diabetes melitus 2 dka

8/13/2019 DIABETES MELITUS 2 DKA

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Angeles University Foundation

Angeles City

College of Nursing

A.Y. 2012-2013

A CASE STUDY on

DIABETES MELLITUS TYPE 2

Presented to:

Rhocette M. San Agustin, RN, MN

Presented by:

Group 4

BSN III-1

De Guzman, Glazier

Ellorin, Lynette

Galang, Carmela Iris

Halili, John Frederick

Lacson, Laiza Fatima


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I. INTRODUCTION

Diabetes mellitus is a condition in which the pancreas no longer produces

enough insulin or cells stop responding to the insulin that is produced, so that glucose in

the blood cannot be absorbed into the cells of the body. Symptoms include frequenturination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet,

oral medications, and in some cases, daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or

adult-onset diabetes, and this form of diabetes occurs most often in people who are

overweight and who do not exercise. Type II is considered a milder form of diabetes

because of its slow onset (sometimes developing over the course of several years) and

because it usually can be controlled with diet and oral medication. The consequences

of uncontrolled and untreated Type II diabetes, however, are the just as serious as those

for Type I. This form is also called noninsulin-dependent diabetes, a term that is

somewhat misleading. Many people with Type II diabetes can control the condition

with diet and oral medications, however, insulin injections are sometimes necessary if

treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both

hereditary (genetic factors passed on in families) and environmental factors involved.

Research has shown that some people who develop diabetes have common genetic

mar kers. In Type I diabetes, the immune system, the body s defense system against

infection, is believed to be triggered by a virus or another microorganism that destroys

cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family

history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells

have become resistant to the insulin produced and it may not work as effectively.

Symptoms of Type II diabetes can begin so gradually that a person may not know that

he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other

symptoms may include sudden weight loss, slow wound healing, urinary tract infections,

gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while


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a patient is seeing a doctor about another health concern that is actually being

caused by the yet undiagnosed diabetes.

Current estimates indicate that 20 million people in the United States have

diabetes, 90-95% of who have type 2 diabetes mellitus. The number of Americans withdiabetes is projected to increase dramatically in forthcoming years due to increasing

rates of obesity, lack of physical activity, and an aging population. Patients with

diabetes have an increased risk of developing a wide range of disease-related

complications, both macro vascular (e.g., cardiovascular disease [CVD]) and micro

vascular (e.g., nephropathy, retinopathy, and neuropathy).

According to the research team led by Peninsula College of Medicine and

Dentistry (PCMD), University of Exeter, lean type 2 diabetes patients have a larger

genetic disposition to the disease than their obese counterparts. The group made a

study that identified a new genetic factor associated only with lean diabetes sufferers.

Type 2 diabetes is popularly associated with obesity and a sedentary lifestyle.

However, just as there are obese people without type 2 diabetes, there are lean

people with the disease.

Using genetic data from genome-wide association studies, the research teamtested genetic markers across the genome in approximately 5,000 lean patients with

type 2 diabetes, 13,000 obese patients with the disease, and 75,000 healthy controls.

The team found differences in genetic enrichment between lean and obese

cases, which support the hypothesis that lean diabetes sufferers have a greater genetic

predisposition to the disease. This is in contrast to obese patients with type 2 diabetes,

where factors other than type 2 diabetes genes are more likely responsible.

Dr. John Perry, one of the lead authors of the study, said: Whenever a new

disease gene is found, there is always the potential for it to be used as a drug target for

new therapies or as biomarker, but more work is needed to see whether or not this new

gene has that potential. According to him, the gene that they found to be present in

lean sufferers of diabetes is now called Jack Spratt which needs more studies and


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researches for it to be used as a drug target and biomarker in the

future (http://www.sciencedaily.com/releases/2012/06/120601103808.htm) .

Reason for choosing such case for presentation

Nursing profession is never an easy job. It entails a lot of responsibilities like

giving the appropriate care for an individual. Nurses should not only possess the

knowledge about a certain disease but also the ability to render nursing care and meet

the needs of their patients. Being skillful and knowledgeable, aside from being

passionate the two are the most important qualities that nurses should have. Enhancing

one s knowledge and skills will serve as foundation. One way to do this is to involve

nurses themselves in researches and case studies. This will update their learning s

regarding a specific disease condition.

The student nurses chose this diagnosis for their case presentation is that they saw

that the patient s SO is very informative about his daughter s condition during the nurse

patient interaction. It triggered that with that kind of attitude of an informant, they can

do their interview with ease being provided with enough information. Another reason is

that the student nurses can appreciate more of what they have learned during their

lecture in Nursing Care Management courses. And also, Diabetes Mellitus is a

widespread disease condition here in the Philippines so that what they have learned

here in this case, they can impart it in the community. Also to show what a single

disease condition can lead to a serious condition which can possibly create

complications and would prevent the individual from functioning well. Thus, through this

case study the student nurses could impart knowledge to their patients. To help them

gain enough knowledge on how to avoid the said condition. This can be learned if they

receive sufficient time, instruction, and help in overcoming disabilities.
http://www.sciencedaily.com/releases/2012/06/120601103808.htmhttp://www.sciencedaily.com/releases/2012/06/120601103808.htm


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Objectives

Nurse-centered:

After the completion of this case study, the student nurses should have:

Interpreted the current trends and statistics regarding the disease

condition and relate the state of the client with her personal and

pertinent family history.

Analysed and interpreted the different diagnostic and laboratory

procedures, its purpose and its essential relationship to client s disease

condition, identified treatment modalities and its importance like

drugs, diet and exercise.

Formulated nursing care plans based on the prioritized health needs of

the client and maintained sound communication by making use of self

as a therapeutic agent thus, acquiring knowledge and understanding

of the development of Diabetes Mellitus Type 2 in relation to risk factors

presented by the patient.

Discusses management and treatment and provide better nursing

care and health teachings through the utilization of the nursing

process.

Patient-centered:

During the course of the study, the patient and the family shall have:

Acquired knowledge on the risk factors that have contributed to the

development of Diabetes Mellitus Type 2,. Gained understanding and demonstrated compliance on the

treatment management rendered by the health care team to prevent

reoccurrence of the disease.


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II. NURSING ASSESSMENT

A. PERSONAL HISTORY

This is a case of Ms. Candy, a 27 year-old female, single, who was born on

November 28, 1985 via Normal spontaneous delivery. She is a natural born

Filipino citizen. She used to live somewhere in Bataan since she was a child and

transferred to Florida Blanca, Pampanga for five years now with her parents, her

mom s own hometow n. She is the youngest daughter among a brood of seven

children. Her mother was 48 years old and her father was 57 years old when she

became the breadwinner of the family at the age of 20. Her siblings still support

and visit them every now and then.

As stated by her Mom she received complete vaccination when she was stilla baby. Ms. Candy does not drink alcohol nor smoke cigarette ever since, when

she was still a student she goes to school at nine o clock in the morning and

comes back at home at six pm, she does not skip meals and she usually sleeps

for about seven hours a day; when she was still at work, she wakes up at six am

because her work starts at eight in the morning, she take her meals at the right

time of the day and finished work at five in the afternoon, she usually sleeps and

take her rest at nine o clock in the evening; and after her hospitalization last 2011

she now stays at the house, she wakes up 7am for breakfast, Ms. Candy eats

lunch between the hours of 12-1pm, she now takes her dinner at 7pm, watch

Television and sleeps for the rest of the hours, and usually sleeps at 9pm. She took

Diamicron (oral hypoglycaemic drug) and metformin (antidiabetic drug) as a

maintenance drug. Ms. Candy was admitted on January 31, 2013, 1 o clock in

the morning in a Government Hospital in Pampanga with an admitting Diagnosis

of Diabetes Mellitus type 2 poorly controlled to consider DKA. Her chief

complaint was vomiting.

