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DIABETES MELLITUS IDDM TYPE 1
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DIABETES MELLITUSIDDM TYPE 1
I. INTRODUCTION
Diabetes mellitus often simply referred to as diabetes—is a condition in which a person has a high blood sugar (glucose) level as a result of the body either not producing enough insulin, or because body cells do not properly respond to the insulin that is produced. Insulin is a hormone produced in the pancreas which enables body cells to absorb glucose, to turn into energy. If the body cells do not absorb the glucose, the glucose accumulates in the blood (hyperglycemia), leading to various potential medical complications.
There are many types of diabetes, the most common of which are:
Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin.
Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency.
Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.
Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes.
All forms of diabetes have been treatable since insulin became medically available in 1921, but a cure is difficult. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM; and gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, and retinal damage. Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cesation and maintaining a healthy body weight.
Most cases of diabetes mellitus fall into the three broad categories of type 1 or type 2 and gestational diabetes. A few other types are described.
The term diabetes, without qualification, usually refers to diabetes mellitus, which roughly translates to excessive sweet urine (known as "glycosuria"). Several rare conditions are also named diabetes. The most common of these is diabetes insipidus in which large amounts of urine are produced (polyuria), which is not sweet (insipidus meaning "without taste" in Latin).
The term "type 1 diabetes" has replaced several former terms, including childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term "type 2 diabetes" has replaced several former terms, including adult-onset diabetes, obesity-related diabetes, and non-insulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standard nomenclature. Various sources have defined "type 3 diabetes" as: gestational diabetes, insulin-resistant type 1 diabetes (or "double diabetes"), type 2 diabetes which has progressed to require injected insulin, and latent autoimmune diabetes of adults (or LADA or "type 1.5" diabetes)
Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas leading to insulin deficiency. This type of diabetes can be further classified as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated nature, where beta cell loss is a T-cell mediated autoimmune attack. There is no known preventive measure against type 1 diabetes, which causes approximately 10% of diabetes mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Type 1 diabetes can affect children or adults but was traditionally termed "juvenile diabetes" because it represents a majority of the diabetes cases in children.
Type 2 diabetes mellitus is characterized by insulin resistance which may be combined with relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known Diabetes mellitus due to a known defect are classified separately. Type 2 diabetes is the most common type.
In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin sensitivity. At this stage hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver. As the disease progresses, the impairment of insulin secretion occurs, and therapeutic replacement of insulin may sometimes become necessary in certain patients.
Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2%–5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable but requires careful medical supervision throughout the pregnancy. About 20%–50% of affected women develop type 2 diabetes later in life.
Even though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin may inhibit fetal surfactant production and cause respiratory distress syndrome. Hyperbilirubinemia may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A cesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia.
The classical symptoms of DM are polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). Symptoms may develop quite rapidly (weeks or months) in type 1 diabetes, particularly in children. However, in type 2 diabetes symptoms usually develop much more slowly and may be subtle or completely absent. Type 1 diabetes may also cause a rapid yet significant weight loss (despite normal or even increased eating) and irreducible mental fatigue. All of these symptoms except weight loss can also manifest in type 2 diabetes in patients whose diabetes is poorly controlled, although unexplained weight loss may be experienced at the onset of the disease. Final diagnosis is made by measuring the blood glucose concentration.
When the glucose concentration in the blood is raised beyond its renal threshold (about 10 mmol/L, although this may be altered in certain conditions, such as pregnancy), reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine (glycosuria). This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water held in body cells and other body compartments, causing dehydration and increased thirst.
Patients (usually with type 1 diabetes) may also initially present with diabetic ketoacidosis (DKA), an extreme state of metabolic dysregulation characterized by the smell of acetone on the patient's breath; a rapid, deep breathing known as Kussmaul breathing; polyuria; nausea; vomiting and abdominal pain; and any of many altered states of consciousness or arousal (such as hostility and mania or, equally, confusion and lethargy). In severe DKA, coma may follow, progressing to death. Diabetic ketoacidosis is a medical emergency and requires immediate hospitalization.
Type 2 diabetes is determined primarily by lifestyle factors and genes.
A number of lifestyle factors are known to be important to the development of type 2 diabtetes. In one study, those who had high levels of physical activity, a healthy diet, did not smoke, and consumed alcohol in moderation had an 82% lower rate of diabetes. When a normal weight was included the rate was 89% lower. In this study a healthy diet was defined as one high in fiber, with a high polyunsaturated to saturated fat ratio, and a lower mean glycemic index. Obesity has been found to contribute to approximately 55% type 2 diabetes, and decreasing consumption of saturated fats and trans fatty acids while replacing them with unsaturated fats may decrease the risk. The increased rate of childhood obesity in between the 1960s and 2000s is believed to have lead to the increase in type 2 diabetes in children and adolescents.
II. PERSONAL DATA Name: Mrs. P.M. Age: 58 years old Address: 86 Bonifacio Dinalupihan, Bataan Birthdate: May 30, 1951 Place of Birth: Dinalupihan Sex: Female Civil Status: Married Nationality: Filipino Religion: Roman Catholic Chief Complaint: Chest Pain Date of Admission: Jan. 22, 2010 Time of Admission: 2:25 AM Attending Physician: Dr. Roda Gutierez Admitting Diagnosis: DM type I
III. PERSONAL – SOCIAL HISTORY
According to Mrs. P.M., She is fond of doing household chores. In her everyday life, she spent most of her time cleaning up their house and cooking. She loves to eat foods like meats and vegetables. According to her, she sleeps at 7:00 PM then wakes up at 4:00 AM. Before going to the market she prepares coffee and bread for her breakfast, after that she buy foods to cook for her family. In her spare time, she enjoys watching TV. and playing cards w/ her neighbors.
