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PRESENTED TO: MRS. DOLORES S. MALOLES RN,MSN PRESENTED BY:

Ayala, Mhel Marjorie Ayala, Rose Ann Banta, Kathleen Molina, Mariel Santos, Kim Genesis

OBJECTIVES OF THE CASE PRESENTATION General Objective:

At the end of the presentation, it is critically important that the students are expected to gain the necessary information regarding Diabetes Mellitus for them to determine the appropriate nursing care management they should provide to those patients having this kind of illness. In addition, students will help the patient to work toward adapting to life with a chronic condition.

SPECIFIC OBJECTIVES: The students will be able to: Understand the nature of DIABETES MELLITUS.  Differentiate between type 1 and type 2 diabetes.  Distinguishes its clinical manifestations and predisposing factors.  Outline the Anatomy and Physiology, as well as its Pathophysiology of the disease or condition. 

 Determine

the health status of the patient through: Knowing the past history and present illnesses of the patient of the patient as well as their family health history.  Conducting physical examinations. 



Analyzing the laboratory examination done and correlate it to the present condition of the patient.

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Determine the appropriate nursing care that should be provided to the client.

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Understand the different drugs that the client is taking and determine how it will benefit the client as well as the possible adverse effect it may give.

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Create a good and a therapeutic nursepatient interaction.

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Teach the client’s relatives on how to minimize the risk developing DIABETES MELLITUS.

OVERVIEW: DIABETES MILLETUS is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from abnormal endocrine secretion by the pancreas (either an absolute or relative insulin sufficiency), an insufficient number of insulin receptor sites on cell, a postreceptor defects, or a combination of abnormalities, alters the metabolism of food. Eventually, structural abnormalities develop in a number of different body tissues. The four general components of diabetes are hyperglycemia, large blood vessel (macrovascular) dse., small blood vessel (microvascular) dse., and neuropathy. A useful definition of diabetes is symptomatic (polyuria, polydipsia, and polyphagia) or asymptomatic state of altered CHON, CHO, and fat metabolism.

Normally a certain amount of glucose circulates in blood. The major sources of glucose are absorption of ingested food in the gastrointestinal (GI) tract and formation of glucose by liver from substances and stored as glycogen. The blood glucose level is consistently monitored by cells of the islet of the langerhans of the pancreas. If the concentration of glucose in the bloodstream begins to increase, more insulin is secreted by the beta cells of the islet of the langerhans and blood glucose level decrease as the excess glucose is converted to glycogen. Conversely, if glucose level decrease, the alpha cells in the islet secrets glucagon, which increase the blood glucose level by stimulating the liver by releasing the glycogen. The release of glycogen is converted to glucose to maintain blood glucose levels within the

Insulin

a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. In the diabetic state, the cell may stop responding to insulin or the pancreas may stop producing insulin entirely.

SIGNS AND SYMPTOMS 

lethargy

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polyuria, polydipsia and polyphagia

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sudden weight loss

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slow wound healing

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urinary tract infections

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gum disease

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blurred vision

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Irreducible mental fatigue

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Numbness of the hand and feet

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Feeling of tiredness much of the times

CLASSIFICATIONS: ☺

Type 1 Diabetes (insulin dependent diabetes mellitus)

☺

Type 2 Diabetes (non insulin dependent diabetes mellitus)

☺

Gestational diabetes mellitus

☺

Diabetes mellitus associated with other conditions or syndrome.

INDIVIDUALS WHO ARE AT HIGH RISK OF DEVELOPING TYPE II DIABETES MELLITUS INCLUDE PEOPLE WHO:     

 



 

obesity have a relative with diabetes mellitus belong to a high-risk ethnic Pregnancy have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg) have high blood have a high density lipoprotein cholesterol level and/or triglyceride have had impaired glucose tolerance or impaired fasting glucose on previous testing Physiologic or emotional stress Some medication

DIAGNOSTIC TESTS ♠

Random blood glucose test — for a random blood glucose test, blood can be drawn at any time throughout the day, regardless of when the person last ate. A random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose suggests a diagnosis of diabetes.

♠

Fasting blood glucose test — fasting blood glucose testing involves measuring blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to

♠

Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose control in people with known diabetes, but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6 percent. The test is done by taking a small sample of blood from a vein or fingertip.

♠

Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) is the most sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended because it is inconvenient compared to a fasting blood glucose test.