Ms. Candy previously worked at Vercon s Grocery in a cake department for 3

years, she does the packaging of the cakes, and her job is located also in

Bataan. She has an income of two hundred pesos per day and working six days

a week that makes her earn approximately five thousand pesos a month. Her


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father also works as a jeepney driver, 3 times a week to augment their family

income. Her mother is a plain housewife who cooks for them and takes care of

household chores. She sometimes picks sampaguita flowers at the backyard and

sells them but she only earns twenty pesos a week. Since Ms. Candy s blood

sugar rises and cannot be controlled fully, she has no other option but to resign

from her job and leaves her father to work twice as hard as seven times a week

in order to provide for their family s needs .

Their electric bill per month usually goes around seven hundred pesos, water

bill of two hundred, and three thousand five hundred pesos for food and others.

She is a second year college Criminology undergraduate, and stopped school

because of having the weakness, headache and dizziness, after experiencing

these signs and symptoms it has prompted to seek medical advised at agovernment hospital in Bataan and was given Diamicron (oral hypoglycaemic

drug) and metformin (antidiabetic drug). And being able to work made her

decide not to study anymore.

The family is Catholics, and they do not believe in any superstitious belief.

Whenever someone gets sick they go to hospital and are not utilizing health

centers and even herbolarios. The family does not use herbal medicines as a

cure when sick, and uses only what the doctor prescribed.


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B. FAMILY HEALTH-ILLNESS HISTORY

Grandpa; Died ofRespiratory Problem at 68y/o

Grandma; died duringdelivery at 46y/o

Father anemia,

hypertension and

arthritis

Grandpa; died ofheart attack at 78y/o

Grandma; died ofheart attack at 67y/o

Uncle2;living with

DM

Uncle1;living withno knowndisease

Uncle3;died of

Kidneyproblem

Uncle4;living withno known

disease .

Aunty1;living withhypertension and DM

Auntie2;living withno known

disease

Auntie3;living withno knowndisease.

BA


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LEGENDS:

MALE

FEMALE

DECEASED

PATIENT

Ms.Candy

Sister2;36y/o,

living withDM

Sister1; diedof

Meningitisat 7mo old

Brother1;

39y/o,living

with DM

Brother2;

38y/o,living

with DM

Brother3; diedof DM

at 28y/o

Brother4;30y/o,livingwith noknowndisease

AuntieAdied of

asthmaand DM

AuntieB;living with

no knowndisease

AuntieC;living with

no knowndisease

AuntieD;living with

no knowndisease

Uncle3;livingwith noknowndisease

Uncle2;livingwith noknowndisease

Uncle1;died ofliverdamage

AuntieF;stillborn

child

AuntieE;living with

no knowndisease

BA

Mother;living

55y/o withhypertension


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EXPALANATION OF THE GENOGRAM

Ms. Candy s grandmother died at the age of 46 prior to her tenth delivery of her child.

She delivered a stillborn child, while her grandfather died at the age of 78 because of

heart attack. AuntieA died because of asthma and Diabetes at the age 50, Mother hashypertension, Uncle1 died because of liver damage, AuntieF died on the day that she

was born, and the rest are still a live and has no illnesses. Ms.Candy s grandfather died

at 68 because of respiratory problem and he is an alcoholic while her grandmother

died at 67 because of heart attack. Ms. Candy s f ather has anemia, hypertension and

arthritis, Auntie1 has hypertension and Diabetes, Uncle2 also has diabetes and Uncle3

died because of Kidney problem. All of her siblings has Diabetes except for Sister1 and

Brother4, Sister1 died at the age of seven months because of Meningitis and Brother3

died because of DM, and now Ms. Candy has DM too because it runs through their

genes.

C. HISTORY OF PAST ILLNESS

As verbalized by Ms. Candy, she was not hospitalized nor had illness for reasons

other than her present condition which is Diabetes or having high glucose in her blood.

She had chicken pox when she was 12 years olds during summer vacation and

managed it with unrecalled antivirals.

D. HISTORY OF PRESENT ILLNESS

Ms. Candy was 19 years old when she was first hospitalized in one

of the hospitals of Bataan because of body weakness, headache and dizziness, from

then she found out she has DM type 2. Last 2011 and 2012 she was confined twice at a

government hospital in Bataan, because of uncontrolled hyperglycemia she usually

stayed in the hospital for one week and was given a maintenance drugs of Diamicron


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(oral hypoglycaemic drug) and metformin (antidiabetic drug), and because of this her

blood sugar decreases. But her medications were stopped 2 days before admission

and now on her fourth time of complain, she was referred to a government hospital in

Pampanga and there she was confined again.

E. PHYSICAL EXAMINATION

1 st day of Nurse-Patient interaction (Jan 31, 2013, thursday)

General Appearance and Mental Status:

Patient is conscious, appears weak and pale. The patient is oriented to person, time

and place. She is wearing t-shirt and shorts and has IVF hooked on her left hand.

She can only perform simple ADLs.

Vital Signs:

Temp.: 36.7C

PR: 96 bpm

RR: 45 cpm

BP: 110/70 mmHg

Skin:

Fair complexion, hair evenly distributed, with good skin turgor, absence of

sores, rashes, lesions and bruises. With dry skin.

Head:

Round head, with thick, no lesions nor dandruff in the scalp, no

tenderness, masses, and nodules noted upon palpation. With headache.

Eyes:


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stabbing pain felt on epigastric region with a pain rate of 7/10. Patient is

complaining of being nauseous.

Musculoskeletal

Feet and legs are symmetric in size, shape, and movement. Extremities

warm and mobile with adequate capillary refill. Has moderate range of motion

with no swelling, redness, or tenderness nor edema on extremities..

2nd day of Nurse-Patient Interaction (Feb 1, 2013, friday)

Vital Signs:

Temp.: 36.6CPR: 97 bpm

RR: 17 cpm

BP: 130/90 mmHg

Skin:

Fair complexion, hair evenly distributed, with good skin turgor, absence of

sores, rashes, lesions and bruises. With dry skin.

Head:

Round head, with thick, no lesions nor dandruff in the scalp, no

tenderness, masses, and nodules noted upon palpation. With headache.

Eyes:

Eyebrows are aligned, hair evenly distributed, with white sclera and pale

conjunctiva , eyelashes evenly distributed, no nodules noted upon palpation of

eyelids. Eyeballs are symmetrically aligned in socket without protruding or sinking.

Ears:


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Symmetrical ears, no lesion, no tenderness and masses noted upon

palpation, no abnormal discharges, presence of cerumen, pinna recoils after

folded.

Nose:

No deformities noted, no nasal flaring nor abnormal discharges. No septal

deviation.

Throat:

Patent, no tenderness and nodules upon palpation.

Mouth:

Lips are symmetrical in shape, with dry pale lips , and with white teeth.

Neck:

No masses and nodules noted upon palpation, no lesions, no jugular veindistention.

Chest and Lungs:

The patient has normal respiratory rate, experiences non-productive cough, with

clear breath sounds upon auscultation. Shoulders and scapulae are in equal

horizontal positions. Sternum is positioned at midline and straight. No retraction.

Aching pain felt at the back (thoracic area) with a pain rate of 5/10.

Breast

No swelling, nodules, or ulceration. Even color, smooth with no edema .

Heart:

With normal heart rate rhythm auscultated on the 4 th intercostals space.

Abdomen:

Flat, soft and with normal contour, no lesions, no tenderness, masses and

nodules noted upon palpation, with a bowel sound of 18/min on the left upper

quadrant. With on and off stabbing pain felt on epigastric region with a pain rate

of 7/10. Patient is still complaining of being nauseous.

Musculoskeletal


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Feet and legs are symmetric in size, shape, and movement. Extremities

warm and mobile with adequate capillary refill. Has moderate range of motion

with no swelling, redness, or tenderness nor edema on extremities..

CRANIAL NERVE ASSESSMENT

Cranial Nerve Type:

Function

Assessment

Procedure

Normal Findings Actual Results

I. Olfactory Sensory:

Smell

With both eyes

closed, asks the

client to smell

different scents

like perfume.