According to Mrs. P.M., one of her stressor was their financial problem. These thing became the biggest burden to Mrs. P.M.
Mrs. P.M’s educational attainment is high school level at Dinalupihan. After high school, she became a cook in a small fast food chain. Since then, she began accepting cooking jobs.
Mrs. P.M consumes their daily expenses through family assistance. She uses Kabalikat and Phil Health in paying her hospital bills.
Mrs. P.M lives from the town. She has no foe in their place so this doesn’t add up to her stressor.
IV. PAST MEDICAL HISTORY
Mrs. P.M., was diagnosed with hypertension last 2007 and was prescribed Vasalat 10 mg OD and Clonidine 75 mg BID as her maintenance drug. According to her, she takes this drug always.
Mrs. P.M., also diagnosed with diabetes mellitus type 1 and was prescribed 40 ”U” of Insulin in AM and 30 “U” of Insulin in PM. Mrs. P.M., was an Insulin dependent.
Mrs. P.M., has 4 children.
V. PRESENT MEDICAL HISTORY
January 22, 2010, Mrs. P.M, suddenly woke up at 1:30 AM and she experienced chest pain, constricting, associated with chest heaviness, difficulty of breathing and shortness of breath. And by 2:25 AM same date she was admitted at Jose C. Payumo Medical Hospital.
VI. FAMILY HISTORY
According to Mrs. P.M., her mother had a history of DM and obesity that caused of death, while her father had a history of HPN and was still alive. She also said that her 4 daughters was diagnosed with HPN, obesity and one of them has DM. according also to Mrs. P.M. her husband was hypertensive and was still alive. Besides of having a history of DM, obesity and HPN in their family, there is no other history of diseases like heart disease, cancer, mental disorder, allergies, arthritis, tuberculosis and bleeding.Mrs. P.M. diseases were inherited to her mother that served to her a big stressor.
VII. THEORETICAL FRAMEWORKDorothea Orem’s Self Care Deficit Theory
Orem's Self-Care Deficit Theory of Nursing is a grand theory, which is comprised of three interrelated theories: 1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems. Incorporated within these three theories are six central concepts and one peripheral concept. Having a thorough understanding of these central concepts of self-care, self-care agency, therapeutic self-care demand, self-care deficit, nursing agency, and nursing system, as well as the peripheral concept of basic conditioning factor, will help you to better understand the general theory.
Within the theory of self-care, Orem identified three categories of self-care requisites: universal self-care requisites, developmental self-care requisites, and health-deviation self-care requisites. Universal self-care requisites are common to all human beings and include physiological and social interaction needs. Developmental self-care requisites are the needs that arise as the individual grows and develops. This has something to do with more specific events in an individual's life. Health-deviation self-care requisites are self-care requisites arise from both the disease state and the measures used in the diagnosis and treatment.
The second of the three interrelated theories is the theory of self care deficit. It states that all limitation for engagement in practical endeavor within the domain and boundaries of nursing are associated with subjectivity of mature and maturing individuals to health related or health-derived actions or limitations that render them completely or partially unable to know existent and emerging requisites for regulatory care for themselves of their dependents. They should also engage in continuing performance of care measures to control or in some way manage factors that are regulatory of their own or their dependents function and develop.
The third and last of the three interrelated theory is the theory of nursing system. Nursing system is defined as an approach nurses use to assist patients with deficits in self care due to a condition of health. The three types of nursing system are (1) wholly compensatory System in which the patient has no active role in the performance of his care. (2) Partly compensatory care in which both nurses and patients perform care measures requiring manipulative task or ambulation. (3) Supportive educative system in which patient is able to perform or can and should learn to perform, required measures of therapeutic self-care but cannot do without assistance.
VIII. ACTIVITIES OF DAILY LIVING
ACTIVITIES Before Hospitalization During Hospitalization
NUTRITION
a. height and weight
- BMI
= wt (60 kilos)/ht 5’2”
=BMI is 24.2; normal
b. time (meals)
c. frequency (feeding)
-- indicate the meals
d. how much food
e. intake and output
f. IV Fluids given
Mrs. P.M prepared foods for breakfast
includes coffee and a loaf of bread.
After eating of breakfast, she goes to public
market to buy dish for lunch such as
seafood, vegetables, and meats.
Her dinner consists of canned goods, meats,
seafoods, vegetables together with a cup of
rice and drinks plenty of water instead of
juices and carbonated drinks.
Her diet consists of a Low Salt Low Fat diet as
ordered by her physician such as vegetables,
fruits, canned fish, soups and some bread. Her
diet also includes low sugar diet.
Intake: low fat low salt
Urination: with IFC connected to bed side urine bag at 1250cc level in a whole day.
ACTIVITIES Before Hospitalization During Hospitalization
ELIMINATION
Bowel
a. Color
b. Odor
c. Amount
d. Consistency
e. Shape
f. Frequency
Urine
a. Color
b. Odor
c. Frequency
Bowel Elimination
Mrs. P.M. defecates one to two times a
day with normal color of stool.
Urine Elimination
According to Mrs. P.M., she urinates in
normal frequency with normal color.
