opinion/view/20080728-151202/Diabetes-warning

http://globalnation.inquirer.net/cebudailynews/opinion/view/20080728-151202/Diabetes-warning

http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html

http://www.merckmanuals.com/home/sec13/ch165/ch165a.html

http://www.mayoclinic.com/health/type-2-diabetes/DS00585/DSECTION=symptoms

http://www.mayoclinic.com/health/type-2-diabetes/DS00585/DSECTION=symptoms

http://books.google.com.ph/books?id=zJyZfvinJ9cC&pg=PA603&lpg=PA603&dq=impaired+immune+function+in+diabetes&source=bl&ots=c2HaCOU1zR&sig=a0JJNOULAbUhYNac8JOi6ffd0vM&hl=en&ei=BD0DTbegLMO8rAfoyZyRDw&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCoQ6AEwAg#v=onepage&q=impaired%20immune%20function%20in%20diabetes&f=false



http://ph.answers.yahoo.com/question/index?qid=20100903004907AAjS6i6

http://www.epodiatry.com/charcot-foot.htm

http://www.epodiatry.com/charcot-foot.htm

http://www.nlm.nih.gov/medlineplus/ency/article/000494.htm

http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.html

http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.html

http://www.uptodate.com/patients/content/topic.do?topicKey=~Wx7Wc9T9hSgGi

http://www.uptodate.com/patients/content/topic.do?topicKey=~Wx7Wc9T9hSgGi

http://emedicine.medscape.com/article/1170337-overview

http://www.kidneyatlas.org/book3/adk3-05.QXD.pdf

http://www.medscape.org/viewarticle/513877

http://www.healingdaily.com/detoxification-diet/insulin.htm

http://www.touchcardiology.com/articles/hypertension-and-diabetes-mellitus

http://highbloodpressure.about.com/od/highbloodpressure101/a/feedbackloop.htm

http://highbloodpressure.about.com/od/highbloodpressure101/a/feedbackloop.htm

http://content.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_86/_40/fdiab19_02.pdf

http://content.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_86/_40/fdiab19_02.pdf

http://pediatrics.aappublications.org/cgi/content/full/116/2/473

http://emedicine.medscape.com/article/766143-overview

http://www.mayoclinic.com/health/diabetes/DS01121/DSECTION=risk-factorshttp://www.medicinenet.com/diabetes_mellitus/article.htm#tocd

http://www.mayoclinic.com/health/diabetes/DS01121/DSECTION=risk-factorshttp://www.medicinenet.com/diabetes_mellitus/article.htm#tocd

http://www.news-medical.net/health/Diabetes-Mellitus-Type-2-Pathophysiology.aspx

http://www.news-medical.net/health/Diabetes-Mellitus-Type-2-Pathophysiology.aspx

http://www.sciencedaily.com/releases/2010/11/101129111735.htm

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http://www.sciencedaily.com/releases/2010/11/101129111735.htm

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