The client must

identify the

scents as she

smells it even if

her eyes are

closed.

The client was

able to identify

the scent.

II. Optic Sensory:

Vision

At a given

distance of 1

meter, ask the

client to read

the

newsprint/book.

At the given

distance the

client must be

able to read the

newsprint/book.

The client was

able to read the

newsprint/book

from a distance

of 14 inches.

III. Oculomotor Motor:

Movement

to four of

six eye

extrinsic

muscles

(inferior

oblique;

superior,

Instruct the

client to open

and close the

eyelid and

follow the

direction of the

penlight. This is

a test for

papillary

Both eyes must

follow the

direction of the

penlight. The

pupils of the

eyes are dilated

without the light

and constricts in

response to

The client was

able to follow

the direction of

the penlight.

Pupil constricts

when light is

introduced.


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medial,

and inferior

rectus) and

upper

eyelid

action. light.

IV. Trochlear Motor:

Upward

and

downward

movementof eyes

(superior

oblique)

Instruct the

client to look

upward and

downward to

assessdirections of

gaze.

Without any

difficulty, the

client must be

able to move

her eyesupward and

downward.

The client was

able to move

his/her eyes

upward and

downwardwithout any

difficulty.

V. Trigeminal Motor:

Chewing

Instruct the

client to open

and clench

jaw.

The client must

be able to

clench jaw and

chew properly.

The client was

able to clench

his/her jaw and

chew properly.

Sensory:

Senses of

face and

teeth

Gently touch

the lateral side

of the client s

eyes using a

cotton wisp.

The client must

be able to elicit

blinking reflex.

The client

blinked when

the cotton wisp

touched the

lateral side of

her eyes.

Motor:

Lateral


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VI. Abducens movement

of eyes

(lateral

rectus)

Ask the client to

move eyes

laterally.

The client must

be able to

move his/her

eyes laterally.

The client was

able to move

his/her eyes

laterally.

VII. Facial Motor:

Movement

of the

muscles of

facial

expression

Instruct the

client to smile,

frown, and raise

eyebrows.

The client must

be able to smile,

frown, and raise

eyebrows easily.

The client was

able to smile,

frown, and raise

his/her eyebrows

easily when told

to do so.

Sensory:Taste

Make use ofdifferent

seasonings like

soy sauce,

calamansi,

sugar to test the

taste sensation

of the client

The client mustbe able to

distinguish and

identify what is

sweet, salty, and

sour.

The client wasable to

distinguish and

identified the

taste.

VIII.

Vestibulocochlear

Sensory:

Hearing

and

Balance

Ask the client to

repeat

whispered

words, Hello.

The client must

be able to

repeat exactly

the whispered

words.

The client was

able to repeat

the whispered

word, Hello.

IX.

Glossopharyngeal

Motor:

Movementof

pharyngeal

muscles

Instruct the

client toswallow and

move mouth in

a chewing

motion.

The client must

be able toswallow and

chew without

difficulty.

The client was

able to swallowand chew food

without difficulty.


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F. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTIC/LABORATORY

PROCEDURES

DATE

ORDEREDDATE

RESULT(S) IN

GENERALDESCRIPTION

INDICATION(S) ORPURPOSE(S)

RESULTS NORMALVALUES

ANALYSIS AND

INTERPRETATION OF RESULTS

BLOOD

CHEMISTRY

Date

Ordered:

Jan. 30, 2013

Date Results

in:

Jan. 30, 2013

This test measures

the amount of

hemoglobin

present in a whole

blood. The

haemoglobin

levels correlates

closely with the

red blood cell

count. (Brunner

and Suddarth,

2010)

This is the part of

HEMOGLOBIN. This

was done to Ms.

Candy to determine if

there was possible

tissue oxygen

deprivation related to

her disease condition.

Hemoglobi

n

93

Hemoglobi

n

115-155 g/L

The results

show that the

Hemoglobin

level of Ms.

Candy is

decreased;

this indicates

decreased

production of

erythropoietin

brought about

by decreased

blood flow to


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organisms.

Absolute

lymphocyte count

predicts overall

survival in follicular

lymphomas.

Random blood

sugar (RBS)

measures blood

glucose regardless

of when you last

ate. This test may

be taken

throughout the

day.

of leukemia. To

determine the stage

and severity of an

infection.

RANDOM BLOOD

SUGAR is done to Ms.

Candy to check and

monitor her blood

sugar levels.

.

20.21 3.85-

9.0mmol/L

count which

indicates that

Ms. Candy has

no infection.

The results

showed that

the patient has

an increased

in blood

glucose since

glucose

uptake is

decreased

because of

inadequate

insulin.


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Creatinine is a

chemical waste

molecule that is

generated from

muscle

metabolism.

Sodium is a

substance that

the body needs to

work properly.

Your blood sodium

level represents a

balance between

the sodium and

water in the food

and drinks you

consume and the

amount in urine.

CREATININE

Is done to the patient

to assess glomerular

filtration and to screen

for renal damage.

SODIUM

To evaluate fluid,

electrolyte, and acid-

base balance and

related renal

functions.

123.6

138.3

58-

100umol/L

135-

145mEq/L

Elevated

creatinine

level signifies

impaired

kidney

function or

kidney disease.

The results

showed a

normal sodium

level which

indicates

normal fluids

and

electrolytes in

the body.


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Date

Ordered:

both-

Jan. 31, 2013

Date Results

in:both-

Jan. 31, 2013

This test measures

the amount of

potassium in the

blood. Potassium

(K+) helps nerves

and muscles

communicate. It

also helps move

nutrients into cells

and waste

products out of

cells.

Blood urea

nitrogen. Urea

nitrogen is what

forms when

protein breaks

down. BUN levels

reflect protein

intake and renal

excretory

POTASSIUM

To evaluate clinical

signs of potassium

excess or depletion.

To monitor renal

function.

BUN

A test can be done to

measure the amount

of urea nitrogen in the

blood.

3.79

8.4

12.1

3.5-

5.5mEq/L

1.7-

8.3mmol/L

The results

showed that

the potassium

levels of the

patient is

normal which

means that Ms.

Candy s renal

system

functions well.

The first results

is between

normal range

while the 2 nd

one shows

increased in

BUN may

indicate

kidney


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HbA1c is a lab test

that shows the

average level of

blood sugar

(glucose) over the

previous 3 months.

It shows how well

you are controlling

your diabetes.

HBA1c30 is done to

Ms. Candy to

determine how well

she is controlling her

diabetes for the past 3

months.

10% 4.2-6.5% The result

shows an

increase in

HBA1c which

may indicate

increase levels

of blood sugar.

NURSING RESPONSIBILITIES:

BEFORE:

Explain to the patient s SO the purpose of the procedure. Inform the patient this test can assist in evaluating the amount of hemoglobin in the blood to assist in

diagnosis and monitor therapy.

Tell the patient s SO that the test requires a blood sample, who will perform the venipuncture and when.

Explain to the patient s SO that she may feel some discomfort from the needle puncture and the

presence of the tourniquet.


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Obtain a history of the patient's complaints, including a list of known allergens, especially allergies or

sensitivities to latex.

Obtain a history of the patient's cardiovascular, gastrointestinal, hematopoietic, hepatobiliary, immune,

and respiratory systems; symptoms; and results of previously performed laboratory tests and diagnostic

and surgical procedures.

Note any recent procedures that can interfere with test results.

Obtain a list of the patient's current medications, including herbs, nutritional supplements, and

nutraceuticals

Sensitivity to social and cultural issues , as well as concern for modesty, is important in providing

psychological support before, during, and after the procedure.

DURING:

Maintain sterile technique

Send the sample to the laboratory as soon as possible to avoid stasis and to allow early separation of

serum from the clotted blood. Handle the sample gently to prevent hemolysis. Be aware that hemolysis caused by rough handling of the sample may influence test results.

Be aware that hemolysis may elevate results. Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess

venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.