Bowel Elimination
Bowel elimination
Because of constipation, she did not
frequently defecate for 4 days.
Urine Elimination
The patient has IFC connected to urine bag
with 850cc from 8 hours of duty
ACTIVITIES Before Hospitalization During Hospitalization
HYGIENE
a. Skin Care
b. Hair Care
c. Oral Care
d. Eye Care
e. Ear Care
f. Nose Care
. Bathing
g. Perineal-Genital Care
h. Foot Care
i. Nail Care
According to Mrs. P.M., she takes
a bath everyday and sponge bath at
night. Uses of shampoo in her hair
and put some lotion after a bath.
She has three remaining teeth on
the upper portion and four
remaining teeth on the lower
portion of the mouth.
She do oral care 1 times a day.
During the whole confinement of
Mrs. P.M,, she does not take a bath
by her own, so with the help of her
daughter and her husband. She clean
herself by means of TSB. She can’t
do or maintain her oral hygiene.
ACTIVITIES Before Hospitalization During Hospitalization
REST and SLEEP
a. Routine (hours, time)
- with
naps/continuous/intermittent
b. sleeping pattern (depends on
the age)
Mrs. P.M. sleep at around 7 pm
regularly after eating supper and
then she woke up at 4 am early
morning
During hospitalization Mrs. P.M.,
seldom sleeps because of the
environmental factors.
IX. PHYSICAL ASSESSMENTBody Parts Technique Findings Analysis
A. General SurveyInitial Vital Signs
With the use of thermometerPalpationInspectionWith the use of BP apparatus
>Temperature: 37°C>Pulse rate: 115 beats / min.>Respiratory rate: 35 bpm>Blood pressure: 170 / 80 mmHg
NormalTavhycardiaTachypneicHypertensive
A. Head
Skull InspectionPalpation
>Normocephalic, Symmetrical to the body>No masses noted
NormalNormal
Hair Inspection >Evenly distributed with some white hair noted.
Normal
Scalp Inspection >No signs of masses and lesions noted
Normal
A. EYES
eyelids, eyebrow, eyelashes Inspection > Eyebrows are symmetrically aligned.
Normal
periorbital region Inspection > No swelling noted Normal
sclera Inspection >Whitish in color Normal
conjunctiva Inspection > Pink and moist Normal
pupils Inspection with the use of penlight
>PERRLA Normal
A. EARS
External Pinnae Inspection >Symmetrical Normal
External Ear Canal Inspection >With good hearing acquity Normal
A. NOSE Inspection >Symmetrical in shape; no discharges noted
Normal
A. MOUTH
Lips Inspection >Pale Due to low hemoglobin
tongue Inspection >Pale Due to low hemoglobin
teeth Inspection >Presence of 3 teeth on upper portion and 4 teeth on lower portion
Due to decreased calcium intake
gums Inspection >Slightly pale Due to low hemoglobin
speech Interview >Oriented Normal
A. NECK Inspection >Muscles equal in size; head centered
Normal
A. CHEST Inspection >With CTT @ Right side of chest connected to 3 way chest drainage, intact , draining into a yellow fluid output.
Due to fluid which is being drained from the lungs
heart Auscultation >115 beats / min. Tachycardia
lungs Auscultation > Wheezing noted Due to fluid accumulation in the lungs
A. BREAST InspectionPalpation
>Refused to be examined
A. AXILLA InspectionPalpation
>Same as body color>No mass noted
NormalNormal
A. ABDOMEN InspectionAuscultationPalpationPercussion
>Same as body color>Bowel sound is hypoactive>No tenderness noted>Dullness
NormalDue to slow peristaltic movement
A. UPPER EXTREMITIES
shoulder Inspection >Symmetrical Normal
upper arm Inspection >No lesions noted Normal
forearm Inspection >Edema noted Due to water retention
hands Inspection >Edema noted Due to water retention
nails Inspection >pale Increased capillary refill
A. GENITALS InspectionREFUSED TO BE EXAMINED
urine Inspection >yellowishDue to medication
A. ANAL AREA InspectionREFUSED TO BE EXAMINED
Stool Inspection >golden brown Normal
A. LOWER EXTREMITIES
a. upper leg Inspection >edema noted Due to water retention
b. lower leg Inspection > edema noted Due to water retention
c. feet Inspection >edema noted Due to water retention
X. LABORATORY AND DIAGNOSTIC PROCEDURES
Name: Mrs. P.M. Physician: Dr.