PREVENTION:  Restrict

eating sweet foods  Limit CHO intake  Eat a nutritious balanced diet  Have a good healthy lifestyle  Exercise daily  Avoid drinking and smoking  Have a regular blood glucose monitoring

TREATMENT AND MANAGEMENT: Have a combination of nutritious diet, exercise and weight loss  Provide supplement e.g. insulin  Oral herb medications such as aloe vera and bitter melon  Enhance lifestyle modifications  Control glucose intake  Peer support  Have a special care for any complications e.g. wound 

PERSONAL DATA Name: Mrs. ER Age: 83 y/o Gender: Female Address: Lucena City Nationality: Filipino Religion: Roman Catholic Birthday: March 19, 1926 Room# 5302 Attending Physician: Dra. Canela Chief Complaints: Fever and chills Admitting Diagnosis: T/C Viremia Final Diagnosis: UTI, CHF 2º to CAD & HASCVD, Anemia

PAST & PRESENT HEALTH HISTORY Present health history: Prior to admission with 6 days of moderately high grade fever then late accompanied by fever, and chills. Past health history: General health ♥ The patient was conscious and coherent. Pale in appearance, with body weakness and in respiratory distress. Childhood Illness: ♥ The only illness she experienced was common colds, cough, and fever. Immunization ♥ Incomplete immunization Hospitalization ♥ Patient hospitalized during her teenage years due to appendectomy in Quezon Medical Center, H-mole surgery on 1992 at MCDGH, DM was diagnosed on 1995, and stroke on 1999.

Current Medications Her current medications are: Tempra Forte, Sodium Chloride, Lactulose, Humulin, Furosimide, Serc, Iberet, Catarstat, Captopril, Clopidogrel, Bactobran, Digoxin, Bumetanide, Ciprofloxasin, Kalium Durule, Zynapse.

Allergies ♂ No

known allergies 

Habits ♂ Eating

sweet foods

Family History Mother

Father Patient

Daughter

Daughter

Husband Son

Daughter

Daughter

LEGEND: DIABETES MELLITUS

HYPERTENSION

HYPERTENTION AND DIABETIS

Nutritional-Metabolic Pattern  Appetite:

poor  Usual daily menu: rice, pork/fish and vegetables  Metabolic: weight loss

Elimination Pattern  The

client defecates once a day  The client voids four times a day

Activity/Exercise  Impaired

range of motion

Oxygenation/Perfusion  with

ineffective breathing pattern.  With oxygen @ 2:31pm.

PHYSICAL ASSESSMENT

General Appearance  Body built is appropriate to age  No body odor  In respiratory distress Skin  Pallor skin  With dry skin  With fair skin turgor  With bed sore approximately 3cm wide in left posterior gluteal muscle

Hair  Black and short hair  Equally distributed on scalp  Without tenderness or lesion on scalp Nails  With long finger and toe nails  With 3secs capillary refill

Skull and Face  Skull is proportionate to body size  Normochepalic  Smooth skull contour  Without masses or nodules  Symmetrical facial grimace Eyes  Eyebrows and eyelashes evenly distributed  With pale conjunctiva  No swelling or tenderness in lacrimal glands  Symmetric eyeballs, with equal size of pupils and white sclera  Pupils equally dilated reacted to light  Blurred vision at times

Ears  Color same as facial skin  With symmetrical auricle position and size  With elastic auricle  Without discharge Nose  Symmetrical  Without nasal secretions  Without tenderness  With pinkish mucosa

Mouth  With slightly dry lips  With permanent teeth Neck  Neck muscle proportionate to body size  With normal range  With palpable lymph nodes

Chest  With symmetrical chest wall expansion  In respiratory distress  With normal and clear breath sounds  With normal heart sounds Abdomen  With soft abdomen upon palpation Lower Extremities  not edematous legs and feet

ANATOMY AND PHYSIOLOGY

Pancreas The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin , as well as an exocrine gland, secreting pancreatic juice containing digestive enzymes that pass to the small intestine. These enzymes help in the further breakdown of the carbohydrates, protein, and fat in the chyme.

Under a microscope, stained sections of the pancreas reveal two different types of parenchymal tissue. Lightly staining clusters of cells are called islets of Langerhans, which produce hormones that underlie the endocrine functions of the pancreas. Darker staining cells form acini connected to ducts. Acinar cells belong to the exocrine pancreas and secrete digestive enzymes into the gut via a system of ducts. Structure

Appearance

Function

Islets of Langerhans

Lightly staining, large, spherical clusters

Hormone production and secretion ( endocrine pancreas)

Pancreatic acini

Darker staining, small, berry-like clusters

Digestive enzyme production and secretion ( exocrine pancreas)

Functions The pancreas is a dual-function gland, having features of both endocrine and exocrine glands. Endocrine The part of the pancreas with endocrine function is made up of approximately a million cell clusters called islets of Langerhans. There are four main cell types in the islets. They are relatively difficult to distinguish using standard staining techniques, but they can be classified by their secretion: glucagon, insulin, somatostatin, and PP cells secrete pancreatic polypeptide. The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes or by direct apposition. The islets are busily manufacturing their hormone and generally disregarding the pancreatic cells all around them, as though they were located in some completely different part of the body.