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AFTER:

Apply pressure to the puncture site to prevent bleeding Properly dispose of the needle in the sharps container. (do not lay down or recap needles) Immediately label the specimen.

Remove your gloves and wash your hands.

Record the client s name, the test performed, and disposition of the specimen collection criteria.

DIAGNOSTIC/LABORATORY

PROCEDURES

DATE

ORDERED

DATE

RESULT(S)

IN

GENERAL

DESCRIPTION

INDICATION(S)

OR PURPOSE(S)

RESULTS NORMAL

VALUES

ANALYSIS AND

INTERPRETATION

OF RESULTS

URINALYSIS Date

Ordered:

Jan. 31,

2013

Urinalysis

evaluates the

physical

characteristics

of urine,

Urinalysis help

Health Care

Providers

diagnose a

urinary tract or

Volume

600 to 2500

mL in 24

hours

The present

urinary results

showed presence

of RBC, WBC,

Proteins, Glucose


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Date

Result in:

Jan31.

2013

Date

Ordered:

Jan. 30,

2013

Date

Result in:

determines

specific

gravity and

pH.

metabolic

disease. It is

also essential in

the diagnosis of

disease or

disorders of the

kidneys or

urinary tract.

Yellow

Cloudy

1.030

5

positive

Color

Pale yellow

to amber

Appearance

Clear to

slightly hazy

Specific

gravity

1.005 to

1.030 with a

normal fluid

intake

pH

4.5 to 8

Glucose

Negative

in the urine which

is not normal

which indicates

altered renal

function.


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Jan 30.

2013

positive

Ketones

Negative

Blood

Negative

Protein

Negative

Bilirubin

Negative

Nitrate for

bacteria

Negative

Casts

Negative,

occasional

hyaline casts

Red Blood


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Date

Ordered:

Jan. 30

and 31,

2013

Date

Result in:

Jan 30

and 31.

2013

.2/hpf

10-15

18-20/hpf

Moderate

Cells

Negative or

rare

Crystals

Negative or

none

White Blood

Cells

Negative or

rare

Epithelial

Cells

Few; hyaline

casts: 0-1/lpf


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NURSING RESPONSIBILITIES:

BEFORE:

Check the physician s order Identify the client Explain the procedure to the patient s SO and its importance Offer the child something to drink.

DURING:

Collect specimens form infants and young children into a disposable collection apparatus consisting of a plastic

bag with an adhesive backing around the opening that can be fastened to the perineal area or around the penis

to permit voiding directly to the bag.

Depending on hospital policy, the collected urine can be transferred to an appropriate specimen container. Cover all specimens tightly, label properly and send immediately to the laboratory. Observe standard precautions when handling urine specimens. If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an

appropriate preservative added.

AFTER:


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III. ANATOMY AND PHYSIOLOGY

Anatomy of the Pancreas

The pancreas is located

retroperitoneal, posterior to the

stomach in the inferior part of the left

upper quadrant. It has a head near the

midline of the body and a tail that

extends to the left where it touches the

spleen. It is a complex organ composed

of both endocrine and exocrine tissues

that perform several functions. Theendocrine part of the pancreas consists

of pancreatic islets (islets of

Langerhans). The islet cells produce the

hormones insulin and glucagon, which

enter the blood. These hormones are

very important in controlling blood levels of nutrients such as glucose and amino acids.

The exocrine part of the pancreas is a compound acinar gland. The aciniproduce digestive enzymes. Clusters of acini are connected by small ducts, which join

to form larger ducts, and the larger ducts join to from the pancreatic duct. The

pancreatic duct joins the common bile duct and empties into the duodenum.

Functions of the Pancreas

The exocrine secretions of the pancreas include HCO 3, which neutralize the

acidic chime that enters the small intestine from the stomach. The increase pH resulting

from the secretion of HCO 3 stops pepsin digestion but provides the proper environment

for the function of pancreatic enzymes. Pancreatic enzymes are also present in the

exocrine secretions and are important for the digestion of all major classes of food.

Without the enzymes produced by the pancreas, lipids, proteins, and carbohydrates

are not equally digested.


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It is very important to maintain blood glucose levels within a normal range of

values. A decline in the blood glucose level below its normal range causes the nervous

system to malfunction because glucose is the nervous system s main source of energy.

When blood glucose decreases, fats and proteins are broken down rapidly by other

tissues to provide an alternative

energy source. As fats are broken

down, some of the fatty acids are

converted by the liver to acidic

ketones, which released into the

circulatory system.

The pancreas is responsible for

controlling and manipulating blood

glucose levels. The pancreas houses

islets responsible for production and

secretion of the hormones, glucagon

and insulin. Because of this, the

pancreas falls under both the endocrine glandular system as well as the exocrine

glandular system. The islets which produce these hormones are semi scattered

throughout the pancreas and are known as the islets of Langerhans. These particularendocrine functioning structures are typically able to be located in the body and along

the tail of the pancreas. Alpha cells and Beta cells are the cells that are known to

secrete the hormones within the islets. Glucagon is administered from the Alpha cells

and insulin comes from the Beta cells. Gulcagon has an affect on insulin by providing

the appropriate stimulus for the liver to convert glycogen into glucose. The Alpha cells

are able to respond appropriately to the feedback provided and thus are able to self

monitor. High blood sugar, which is also known as hypoglycemia, can be the result of

continuous output of glucagon.

Insulin s function on the human physiology is opposite of its counterpart, glucagon.

Insulin is designed to lower the blood sugar in the body. Insulin is the initiating factor that
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allows blood glucose to the necessary movement through the cell membranes.

Muscular cells and adipose cells rely on this movement of glucose for their ability to

function. The glucose level within the cell drops as the glucose moves throughout the

cell membrane. Insulin is also an initiating

factor in the conversion of glucose to

glycogen by the cells of the muscles and

liver. This action actually assists amino acids

into the cells and provides the foundation

for the creation of fats and proteins. When

Beta cells are incapable of producing the

appropriate amount of insulin, diseases

such as diabetes occur.

The pancreas is rather soft, created from

lobes, Measures about 6 inches long and 1

inch thick, and performs the functions of a mixed gland. Serving both endocrine

functions and exocrine functions, the pancreas is serving dual systems. The islets of

Langerhans, or pancreatic islets, are the cell clusters responsible for the pancreas

endocrine functions. Insulin and glucagon are required hormones of the bloodstream to

maintain optimal homeostasis. Performing the exocrine functions requires the proper

ability to secrete pancreatic juices which aid in digestion. The pancreatic juice is

created within the pancreas and immediately released into the pancreatic duct which

empties into the duodenum.

The pancreas is positioned snugly up against the greater curvature of the stomach,

which runs along the posterior wall of the abdominal cavity. It head is located close to

the duodenum, which is expanded over the central body. The tail tapers off near the

location of the spleen. The entire organ is in the retroperitoneal cavity with the

exception of the expanded head.
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THE CIRCULATORY SYSTEM

The complex nature of the human body demands an efficient circulatory system

in order to sustain life. The trillions of cells which comprise the human body demand this

efficiency in order to maintain the

functions of the multitudes of systems

within the human body, which

represents an ingenious division of

labor. The majority of the body s cells is

immobile, and therefore cannot

retrieve the basics of their existenceindependently. This means a well

organized and efficient circulatory

system is responsible for deliver life

sustaining oxygen and nutrients to the

cells which are incapable of fending

for them.

The blood within the circulatorysystem is responsible for delivering this

life sustaining oxygen and nutrients. The adult human body hosts nearly 60,000 miles of

passageway for the blood, also known as the blood vessels, in order to effectively

deliver life to the immobile cells.