Age: 58 years oldDr. Roda Gutierez
Sex: Female
DATELABORATORY
EXAMRESULT
NORMAL VALUESINTERPRETATION
OLD UNIT SI UNIT
JANUARY 27, 2010
RBC 2.90 4.5x10/L
HEMOGLOBIN 83.0 g/l 12-15 gm% F120-160 g/L F
14 – 17g/L MAnemic
HEMATOCRIT 0.2338 – 48 Vol.% F
40 – 50 Vol.% M
0.38 – 0.48 F
0.40-0.50 Mhemodilution
WBC COUNT 8x108 /L 4000-10000/mm3 4-10x109/L Normal
SEGMENTERS 0.74 45 – 65 % 0.45 – 0.65
LYMPHOCYTES 0.26 20 -35% 0.20 – 0.35 Normal
Date Type of Examination
Normal Values Result Interpretation
02-27-2010 Sodium 135-153 mmol/L 135.6 mmol/L Normal
02-27-2010 Potassium 3.5-5.3 mmol/L 5.26mmol/L Normal
02-27-2010 Chloride 95-111mmol/l 99.3mmol/l Normal
Troponin I Negative
JANUARY 27, 2010
RBS 91.0 mg/dl >200mg/dl Normal
FBS in mmo/l 5.27 mmol/L <5.60mmol/L Normal
CHOLESTEROL (female)
5.45 mmol/L <3.90 mmol/L
TRIGLYCERIDES 1.27 mmol/L 0.50 – 1.67 mmol/L Normal
HDL – Cholesterol 0.75 mmol/L 1.04 – 1.56 mmol/L
LDL – Cholesterol 4.12 mmol/L <3.88 mmol/L
XI. ANATOMY AND PHYSIOLOGYPancreasThe pancreas is located posterior to the stomach and in close association with
the duodenum. The pancreas is a 6-10 inch elongated organ in the abdomen located retro peritoneal. It is often described as having three regions: a head, body and tail. The pancreatic head abuts the second part of the duodenum while the tail extends towards the spleen. The pancreatic duct runs the length of the pancreas and empties into the second part of the duodenum at the ampulla of Vater. The common bile duct commonly joins the pancreatic duct at or near this point.
The pancreas is supplied arterially by the pancreaticoduodenal arteries, themselves branches of the superior mesenteric artery of the hepatic artery (branch of celiac trunk from the abdominal aorta). The superior mesenteric artery provides the inferior pancreaticoduodenal arteries while the gastroduodenal artery (one of the terminal branches of the hepatic artery) provides the superior pancreaticoduodenal artery. Venous drainage is via the pancreatic duodenal veins which end up in the portal vein. The splenic vein passed posterior to the pancreas but is said to not drain the pancreas itself. The portal vein is formed by the union of the superior mesenteric vein and splenic vein posterior to the body of the pancreas. In some people (as many as 40%) the inferior mesenteric vein also joins with the splenic vein behind the pancreas, in others it simply joins with the superior mesenteric vein instead.
The function of the pancreas is to produce enzymes that break down all categories of digestible foods (exocrine pancreas) and secrete hormones that affect carbohydrates metabolism (endocrine pancreas).
The pancreas is near the liver, and is the main source of enzymes for digesting fats (lipids) and proteins - the intestinal walls have enzymes that will digest polysaccharides. Pancreatic secretions from ductal cells contain bicarbonate ions and are alkaline in order to neutralize the acidic chyme that the stomach churns out. Control of the exocrine function of the pancreas are via the hormone gastrin, cholecystokinin and secretin, which are hormones secreted by cells in the stomach and duodenum, in response to distension and/or food and which causes secretion of pancreatic juices.
XII.PATHOPHYSIOLOGY OF DM TYPE 1
Increase blood sugar level at the circulation
Unable to enter glucose to the cell
Pancreas will not release insulin
Modifiable factorsSedentary lifestyle
Diet
Non-modifiable factorsAge (above 30)
Genetics
Decrease utilazation of glucose
Hyperglycemia
Increase ventricular contraction
Blood became viscous
Increase workload in the heart
Leads to cellular starvation
Stimulate appetite
PolyphagiaPolydipsia
Increase osmotic pressure
PolyuriaVentricular dilation
Back flow of blood to the lungs
Pleural effusion
Left sided heart failure
Pulmonary congestion
Right sided heart failure CHF
XIII. NURSING CARE PLANASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S> “Sumasakit ang dib-dib ko”, as claimed.O> Pain scale 8/10 noted>c - Facial grimace>c- RR 32 Bpm>c- Bp 170/80 mmhg> rubs the painful part noted
>Acute pain rt tissue trauma and reflex muscle spasms secondary to visceral disorder of cardiac in origin.
After 8hrs of nursing intervention the pt will verbalize pain is controlled or relief, from pain scale of 8-4, where 10 is worst pain and 0 is no pain.
Independent:>monitor v/s >Determine specific of pain, such as location, characteristics, intensity, onset/duration> encourage to maintain bed rest during acute phase.>advice to minimize vasoconstricting activities that may aggravates pain. Such as straining at stool, prolong coughing.>instruct to do deep breathing exercises.>encourage diversional activities, such as listening to radio, watching t.v.>Provide comfort measures, such as back rub, change in position.Dependent:>Administer analgesic as indicated.
-to serve as a baseline data-facilitates diagnosisOf problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy-minimize stimulation/promotes relaxation-activities that increase vasoconstriction accentuate the pain.-minimizes the pain sensation.- May help diverting the pain sensation of the pt.-to provide non pharmacologic pain management.
>Goal partially met as pain scale is decrease from 8 to 6.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS>”Hinihingal ako kapag nagkikilos”, as verbalized by pt.O>c- 02 inhalation via nasal
canula @ 2-3 L/hr>c- CTT @ Right side of chest connected to 3 way chest drainage, intact , draining into a yellow fluid output.>c- RR 32 Bpm>c- nasal flaring> Wheezes upon auscultation noted > Orthopnea noted
>Ineffective airway clearance rt bronchospasm as evidence by tachypnea and abnormal breath sounds
After 8hrs of nursing intervention the pt will demonstrate reduction of congestion with breath sounds clear.