Exocrine 

In contrast to the endocrine pancreas, which secretes hormones into the blood, the exocrine pancreas produces digestive enzymes and an alkaline fluid, and secretes them into the small intestine through a system of exocrine ducts in response to the small intestine hormones secretin and cholecystokinin. Digestive enzymes include trypsin, chymotrypsin, pancreatic lipase, and pancreatic amylase, and are produced and secreted by acinar cells of the exocrine pancreas. Specific cells that line the pancreatic ducts, called centroacinar cells, secrete a bicarbonate- and salt-rich solution into the small intestine]

Regulation 

The pancreas receives regulatory innervation via hormones in the blood and through the autonomic nervous system. These two inputs regulate the secretory activity of the pancreas.

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

decreases secretion from beta cells, increases secretion from alpha cells

increases stimulation from alpha cells and beta cell

PATHOPHYSIOLOG Y

COURSE IN THE WARD

The patient was admitted last July 1, 2009 at the Emergency Room of Mt. Carmel Diocesan General Hospital under Dra. Canela, attending to the chief complaint of 6 days fever and chills. The following orders were given: ordered DM diet, CBC, urinalysis, NA, K exam, plain NSS 1Lx12hrs, ECG, to start TEMPRA FORTE 1tab every 4 hrs. 

1:30 am through verbal order of Dr. Custodio to NOD, give humolin R “u” SQ now, for repeat RBS after 1 hr., urinalysis, urine c & s now acquire sample by straight catch, spot oxygen check, RBS, BUN, creatinine, AST, ALT serum NA, same IVF to follow, medications starts given were: NACL tab 1tab TID, Ciprofloxacin (ciprobax XR) 500mg tab 1 tab OD, start lactalose 30ml OD HS, fecalysis to include exam for occult blood, humulin R 4 “u” SQ now, monitor RBS TID ac, refer to Dr. Edwin Dayahan for DM.



6:45 pm may give serc 8mg 1tab, 1tab now + dizziness

o

On July 2 ordered to continue RBS, insulin same done frequency, at 10am verbal order of Dra. Guinto to NOD, same IVF to follow PNSS 1Lx 2hrs, erythropoietin 4,000 “V” (RENOGEN) SQ stat dose only, start Furosemide (LASIX) 40mg tab ½ tab OD, refer to Dra. Grace Sy for optha evalis, same IVF to follow, continue O2 inhalation at 2LPM via nasal cannula, if ok with Dra. Canela and patient please refer to Dra. Alba,



6pm phone order of Dra. Canela to NOD, please refer to Dra. Alba, at the same time Dra. Alba had a phone order to NOD, OR will see patient, patient seen and examined, may give jerc 8mg tab every 8hrs for dizziness, please send to KM 18 (MAB) tom at 10am for cooperation of Optha Exam, refer PRN



7:59pm txt order by Dra. Canela to NOD, carry out suggestion of Dra. Alba.

o

On July 3 at 1:50am txt order by Dra. Canela to NOD, may give Dulcolax adult suppository per anum, continue manitor RBS same frequency, CXR-PA, spot O2 check, serum NA+ today, present IVF to consume, start from supplement 1 Beret Active 1tab OD, Furoremide 20mg now, at 4pm the patient unable to go to for completion of optha exam, refer PRN, resume Catarstat 1 drop 3x a day, present IVF to consume, spot O2 check.

o

On July 4 2D echo with Doppler study, spot O2 check, atrovent UDV nebulizer now, MGH anytime, Home Meds were CIPROBAX XR 500mg 1tab OD #5, NACL tab 1tab BID #60, FLURERAMIDE (LASIX) 40mg tab ½ tab OD q AM #30, DIGOXIN (LANOXIN) 0.25mg tab ½ tab OD q AM #30, IEBRET Active 1cup OD #30, ATROVENT UDV nebulizer BID #30,ERYTHROPOIETIN (RENOGEN) 4,000 “V” SQ injection stat dose only, refer discharge, continue meds, start CAPTOPRIL 25mg tab ¼ tab OD,



9:45pm textorder by Dra. Canela to NOD (insert d5w 1L x KVO)

o

ON July 5 continue meds, decrease Flureramide 40mg tab ½ tab BID, start CLOPIDOGREL 75mg tab (plavix) 1tab OD.

o

On July 6 Verbal Order of Dra Canella to NOD same IV fluids to Follow D5W 1L x KVO, expose pressure sort air dry apply BACTROBAN ointment BID, start DIGOXIN (lanoxin) 0.25mg ½ tab OD



On July 7 the Doctor ordered to continue the meds at the same dose, ordered some procedure like CBC, CREATININE, NA+, RBS, K+, TP, A/G now, strict aspiration, precaution please, strict turning sched, include 3 eggwhites in patient diet, and to D/C FLURORIMIDE, BUMETAMIDE (blurirex) 1mg tab 1tab BID, chest pain: PO of Dra. G Reyes to NOD that the patient amy give ISODRIL 5mg / 1tab now, repeat ECG, once with chest pain, give high Biologic Value, protein in diet