The red blood cells, which are responsible for the delivery of oxygen and

nutrients, can also deliver within its frame work, bacteria, fungus, infection, disease, and

other life denying (to the cells) toxins that can compromise the integrity of the immobile

cells. The human body has a built in defense system to counteract this situation and

come to the aid of the compromised cells known as white blood cells. The white blood

cells in conjunction with the lymphatic system are often able to target cells which are

being attacked by a toxic element and come to their rescue like little warrior cells.
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The circulatory system is not a standalone system, and it requires the assistance

of systems such as the respiratory, urinary, endocrine, digestive, and integumentary

systems in order to maintain its proper function and give the body the life sustenance it

requires to live. While the circulatory system has numerous functions, the various

capabilities and functions of this intense system can be segregated into two basic

responsibilities.

Transportation of the substances necessary to maintain cellular metabolism is one of

two main functions of the circulatory system. In conjunction with the respiratory system,

red blood cells by the name of erythrocytes are responsible for the transportation of

oxygen which are systematically delivered to the cells waiting throughout the body. The

human body takes a breath, which enters the lungs. In the lungs, the oxygen molecules

attach themselves to hemoglobin molecules, which reside within the erythrocytes, and

then make their way via transport by these cells to cells in need of oxygen. Once the

cells have used the oxygen which has been delivered, the carbon dioxide that they

have produced are then transported back to the lungs and expelled in exhaled air.

The blood and lymph vessels work in

conjunction with the digestive systemin order for the circulatory system to

perform the delivery of nutrition. When

food is eaten it is broken down by the

digestive system and the nutrients are

absorbed through the wall of the

intestines, which is then picked up by

the blood vessels and carried off to the

cells requiring the nutrition with a pit

stop through the liver for nutrient

absorption and toxic cleansing.

The wastes associated with excess

waters, ions, plasma, and metabolic waste produced by the cells which were delivered
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their nutrients, are then filtered through capillaries which belong to the kidneys. From

there wastes enter the kidney tubes and are excreted in urine.

The circulatory system is also responsible for thetransportation of hormones through the blood

stream. This contributes to the regulatory process

of maintaining health of the endocrine system.

The second basic function associated with the

circulatory system involves protection. It

effectively protects against both injury anddisease through clotting, white blood cells, and

the process of phagocytosis. White blood cells

called leukocytes fight off disease and foreign

material in the body. The body becomes feverish

in this action as it works harder to produce a

greater number of leukocytes.

The body s natural ability to clot prevents excessive bleeding when blood vessels are

harmed or damaged. Excessive damage may cause bleeding faster than the body

can create clotting agents, but in most cases the clotting agents cease bleeding for

long periods of time.

The circulatory system and the cardiovascular system are often interchangeable and

interdependent within their specified roles. The circulatory system relies on the

cardiovascular system in order to assist it with transporting required cells, nutrients, or

other key vitalities in the blood stream. Without the heart to pump the 5 liters of blood

per minute through the average adult body, the cells would float aimlessly along in a

limp bloodstream. The four chambered heart pumps blood with enough force that

blood pressure plays a vital role in forcing the blood through the body in less than a
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minute. The blood vessels form a network throughout the body of thin tubes that act as

the transporters for the blood and its vital nutrients and blood cells. Arteries and veins

form additional pathways much like tributaries to supply blood to every extremity and

crevice of the body.

The microscopic arteries are known as arterioles, while microscopic veins are known as

venules. Each play a role in either delivering blood to the necessary body parts or

returning used blood back for recirculation.

Blood leaves the arteries through a capillary system which contain the thinnest and

smallest of all the veins in the body, with the exception of microscopic systems.Capillaries, which are basic functional unit of the circulatory system, are responsible for

the exchange of fluids, blood cells, nutrients, and wastes. When tissue cells have utilized

the oxygenation or the nutritional value from a blood cell, it is returned to the blood

stream via capillaries.

Tissue fluid, also known as interstitial fluid, comes from fluid derived from the plasma and

becomes protective liquid for tissues that are not surrounded by blood. A smallpercentage of this fluid is returned through the capillaries and is likely to enter the

lymphatic system via the connective tissues around the blood vessels. Fluid within the

lymphatic system, which is known as lymph, is then discharged back into the venous

blood. Strategically placed lymph nodes are responsible for the cleansing of the lymph

before it is returned for another use. This is the body s natural form of recycling and the

entire circulatory system is based on this notion of natural recycling.
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IV. PATHOPHYSIOLOGY

SCHEMATIC DIAGRAM (Book-based)

NON-MODIFIABLE FACTORS

Familial predisposition

Age (non-obese- 45 yrs. Old) & (obese -

30 years old)Gender (Female)

Race (Asians, African-Americans, NativeAmericans, Pacific Islanders)

MODIFIABLE FACTORS

Diet (High in fats and carbohydrates)

Emotional Stress

Physical Stress (infections and Diseases)

Obesity

Sedentary Lifestyle

Prolonged Increase in blood glucose Altered sensitivity of target tissues to insulin/

Resistance of target tissues to insulinCompensatory mechanism of beta cells to

increase insulin production and alpha cells to

decrease glucagon secretion

Beta cells exhaustion

Impaired transport of glucose by insulin to target

tissues (Insulin resistance)

Inability of fats and muscles to take up glucose

Limited beta cell

functions

Decrease sensitivity

of insulin to

lucose levels

A

B


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Synthesis of the Disease

b.1. Definition of the Disease (Diabetes Mellitus)

Diabetes Mellitus is a chronic health problem affecting more than 20 million

persons in the United States and affects all ages from all walks of life. And according to

Joyce Black and Jane Hokanson Hawks, it is the most common endocrine disorders

characterized by metabolic abnormalities and by long-term complications involving

the eyes, kidney, nerves and blood vessels. The diagnosis is not usually difficult to

distinguish duet to three classic symptoms like polyuria, polyphagia and polydypsia.

Diabetes Mellitus has two types.

Diabetes mellitus type 2 formerly non-insulin-dependent diabetes mellitus

(NIDDM) or adult-onset diabetes is a metabolic disorder that is characterized by

high blood glucose in the context of insulin resistance and

relative insulin deficiency Diabetes is often initially managed by

increasing exercise and dietary modification. As the condition progresses, medications

may be needed.

Unlike type 1 diabetes, there is very little tendency toward ketoacidosis though it

is not unknown. One effect that can occur is non-ketonic hyperglycemia. Long term

complications from high blood sugar include an increased risk of heart attacks, strokes,

amputation, and kidney.

Insulin resistance means that body cells do not respond appropriately when

insulin is present. Unlike type 1 diabetes mellitus, insulin resistance is generally "post-

receptor", meaning it is a problem with the cells that respond to insulin rather than aproblem with the production of insulin.

This is a more complex problem than type 1, but is sometimes easier to treat,

especially in the early years when insulin is often still being produced internally. Severe

complications can result from improperly managed type 2 diabetes, including renal
http://en.wikipedia.org/wiki/Metabolic_disorderhttp://en.wikipedia.org/wiki/Blood_glucosehttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Physical_exercisehttp://en.wikipedia.org/wiki/Dietinghttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Ketoacidosishttp://en.wikipedia.org/wiki/Non_Ketonic_Hyperglycemic_comahttp://en.wikipedia.org/wiki/Heart_attackhttp://en.wikipedia.org/wiki/Strokeshttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Strokeshttp://en.wikipedia.org/wiki/Heart_attackhttp://en.wikipedia.org/wiki/Non_Ketonic_Hyperglycemic_comahttp://en.wikipedia.org/wiki/Ketoacidosishttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Dietinghttp://en.wikipedia.org/wiki/Physical_exercisehttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Blood_glucosehttp://en.wikipedia.org/wiki/Metabolic_disorder


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failure, erectile dysfunction, blindness, slow healing wounds (including surgical incisions),

and arterial disease, including coronary artery disease. The onset of type 2 has been

most common in middle age and later life, although it is being more frequently seen in

adolescents and young adults due to an increase in child obesity and inactivity. A type

of diabetes called MODY is increasingly seen in adolescents, but this is classified as

diabetes due to a specific cause and not as type 2 diabetes.