Independent:>Monitor respiratory rate.>Assist pt to assume position of comfort, such as elevate head of bed, have pt lean on overbed table or sit on edge of bed.>Keep environmental pollution to a minimum, such as dust, feather pillows, according to individual situation.>Encourage/assist with abdominal or pursed-lip breathing exercises.>Observe characteristics of cough. Assist with measures to improve effectiveness of cough effort.>Increase fluid intake to 3000ml/day within cardiac tolerance. Provide warm/tepid liquids. Recommend intake of fluids between, instead of during meals.Dependent:>Apply Nebulization as indicated>Administer medication as indicated
-Tachypnea is usually present to some degree and may be pronounced on admission or during stress/concurrent acute infection process.>Elevation of the head of the bed facilitates by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms/legs with table, pillows and so on helps reduce muscle fatigue and can aid chest expansion.-precipitators of allergic type of respiratory reactions that can trigger/exacerbate onset of acute episode.Provides patient with some means to cope with/control dyspnea and reduce air –trapping.-cough can be persistent but ineffective, especially if pt is elderly, acutely ill, or debilitated. Coughing is effective in an upright or in a head-down after chest position.-Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distention and pressure on the diaphragm.
>Goal met as pt reduced congestion of her lungs with clear breath sounds
ASSESSMENT NURSING DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
S>”Nanghihina ako”, as claimedO> Pale in appearance noted>Body weakness noted>c- limited ROM> Bp 170/80 mmhg
>Activity intolerance rt generalize weakness as evidence by limited ROM
After 8hrs of nursing intervention the pt will demonstrate increase in activity tolerance.
Independent:>Determine baseline activity level and physical condition>Instruct pt in energy-conserving technique, such as using chair when showering, sitting to brush teeth or comb hair, carrying out activities in a slower pace.>Encourage progressive activity/ self-care when tolerated.>Assist pt ADL>Recommend adequate rest and sleep.
-provides opportunity to tract changes.-Energy –techniques reduces the energy expenditure, thereby assisting in equalization of O2
supply and demand.-Gradual activity progression prevents a sudden increase in cardiac workload.-providing assistance only as needed encourages independence in performing activities.- Enhances O2
circulation for cellular uptake.
Goal met as pt increase activity tolerance.
ASSESSMENT NURSING DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
S>”Hindi ako madumi” , as claimedO> 4 days of without defacation noted>Hypoactive bowel sound upon auscultation noted.>Distended abdomen upon palpation noted.>Percussed abdominal dullness noted.
>Constipation rt irregular defacation habits as evidenced by 4 days of without defacation.
After 8hrs of nursing intervention the pt will regain normal pattern of bowel functioning.
Independent:>Encourage balanced fiber and bulk in diet>Promote adequate fluid intake.>Encourage activity/exercise within limits of individual ability.>provide privacy and routinely scheduled time for defacation.>administer lubricant to anus if needed>administer enemasDependent:>Administer laxative as indicated.
-to improve consistency of stool and facilitate passage through colon.-to promote moist/soft stool.-to facilitate contractions of the intestines.-to help pt to concentrate on defacation.-for ease of passage of stool in the anal area.-digitally remove impacted stool.
Goal met as the pt was able to regain normal pattern of bowel functioning.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS> “Namamanas ako”, as claimedO> Edema on Right and left arm, and both legs noted. >c- 02 inhalation via nasal canula @ 2-3 L/hr>c- CTT @ Right side of chest connected to 3 way chest drainage, intact , draining into a yellow fluid output.>c- RR 32 Bpm>BP 170/80 mmHg>Orthopnea noted>Urine output 250cc/day (Oliguria)
>Fluid volume excess rt reduced glomerular filtration rate as evidenced of oliguria.
After 8hrs of nursing intervention the pt will stabilize fluid volume as evidenced by balanced I/O, vital signs within normal limits, stable weight, and free of signs of edema.
Independent:>Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.>Monitor /calculate 24-hour intake and output balance.>Maintain chair or bed rest in semi- fowler’s position during acute phase. >Weigh daily>Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated.
-Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors dieresis; therefore, urine output may be increased at night/ during bedrest.-Diuretic therapy may result in sudden/ excessive fluid loss (circulating hypovolemia), even though edema remains.-Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing dieresis.>Documents changes in resolution of edema in response to therapy. A gain of 5lb represents approximately 2 L of fluid. Conversely, diuretics can result in rapid/ excessive fluid shifts and weight loss.-Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility/Bed rest are cumulative stressor that effect skin integrity and require close supervision/preventive interventions.
Goal Unmet needs further evaluation.
XIV. DRUG STUDYGENERIC NAME
ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATIONS
Cefuroxime
BRAND NAME
Ceftin
CLASSIFICATION
Cephalosporins
750mg q8
Second generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
> Serious lower respiratory tract infection, UTI, skin or skin structure infections, bone or joint infection, septicemia.
> Perioperative prevention
> Bacterial exacerbations of chronic bronchitis or secondary bacterial infection of acute bronchitis
> Contraindicated in patients hypertensive to drug or other cephalosporins.
CV:phlebitis, thrombophlebitis
GI: pseudomembranous colitis, nausea, anorexia, vomiting.
Hematologic: thrombocytopenia, transient neutropenia.
Other: anaphylaxis
> Before giving drug, ask patient if he is allergic to penicillins or cephalosporins.
> Tablets may be crushed if absolutely necessary, for patients who can’t swallow tablets. Tablets may be dissolved in small amount of apple, orange, or grape juice or chocolate milk. However, the drug has a bitter taste that is difficult to mask, even with fopd.
> Tablets and suspension aren’t bioequivalent and can’t be substituted milligram-for-milligram.