Diabetes mellitus with a known etiology, such as secondary to other diseases,

known gene defects, trauma or surgery, or the effects of drugs, is more appropriately

called secondary diabetes mellitus or diabetes due to a specific cause. Examples

include diabetes mellitus such as MODY or those caused by hemochromatosis,

pancreatic insufficiencies, or certain types of medications (e.g., long-term steroid use).

Diabetic Ketoacidosis

Diabetic Ketoacidosis is a complication of Diabetes Mellitus. The inadequate

insulin would promote cellular starvation which would stimulate a hypothalamic-

pituitary-adrenal activity. Cortisol would be prompt carbohydrate, protein and fat

metabolism to counteract cellular starvation. The Fat metabolism would lead to the

release of free fatty acids or ketones. The accumulation of ketones in the bloodstreamwould result to metabolic acidosis, vomit ing and Kussmaul s respiration.

Etiology (Book-based)

Non-modifiable Factors:

Familial Predisposition- Type 2 DM has a strong genetic component. It is clear the

disease is polygenic and multifactorial still the major genes responsible for the disease

are not yet indentified. An individual with parents who has DM is at risk of acquiring it.

Also, genetic factors are thought to play a role in insulin resistance and impaired insulin

section in Type 2 DM (Black and Hawks, 2009).
http://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Erectile_dysfunctionhttp://en.wikipedia.org/wiki/Arteryhttp://en.wikipedia.org/wiki/Coronary_artery_diseasehttp://en.wikipedia.org/wiki/Middle_agehttp://en.wikipedia.org/wiki/Old_agehttp://en.wikipedia.org/wiki/MODYhttp://en.wikipedia.org/wiki/Genetic_disorderhttp://en.wikipedia.org/wiki/Hemochromatosishttp://en.wikipedia.org/wiki/Steroidhttp://en.wikipedia.org/wiki/Steroidhttp://en.wikipedia.org/wiki/Hemochromatosishttp://en.wikipedia.org/wiki/Genetic_disorderhttp://en.wikipedia.org/wiki/MODYhttp://en.wikipedia.org/wiki/Old_agehttp://en.wikipedia.org/wiki/Middle_agehttp://en.wikipedia.org/wiki/Coronary_artery_diseasehttp://en.wikipedia.org/wiki/Arteryhttp://en.wikipedia.org/wiki/Erectile_dysfunctionhttp://en.wikipedia.org/wiki/Renal_failure


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Age- Type 2 DM usually occurs at the age 45 years old and above in non- obese

people. Type 2 DM occurs most commonly in people who are obese at the age of 30

years old and above (Black and Hawks, 2009).

Gender- Around the globe, it affects 62 million in men versus 73 million among women.

It is said to be the sixth leading cause of death among women in the United States.

More of, Type 2 DM occurs in more women prior to having Gestational Diabetes Mellitus

of 25% to 50% compared with those going through pregnancy with normal glucose

tolerance (Black and Hawks, 2009).

Race- People with ethnic background such as African Americans, Native Americans,Mexican Americans and Asian/ Pacific Islanders are those populations who have high

incidence of Type 2 DM (Black and Hawks, 2009).

Modifiable Factors:

Diet- Foods rich in carbohydrates can easily promote the increasing level of glucose

along the bloodstream which can contribute to having DM Type 2 while increase in fat

can lead to development of Obesity which is a major risk factor of insulin resistance

(Black and Hawks, 2009).

Stress- When an individual is stressed, his/her blood sugar levels rise. Stress hormones like

epinephrine and cortisol kick in since one of their major functions is to raise blood sugar

to help boost energy when it's needed most. Think of the fight-or-flight response. A

person can't fight danger when his/her blood sugar is low, so it rises to help meet the

challenge. Both physical and emotional stress can prompt an increase in thesehormones, resulting in an increase in blood sugars. Any form of stress with the

neuroendocrine response increases glucogenesis and glycogenolysis. Infection, life

changes and various environmental factors can be stressors that induce or worsen a

diabetic state. (Black and Hawks, 2009).
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Obesity- About 80% of persons with NIDDM are obese and the frequency of diabetes in

obese people is greater than in the general population. The interrelations occurs

because obesity is associated with insulin insensitivity in target tissues (muscles, liver and

adipose cells). It is well known that blood levels of insulin are higher in an obese person

and take to return to the fasting state. Obesity acts as a diabetogenic factor because

the accompanying insulin resistance increases the need for insulin. Because the obese

are resistant to the effects of insulin, in practice, the obese diabetic responds poorly to

treatment with insulin (Black and Hawks, 2009).

Sedentary Lifestyle- This kind of lifestyle had contributed in the occurrence of DM due to

the fact that the lack of muscle activities decreases the need for the body to utilize the

glucose as a form of energy, resulting to an increase in its availability in the blood andincrease in the insulin production.

Signs and Symptoms with rationale (Book-based):

Hyperglycemia- Due to increase hepatic glucose production secondary to deacreas

insulin production associated with impaired Beta cell functions and altered glucose

utilization by cells due to tissue insensitivity or an inadequate insulin production by beta

cells of the pancreas.

Polyuria- Due to excessive blood volume secondary to increase volume of water in the

blood. Water not reabsorb from renal tubules secondary to osmotic activity of glucose

leads to osmotic activity of glucose leads to loss of water, glucose and electrolytes.

Polydypsia- Due to dehydration brought by frequent urination, the thirst center of the

brain will be triggered making the patient to urge for thirst. Not only this, but because of

the increase osmolality of the blood glucose due to increase glucose.

Polyphagia- Starvation secondary to tissue breakdown (catabolism) causing hunger.

And because the cells are not able to utilize glucose in the presence of inadequate

insulin level or resistance to insulin.


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Hypertension- Due to increase blood flow secondary to increase blood viscosity, in

return due a decrease blood flow will activate the rennin-agiontensin aldosterone

system.

Altered tissue perfusion- Due to decrease oxygen transport to the cells secondary to

decreased blood flow associated with increased blood viscosity.

Weight loss- Due to insulin deficiency, glucose cannot enter into the cells, as a

compensatory mechanism, the liver would be stimulated to undergo gluconeogenesis

wherein the body will utilize proteins and fats in order to produce energy. Thus rapid

muscle wasting will lead to sudden decline in body weight.

Extracellular Dehydration- Due to increase excretion of glucose by the kidneys there will

also be an increase in water excretion, osmosis diuresis occurs.

Intracellular Dehydration- Due to increase serum glucose, there is increase osmolarity,

osmosis occurs wherein intracellular fluids go into the interstitial space to the

intravascular.

Weakness and fatigue, dizziness- Due to the decrease glucose intake by the cells

leading to decrease energy production. Decreased plasma volume to postural

hypotension, potassium loss and protein catabolism contribute to weakness.

Blurring of vision- Due to viscosity of the blood, there would be increase intaoccular

pressure which makes the arteries in the retina become weakened and leak, forming,

dot-like hemorrhages. These leaking vessels often lead to swelling or edema in theretina and decreased vision.

Oliguria- this resulted from impairment in the selective permeability of the glomerulus.

The water together with other electrolytes are not excreted properly, these could lead

to water retention and therefore decrease in urine output. Another etiology is due


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shifting of blood from intravascular to interstitial, decrease in the intravascular fluid

decreases the blood supply to the kidney and therefore decrease in the filtration

capacity of the kidneys.

Headache- this is a complication of cerebral edema. Cerebral edema increases

intracranial pressure and therefore there is decrease functioning of the brain due to

congestion.

Ulcer formation- this is due to problems in the nutrients supply in the nerves leading to

altered nerve function which can lead to symmetrical loss of protective sensation that

the patient is unable to feel that he/she had already injured his/her body.

Abnormal Glycosylated Hemoglobin- when glucose is elevated, it attaches to the

hemoglobin. This test is very important to check for the compliance of the patient to

treatment since the life span of hemoglobin can last up to 120 days.

Glucosuria- this is a manifestation due to chronic elevation of glucose. When there is

too much glucose, it exceeds the renal threshold leading to urination in addition to the

osmotic diuretic effect of glucose.

Hypertension- this is caused by elevated glucose level. Glucose makes the blood more

viscous and therefore harder to pump leading to increase effort of the heart to pump

blood leading to elevated blood pressure.

Dehydration- this is caused by polyuria induced by elevated glucose levels that exceed

the renal threshold leading to loss of water in the plasma. This is manifested by dryness

of the skin and mucus membrane, altered LOC, weight loss and hemoconcentration.

Dysryhthmias- caused by sluggisg blood flow in the coronary arteries leading to

decrease blood flow in the SA node leading to altered conduction of the heart.


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Proteinuria and Hematuria- When diabetes leads to diabetic nepropathy, it could lead

to alteration in the selective permeability of the glomerulus leading to passage of large

molecules like protein and RBCs.

Anemia- When diabetes leads to diabetic nepropathy, it could lead to loss of

erythropoietin production causing decrease stimulation of RBC formation leading to

signs and symptoms associated with Anemia.

Hypocalcemia- this is due to decrease Vitamin D activation caused by diabetic

nephropathy leading to signs and symptoms of Hypocalcemia like Chvostek s sign and

Trousseau sign.


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PATHOPHYSIOLOGY

SCHEMATIC DIAGRAM (Patient-centered)

NON-MODIFIABLE FACTORS

Familial predisposition

Gender (Female)

Race (Asians)

MODIFIABLE FACTORS

Diet (High in carbohydrates)

Stress

Sedentary Lifestyle

Prolonged Increase in blood glucose Altered sensitivity of target tissues to insulin/

Resistance of target tissues to insulinCompensatory mechanism of beta cells to

increase insulin production and alpha cells to

decrease glucagon secretion

Beta cells exhaustion

Impaired transport of glucose by insulin to target

tissues (Insulin resistance)

Inability of fats and muscles to take up glucose

Limited beta cell

functions

Decrease sensitivity

of insulin to

lucose levels

A

B


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A B

Decrease in Insulin production

Impaired functions

of liver to store

excess glucose as

glycogen

Decrease glucose

utilization

Cell Starvation

Not enough energy is utilized

b the tissues

Stimulation of hypothalamus

that controls hunger

Compensatory mechanism of

liver by glycogenolysis

ATP is not

produced

Polyphagia

Weakness/ easy

Fatigability

Weight loss Dizziness

Continuous elevation of

glucose (hyperglycemia)

Chronic elevation in blood

glucose

Increase viscosity of blood

D

Glucose molecules

attaches to hemoglobin

Abnormal Glycosylated

hemoglobin

Increasedfat

metabolism

Accumulation

of ketones in

the

bloodstream

Metabolic Acidosis

Body compensates toreduce carbon dioxide in

the blood

Kussmauls

breathing resultingto increased

respiration


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Synthesis of the Disease

Etiology (Patient-centered)

Non-modifiable Factors:

Familial Predisposition- Type 2 DM has a strong genetic component. It is clear the

disease is polygenic and multifactorial still the major genes responsible for the

disease are not yet indentified. An individual with parents who has DM is at risk of

acquiring it. Also, genetic factors are thought to play a role in insulin resistance and

impaired insulin section in Type 2 DM (Black and Hawks, 2009). DM runs through the

bloodline of Candy.

Gender- Around the globe, it affects 62 million in men versus 73 million among

women. It is said to be the sixth leading cause of death among women in the UnitedStates. More of, Type 2 DM occurs in more women prior to having Gestational

Diabetes Mellitus of 25% to 50% compared with those going through pregnancy with

normal glucose tolerance (Black and Hawks, 2009). Candy is a female patient which

makes her at greater risk for Diabetes Mellitus.

Race- People with ethnic background such as African Americans, Native

Americans, Mexican Americans and Asian/ Pacific Islanders are those populations

who have high incidence of Type 2 DM (Black and Hawks, 2009). Candy is an Asian

population and a full-blooded Filipina.

Modifiable Factors:

Diet- Foods rich in carbohydrates can easily promote the increasing level of glucose

along the bloodstream which can contribute to having DM Type 2 while increase in

fat can lead to development of Obesity which is a major risk factor of insulinresistance (Black and Hawks, 2009). Candy loves to eat preserved foods like tocino

and longganisa. Rice is also a staple food in their family.

Stress- When an individual is stressed, his/her blood sugar levels rise. Stress hormones

like epinephrine and cortisol kick in since one of their major functions is to raise blood
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Polyphagia- Starvation secondary to tissue breakdown (catabolism) causing

hunger. And because the cells are not able to utilize glucose in the presence of

inadequate insulin level or resistance to insulin.

Weight loss- Due to insulin deficiency, glucose cannot enter into the cells, as a

compensatory mechanism, the liver would be stimulated to undergo

gluconeogenesis wherein the body will utilize proteins and fats in order to produce

energy. Thus rapid muscle wasting will lead to sudden decline in body weight.

Candy have narrated that she is even fatter when she was newly diagnosed with

Diabetes Mellitus.

Dizziness- Due to the decrease glucose intake by the cells leading to decrease

energy production. Decreased plasma volume to postural hypotension, potassium

loss and protein catabolism contribute to weakness. Patient reported dizziness

especially when moving and standing up.

Ulcer formation- This is due to problems in the nutrients supply in the nerves leading

to altered nerve function which can lead to symmetrical loss of protective sensation

that the patient is unable to feel that she had already injured her body.

Abnormal Glycosylated Hemoglobin- when glucose is elevated, it attaches to the

hemoglobin. This test is very important to check for the compliance of the patient to

treatment since the life span of hemoglobin can last up to 120 days. Candy s

HbA1C is 10% far from the normal 4.2-6.5%.

Glucosuria- this is a manifestation due to chronic elevation of glucose. When there istoo much glucose, it exceeds the renal threshold leading to urination in addition to

the osmotic diuretic effect of glucose. Patient reported that she always sees ants on

the urinary bowl upon urinating.


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Health Promotion and Preventive Aspects of the Disease

As a health care provider, the nurse should help his/her patients understand their

disease condition. As nurses, they should be more of the preventive aspects of the

disease not on the curative aspects. Health promotion and health education must be

the nurses primary inte rventions they should prioritize and they should prepare

beforehand or before they will encounter their patients.

Diabetes Mellitus Type 2 is a preventable disease since the risk factors are more of the

modifiable side. Nurses should provide them knowledge of living a healthy lifestyle.

Nurses should provide all the essential food constituents, inform the patient to achieve

and maintain an ideal body weight, meet energy needs, achieve more normal glucoselevels.

Also the patients must be educated in doing active range of motions. The nurse should

educate their patients to start from simple active ROM until to the patient s capacity in

doing these activities. Exercise is important in the management of DM since it lowers

blood glucose by increasing the uptake of glucose by body muscles and lowers lipids in

the blood. Also the patient is advised to maintain an ideal body weight and also the

patient should be educated about the medications prescribed to manage her

conditions.


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V. PATIENT AND HIS CARE

A. Medical Management

a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy , etc

i. Intravenous Fluids

Medical Management

Treatment

Date Ordered

Date(s)

Performed

Date Changed

General Description Indication or Purpose(s)Clients Response

to the treatment

PNSS 1L x

30-31gtts/min

Dated Ordered:

Date Changed:

Plain Normal Saline Solution or

PNSS (or 0.9% NaCl) is used

after blood transfusion

because it is the only

compatible diluent or'cleaner' after transfusion. Its

sole content of Sodium and

Chloride does not cause

blood reactions that may be

dangerous to the client.

An Isotonic solution that

provides Sodium,

Potassium, Chloride,

and Calcium and

Lactate. A solution thatexerts the same

osmotic pressure found

in plasma. This solution is

free from water and is

used to the patient to

The patient

maintained

hydration status

and was able to

comply with all ofhis medication

regimens.


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D5LRS for example is

discouraged as it has calcium

which is a clotting factor.