> Monitor patient for signs and symptoms of superinfection
GENERIC NAME
ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATIONS
Simenthicone
BRAND NAME
Flatulex
CLASSIFICATION
Antacids, adsorbents, and
antiflatulents
20 ml q4
Disperses or prevents formation of mucus-surrounded gas pockets in the GI tract.
> Flatulence, functional gastric bloating.
> Contraindicated in patients hypersensitive to drug.
> For infant colic, safety is unknown.
GI: nausea, vomiting, diarrhea, constipation, belching, passing of flatus.
> Drug doesn’t prevent gas formation.
> Don’t confuse simethicone with cimetidine.
Name of Drug Mechanism of action Indication Contraindication Side effect Nursing
consideration
Generic name
Clonidine
Brand name
Catapres
Classification
Anti hypertensive
Dosage and frequency
5mg 1 tab Bid
Clonidine acts as an agonist at
presynaptic alpha(2)-receptors
in the nucleus tractus solitarius
of the medulla oblongata.
Stimulation of these receptors
results in the supression of
efferent sympathetic pathways
and the subsequent decrease in
blood pressure and vascular tone
in the heart, kidneys, and
peripheral vasculature.
Clonidine is also a partial
agonist at presynaptic alpha(2)-
adrenergic receptors of
peripheral nerves in vascular
smooth
muscle.
For the treatment of
hypertension and
maybe used in
prophylaxis of
migraine or
recurrent vascular
headache;
Menopausal
flushing
Clonidine HCl is
contraindicated in patients
with a history of
sensitization or allergic
reactions to clonidine.
Epidural administration is
contraindicated in the
presence of an injection
site infection, in patients
on anticoagulant therapy,
and in those with a
bleeding diathesis.
Administration of epidural
clonidine HCl above the
C4 dermatome is
contraindicated since there
are no adequate data to
support such use
Lightheadedness or
fainting, which can be a sign
of dangerously low blood
pressure (hypotension)
A fast or slow heart rate
Chest pain or heart
palpitations
Depression or anxiety
Hallucinations
Congestive heart failure
Signs of an allergic
reaction, including
unexplained rash, hives,
itching, unexplained
swelling, wheezing, or
difficulty breathing or
swallowing.
Hypersensitivity to
clonidine or
adhesive layer
components of the
transdermal
system.
Name of Drug Mechanism of action Indication Contraindication Side effect Nursing
consideration
Generic name
Insulin
Brand name
Insulin Lispro (Eli Lily)
Classification
Dosage and frequency
40 units for AM
30 units for PM
Injection, solution
Subcutaneous
The primary activity of
insulin is the regulation
of glucose metabolism.
In muscle and other
tissues (except the
brain), insulin causes
rapid transport of
glucose and amino acids
intracellularly ...
For treatment of diabetes
(type I and II)
Because there are no
alternatives for insulin
when it is used for
diabetic indications,
there are no absolute
contraindications to its
use.
Adverse effects of
insulin therapy can
include, hypoglycemia
(see overdosage below),
insulin-induced
hyperglycemia
(“Somogyi effect”),
insulin
antagonism/resistance,
rapid insulin
metabolism, and local
reactions to the “foreign”
proteins.
Allergy to pork
products,pregnancy,
lactation
Name of Drug Mechanism of action Indication Contraindication Side effect Nursing
consideration
Generic name
Salbutamol
Brand name
Ventolin
Classification
Bronchodilator.
Dosage and frequency
0.63 mg, 1.25 mg or 2.5
mg 3-4 times a day
Salbutamol is a beta(2)-adrenergic agonist and
thus it stimulates beta(2)-adrenergic receptors.
Binding of albuterol to beta(2)-receptors in
the lungs results in relaxation of bronchial
smooth muscles. It is believed that salbutamol
increases cAMP production by activating
adenylate cyclase, and the actions of
salbutamol are mediated by cAMP. Increased
intracellular cyclic AMP increases the activity
of cAMP-dependent protein kinase A, which
inhibits the phosphorylation of myosin and
lowers intracellular calcium concentrations. A
lowered intracellular calcium concentration
leads to a smooth muscle relaxation. Increased
intracellular cyclic AMP concentrations also
cause an inhibition of the release of mediators
from mast cells in the airways.
For relief and
prevention of
bronchospasm due to
asthma, emphysema,
and chronic bronchitis.
VENTOLIN
Inhalation Aerosol is
contraindicated in
patients with a
history of
hypersensitivity to
albuterol or any of
its components.
Severe side effects
of salbutamol
include swelling of
the throat, rash, chest
tightness and hives.
If any of these
symptoms occur,
seek medical
attention
immediately
Hypersensitivity to
salbutamol
Name of Drug Mechanism of action Indication Contraindication Side effect Nursing
consideration
Generic name
ambroxol
Brand name
ambrolex
Classification
Cough and cold
remidies
Dosage and frequency
Adults: daily dose of 30
mg (one Ambroxol
tablet )to 120 mg (4
Ambroxol tablets) taken
in 2 to 3 divided doses
Ambroxol is a
metabolite of
bromhexine and is used
similarly as a mucolytic.
All forms of
tracheobronchitis,
emphysema with
bronchitis
pneumoconiosis, chronic
inflammatory pulmonary
conditions,
bronchiectasis,
bronchitis with
bronchospasm asthma.
During acute
exacerbations of
bronchitis it should be
given with the
appropriate antibiotic.
There are no absolute
contraindications but in
patients with gastric
ulceration relative
caution should be
observed.
Occasional
gastrointestinal side
effects may occur but
these are normally mild
Early month of
pregnancy,
hypersensitivity
Name of Drug Mechanism of action Indication Contraindication Side effect Nursing
consideration
Generic name
Amlodipine besylate
Brand name
vasalat
Classification
calcium-channel
blockers
Dosage and frequency
5-10 mg once daily
Amlodipine is a
dihydropyridine calcium-
channel blocker, which is
also known as calcium
antagonists, calcium-
entry blockers, and slow-
channel blockers. It
inhibits the cellular
movements of calcium
ions across cell
membranes. It acts
primarily via inhibition
of calcium into vascular
smooth muscle and, to
lesser extent cardiac
muscle.
In the management of
hypertension and
prophylaxis of angina
Severe hypotension.
Lactation.
Calcium-channel
blockers are normally
avoided in patients with
heart failure but
amlodipine has not been
found to have any
adverse effects on
morbidity or mortality in
patients with sever heart
failure receiving drug.
Therefore it may be
suitable treatment for
angina pectoris or
hypertension in some
patients.
Hypotension
(severe): amlodipine
may aggravate this
condition.
NAME OF DRUGMECHANISM OF
ACTIONINDICATION CONTRAINDICATION ADVERSE EFFECT
NURSING
CONSIDERATION
Aldactone®
(spironolactone)
Tablets, USP
CLASSIFICATION
potassium-sparing
diuretics
DOSAGE
FREQUENCY AND
PREPARATION
250mg, Tab, BID
Spironolactone inhibits
the effect of aldosterone
by competing for
intracellular aldosterone
receptor in the distal
tubule cells. This
increases the secretion
of water and sodium,
while decreasing the
excretion of potassium.
Long-term maintenance
therapy for patients with
bilateral micro- or
macronodular adrenal
hyperplasia (idiopathic
hyperaldosteronism).
Congestive heart failure
Cirrhosis of the liver
accompanied by edema
and/or ascites
Essential hypertension
Hypokalemia
Aldactone is
contraindicated for
patients with anuria,
acute renal
insufficiency, significant
impairment of renal
excretory function, or
hyperkalemia.
Spironolactone is
associated with an
increased risk of
bleeding from the
stomach and duodenum,
but a causal relationship
between the two has not
been established. Since
it also affects steroid
receptors elsewhere in
the body, it can cause
gynaecomastia,
menstrual irregularities
and testicular atrophy.
Other side effects
include ataxia,
impotence, drowsiness
and rashes.
NAME OF DRUG
MECHANISM OF
ACTIONINDICATION CONTRAINDICATION ADVERSE EFFECTS
NURSING
CONSIDERATION
LACTULOSE
BRAND NAME
Duphalac
CLASSIFICATION
LAXATIVE
DOSAGE
FREQUENCY AND
PREPARATION
15 ml, OD,
Inhibits bacterial DNA
gyrase thus preventing
replication in
susceptible bacteria
Constipation,
salmonellosis.
Treatment of hepatic
encephalopathy
Pt who require a low
lactose diet.
Galactosemia
deficiency. Intestinal
obstruction.
PRECAUTION:
Lactose intolerance,
diabetes
Adverse Rxn:
Abdominal discomfort
associated with
flatulence and intestinal
cramps. Nausea,
vomiting, diarrhea on
prolonged use.
>Assess condition
before therapy and
reassess regularly
thereafter to monitor
drug’s effectiveness
>Monitor pt for any
adverse GI reactions,
nausea,vomiting,diarrhe
a,
>Assess for adverse
reactions
>for pt. with hepatic
encelopathy: regularly
assess mental condition
>monitor I & O
>monitor for Inc.
glucose level in diabetic
pts
GENERIC NAME ACTION INDICATION CONTRAINDICATIONADVERSE
REACTION
NURSING
CONSIDERATION
Mefenamic acid
BRAND NAME
Dolfenal
CLASSIFICATION
Analgesic
DOSAGE
FREQUENCY AND
PREPARATION
50mg, 1 tab, TID
Aspirin-like drug that
has
analgesic,antipyretic, &
anti-inflammatory
activities
Relief of pain
including muscular,
rheumatic, traumatic,
dental, post-op and
postpartum pain,
headache, migraine,
fever, dysmenorrhea
Pregnancy & lactation,
hypersensitivity, active
ulceration or chronic
inflammation of either upper
or lower GIT, blood
disorders, poor platelet
function, kidney or liver
impairment, children < 14
yrs
PRECAUTION:
If rash occurs,
administration should
be stopped, asthmatics,
Hx of liver and kidney
disease
ADVERSE RXN
GI discomfort, diarrhea
or constipation, gas
pain, nausea, vomiting,
drowsiness
> assess pt.’s pain
before therapy
>monitor for possible
drug induced adverse
reactions
>advice pt. not to take
drug for more than 7
days
>advice pt. to report
immediately persistence
or failure to relieve pain
GENERIC NAME ACTION INDICATION CONTRAINDICATIONADVERSE
REACTION
NURSING
CONSIDERATION
Bisacodyl
BRAND NAME
Dulcolax
CLASSIFICATION
Laxative
DOSAGE FREQUENCY
AND PREPARATION
2 tab, O.D., at H.S.
Increases
peristalsis &
motor activity
of the small
intestines by
acting directly
on the smooth
muscles.