Introducing D5LRS after blood

transfusion may cause

massive thrombosis or

clotting.

correct hyponatremia

because this solution

contains smaller

amount of sodium.

NURSING RESPONSIBILITIES

IVF PNSS x 30-31 gtts/min

BEFORE

Verify the physician s order indicating the type of solution, the amount to be administered, the rate of flow of the

infusion and any allergies.

Explain the procedure and prepare the client Assess client s VS for baseline data, skin turgor, bleeding tendencies, disease or injury to the extremities, status of

vein to determine the appropriate puncture site.

DURING

Wash hands before proceeding with the procedure. Open and prepare infusion set and proceed with the procedures. Select the venipuncture site. Put on clean gloves and clean the venipuncture site before inserting the catheter

and initiating infusion. Tape the catheter properly.

Ensure appropriate infusion flow.


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AFTER

Apply a medication label on the solution if a medication is added. Document relevant data.

Monitor client s response. Check infusions at least every 2 hours to ensure that the indicated milliliters per hour have

infused and that IV patency is maintained.

Medical

Management

Treatment

Date Ordered

Date(s) Performed

Date Changed

General DescriptionIndication or

Purpose(s)

Clients Response to

the treatment

D5LRS 1L

x 30-31gtts/min

Date Ordered: Lactated Ringer s Solution in

5% of Dextrose is a hypertonic

solution which has an

effective osmolarity greater

than the body fluids. This pulls

the fluid into the vascular by

osmosis resulting in an

increase vascular volume. It

raises intravascular osmotic

pressure and provides fluid,

This is a treatment

for persons needing

extra calories who

cannot tolerate

fluid overload. It is

also a treatment of

shock.

The patient

maintained hydration

status and was able to

comply with all of his

medication regimens.

In some cases, the

patient manifested

swelling on IV insertion

site.


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AFTER

Apply a medication label on the solution if a medication is added. Document relevant data.

Monitor client s response. Check infusions at least every 2 hours to ensure that the indicated milliliters per hour have

infused and that IV patency is maintained.

b. Drugs

Name of Drug

Generic

(Brand)

Date Ordered

Date

taken/given

Date Changed

Route of Admin.

Dosage

Frequency of Admin

Gen. Action, functional classification,

mechanism of action

Clients response to

the medication with

actual side effect

metoclopram

ide

Date Ordered:

1.31.13 IV 1amp

q 8 for PRN for nauseaand vomiting

Metoclopramide inhibits gastric smooth

muscle relaxation produced by

dopamine, therefore increasingcholinergic response of the

gastrointestinal smooth muscle. It

accelerates intestinal transit and gastric

emptying by preventing relaxation of

gastric body and increasing the phasic

The patient did not

manifest any side

effects as iteradicates the

patient s feeling of

nauseated.


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activity of antrum. Simultaneously, this

action is accompanied by relaxation of

the upper small intestine, resulting in an

improved coordination between the

body and antrum of the stomach and

the upper small intestine.

Metoclopramide also decreases reflux

into the esophagus by increasing the

resting pressure of the lower esophageal

sphincter and improves acid clearance

from the esophagus by increasing

amplitude of esophageal peristaltic

contractions. Metoclopramide's

dopamine antagonist action raises the

threshold of activity in the

chemoreceptor trigger zone and

decreases the input from afferent

visceral nerves. Studies have also shown

that high doses of metoclopramide can

antagonize 5-hydroxytryptamine (5-HT)

receptors in the peripheral nervous


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system in animals.


Before

-Observe 15 rights in drug administration.

- Assess for allergy to metoclopramide

. - Assess for other contraindications.

- Keep diphenhydramine injection readily available in case extrapyramidal reactions occur (50 mg IM).

- Have phentolamine readily available incase of hypertensive crisis.

During

- Monitor BP carefully during IVadministration.

- Monitor for extrapyramidal reactions, and consult physician if they occur.

- Monitor diabetic patients. - Give direct IV doses slowly over 1-2minutes.

- For IV infusion, give over at least 15minutes.

After

- Dispose of used materials properly.

- Educate patient about side effects.

- Instruct to report involuntary movement of the face, eyes, or limbs, severe depression, and severe diarrhea.

- Instruct patient to take drug exactly as prescribed.


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- Instruct not to use alcohol, sleep remedies or sedatives; serious sedation could occur.

- Do proper documentation.

Name of DrugGeneric(Brand)

Date OrderedDate

taken/given

Date Changed

Route of Admin.Dosage

Frequency of Admin

Gen. Action, functional classification,mechanism of action

Clients response to themedication with actual

side effect

Omeprazole Date Ordered:

1.31.13 40mg IV/ OD

Omeprazole suppresses gastric acid

secretion by specific inhibition of the

enzyme system hydrogen/potassium

adenosine triphosphatase (H +/K+ ATPase)

present on the secretory surface of the

gastric parietal cell.

The patient did not

manifest any allergic

reactions


BEFORE

1. Assess for any history of allergy pregnancy or lactation

2. Assess skin color and lesions, affect and orientation

3. Orient the patient about the drug to be given

4. Perform an abdominal and respiratory examination


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insulin 5 u PM 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 promotes uptake of carbohydrates, proteins, and fats inmost tissues. Also, insulin influences carbohydrate, protein, and fat

metabolism by stimulating protein and free fatty acid synthesis,

and by inhibiting release of free fatty acid from adipose cells.

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). Although

the liver does not require active glucose transport, insulin

increases hepatic glucose conversion to glycogen and

suppresses hepatic glucose output. Even though the actions ofexogenous insulin are identical to those of endogenous insulin, the

ability to negatively affect hepatic glucose output differs on a unit

per unit basis because a smaller quantity of an exogenous insulin

dose reaches the portal vein.

manifest any allergic

reactions or

hypoglycemia during

the administration of

the medication.


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Combination with protamine and low concentrations of zinc in

NPH insulin enhances the aggregation of insulin into dimers and

hexamers after subcutaneous injection; a depot is formed after

injection and the insulin is released slowly.


BEFORE

1. Explain the procedure to the patient and its side effects.

2. Use a tuberculin or insulin syringe for accuracy of measurements.

DURING

1. Administer only water and clear solution. Discoloration, turbidity, or unusual viscosity means deterioration or

contamination.

AFTER

2. Observe closely signs and symptoms of hyper- or hypoglycemia until dosage is established.

3. Be alert for signs of hypoglycemia which may indicate responsiveness has been regained and that a reduction in

the dosage is warranted.


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c. Diet

Type of Diet

Date ordered

Date Started

Date Changed

General DescriptionIndications or

Purpose(s)

Specific foods

taken

Clients response and

for reaction to the

diet

NPO

(Nothing Per

Orem)

No food in any form

( solid and

liquid)and will be

taken by mouth

None. The patient complied

by not eating or

having any food in

the mouth or per

Orem


BEFORE:

1. Check the doctor s order

2. Explain to the patient the importance of placing her on NPO.

3. Ask patient s preference that may be included in her diet list

4. Assure the fluid therapy when the patient is NPO


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5. Instruct the patients SO not to give anything through the mouth.

DURING:

1. Assure that nothing is taken through mouth either liquid or solid

2. Assess the client condition

3. Place NPO sign on the bed where the patient can always see it

4. Remove foods and drinks on the patients side

AFTER:

1. Observe patients response to the diet

d. Diet

Type of Diet

Date ordered

Date Started

Date

Changed

General DescriptionIndications or

Purpose(s)

Specific foods

taken

Clients response and for

reaction to the diet

Diabetes

Mellitus (DM)

Diet

1.31.13 Diabetes Mellitus diet

or low caloric diet is a

diet composed of

decreased intake in

food containing high

calories

The purpose of a low

caloric diet is to

achieve a balance

between the numbers

of calories you

consume, the number

rice porridge The patient responded

well to his diet because

he was able to eat the

foods he likes and

control his blood sugar

as well.

8/13/2019 DIABETES MELITUS

diabetes melitus 2 dka

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