Constipation, relief
of evacuation in
hemorrhoids, prep
for barium enema,
pre and post-op
Nausea, vomiting or other
symptoms of appendicitis,
acute surgical abdomen,
abdominal pain, ulcerative
lesions of colon
PRECAUTION:
Caution is advised
during 1st 3 mos of
pregnancy as well as
administration to
children < 4 yrs
ADVERSE RXN
Occasional
abdominal
discomfort, soreness
in anal region
> monitor frequency &
character of stool
>monitor occurrence of
adverse rxn
>swallow the tablet
whole, do not crush or
chew
GENERIC NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATION
Furosemide
BRAND NAME
Lasix
CLASSIFICATION
Diuretic
DOSAGE
FREQUENCY AND
PREPARATION
20mg, q12
inhibits sodium
and chloride
reabsorption at
the proximal and
distal tubules
and the
ascending loop
of Henle
acute pulmonary edema
edema
hypertension
Anuria
hepatic coma & precoma
severe hypokalemia &/or
hyponatremia
hypovolemia w/ or w/o
hypotension
Hypersensitivity to
furosemide or
sulfonamides
vertigo,
dizziness,
headache,
paresthesia,
orthostatic
hypotension,
thrombophlebitis,
abdominal pain,
hypokalemia,
anemia
muscle spasm
To prevent nocturia, give
preparation in the morning
and early in the afternoon
Watch for signs of hpokalemia
do not confuse with Torsemide or
Lasix with Lonox
advise patient to take drug with
food to prevent GI upset
inform patient of possible need
for potassium or magnesium
supplements
GENERIC NAMEACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATION
Ranitidine HCL
BRAND NAME
CLASSIFICATION
Histamine H2
Receptor antagonist.
DOSAGE
FREQUENCY AND
PREPARATION
50mg, IV, q8
Completely
inhibits action
of histamine on
the H2 at
receptor sites of
parietal cells,
decreasing
gastric acid
secretions
•Duodenal and gastric
ulcers
•Maintenance therapy for
gastric and duodenal
ulcer
•GERD
•Erosive esophagitis
•Heartburn
Contraindicated in
patients hypersensitive to
drug and those with
porphyria
•Use cautiously in
patients with hepatic
dysfunction. Adjust dose
in patients with impaired
renal function
• Vertigo, malaise,
headache, blurred
vision, jaundice,
burning and itching
at injection site
•Assess patient for abdominal
pain. Note presence of blood in
emesis, stool, or gastric aspirate
•Ranitidine may be added to
total parenteral nutrition
solution
•Instruct patient on proper use
of OTC preparation as
indicated.
•Remind patient to take once
daily prescription drug at
bedtime for best results
•Instruct patient to take without
regard to meals because
absorption isn’t affected by food
GENERIC NAMEACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATION
Ceftriaxone Sodium
BRAND NAME
CLASSIFICATION
Cephalosporin
antibiotic
DOSAGE
q8 ANST (-)
Semisynthetic 3rd
generation
cephalosphorin
antibiotic.
Preferentially binds to
one or more of the
penicillin-binding
proteins (PBP)
located on cell walls
of susceptible
organisms. This
inhibits 3rd and final
stage of bacterial cell
wall synthesis, thus
killing the bacterium.
Infections caused by
susceptible
organisms in lower
respiratory tract,
skin, and structures,
urinary tract, bones
and joints, also intra-
abdominal infections,
pelvic inflammatory
disease,
Hypersensitivity to this
drug and related
antibiotics, pregnancy
Prutitus, fever,
chills, pain,
induration at IM
injection site,
phlebitis, diarrhea,
abdominal cramps
Determine history of
hypersensitivity to reactions to
cephalosporins and peniccilins
and history of other allergies,
particularly to drugs before
therapy is initiated.
GENERIC NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATION
Metronidazole
BRAND NAME
CLASSIFICATION
Antibiotic
Antibacterial
Amebicide
Antiprotozoal
DOSAGE
q8 , IV, 5mg
Bactericidal:
Inhibits DNA
synthesis in
specific (obligate)
anaerobes, causing
cell death;
antiprotozoal-
trichomonacidal,
amebicidal:
Biochemical
mechanism of
action is not
known.
Acute infection with
susceptible anaerobic
bacteria
Acute intestinal amebiasis
Amebic liver abscess
Trichomoniasis (acute and
partners of patients with
acute infection)
Contraindicated with
hypersensitivity to
metronidazole;
pregnancy (do not use
for trichomoniasis in
first trimester).
Use cautiously with
CNS diseases, hepatic
disease, candidiasis
(moniliasis), blood
dyscrasias, lactation.
CNS: Headache,
dizziness, ataxia, vertigo,
incoordination, insomnia,
seizures, peripheral
neuropathy, fatigue
GI: Unpleasant metallic
taste, anorexia, nausea,
vomiting, diarrhea, GI
upset, cramps
GU: Dysuria,
incontinence, darkening
of the urine
Local: Thrombophlebitis
(IV); redness, burning,
dryness, and skin
irritation (topical)
Other: Severe, disulfiram-
like interaction with
alcohol, candidiasis
(superinfection)
History: CNS or hepatic
disease; candidiasis
(moniliasis); blood dyscrasias;
pregnancy; lactation
Physical: Reflexes, affect; skin
lesions, color (with topical
application); abdominal exam,
liver palpation; urinalysis,
CBC, liver function tests
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