On July 9 Dra. Guinto ordered the same IVF to follow D5W KVO, to continue meds with the same dose, advice NGT insertion for Tube feedings,



On July 10 at 1am VO by Dra. Guinto to NOD same IVF to follow D5W KVO, refer to Dr. Gerard Salazar for Neuroconsult and NGT, insert NGT, tube start of 1000 KCAL/day with egg whites / high biologic value protein devided into 6 equal feedings, on the same date the Dr. ordered to continue meds/ NGT incorporate ZUCOVIAMINE S2 to present IVF, CONSUME CIPROBAX XR, pullout NGT and refuse insertion, continue diet and meds per orem



On July 11 Strict turning scheds, exposed pressure sore all the time, and to continue meds,



On July 12 Dra. Canella Important cinsider new cerebral infarction on the L MCA disturbation have been precepatated by her current infection, suggest do Cranial CT SCAN, plainm tom am, zynapse 1g / IV q 8, observe strict aspiration prec. When feeding, hold IBERET ACTIVE AND SERC, start Erythropoietin (RENOGEN) 4,000 “U” SQ, 2x/week, IVF to follow PNSS,1L + MOVIAMIN S2 KVO, carry out, suggestion of

Dr. Salazar.



On July 13 the Doctor ordered to continue monitoring RBS , same dose & frequency, relay CT SCAN result to DR. Salazar, spot O2 check, CBC serum Creatinine, NA+, K+ in am cranial CT SCAN noted, old THALAMI INFARCT R, NEW CORONA RADEATH INFARCT L (PEREVENTICULAR)., The Doctor also ordered to elevate head to 30 degrees and to continue zynapse; clopodogrel



On July 14 , the Doctor suggest kalium DUROL TID,

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11:30 V.O by Dra. Reyes to NOD same IV fluids to follow plain NSS 1L=MS2 x KVO.

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On July 15 the doctor ordered to continue meds and IVF, spot O2 check



On July 16 the doctor ordered to continue meds and IVF and possible Discharge once ok with Dr. Salazar.

NURSING CARE PLAN

DRUG STUDY

LABORATORY INTERPRETATION LABORATORY TEST

RESULT

Crea

NORMAL RANGE

0.5-1.5 mg/dL

July 2 – 1.1 July 5 – .8

K+

July 1 - 4.8 July 4 - 3.7 July 5 - 2.9

3.5-5.0 mEq/L

INTERPRETATION

HIGHER: impaired renal function, dehydration, cancer, heart failure, shock LOWER : decreased mucous muscle mss (e.g., myasthenia gravis, muscular dystrophy), debilation HIGHER: acidosis, daibetic ketoacidosis, hypoaldestrionsm, assive crshing tissue disfunction, rnal failure use of pottasiumsparring diuretics. LOWER: alkalosis, cushing’s syndrome, diarrhea (severe) diuretic therapy, GI fistula, pyloric obstruction, starvation, vomiting, alcoholism, burns.

LABORATORY INTERPRETATION LABORATORY TEST

Na+

RESULT

July 1 – 124

NORMAL RANGE

INTERPRETATION

136-145 mEq/L

HIGHER: Cushing’s syndrome, dehydration, diabetis, incipidus, excessice IV sodium, insufficient water intake, impaired renal fucntion LOWER: severe burns, addison’s disease, diabetic ketoacidosis, diuretic therapy, excessive gastrointestinal tract loss, water intoxication. Higher: dehydration, eclampsia, high altitudes, polycythemia, congenital heart disease, burns. LOWER:anemia, bone mwrrow dysfunction, cirrhosis, hemorrhage hemolytic reactions, leukemia.

July 2 – 129 July 3 – 132 July 4 – 133 July 5 – 139 Hematocrit

July 1 - .29

M: 42 – 52 vol. %

July 4 - 0.30

F: 37 – 47 vol. %

July 5 - .31

LABORATORY INTERPRETATION LABORATORY TEST

HgB

RESULT

July 1 - 9.7 July 4 - 10.4

NORMAL RANGE

INTERPRETATION

M- 14-18.0 g/dL F- 12.0-16.0 g/dL

HIGHER:Chronic obstructive pulmonary disease (COPD), heart failure, hemoconcentration, high altitudes, polycythemia.

July 5 - 10.30

WBC

July 1 - 8.95 July 4 - 10.5 July 5 - 7.01

LOWER:hemolytic reactions, hemorrhage, iron deficiency anemia, renal disease, sickle cell disease, synthemic dupuss erythematozus. 5-10,000/ uL

Higher:inflammatory and infectious process, leukemia, tissue necrosis. LOWER: bone marrow failure, chemotherapy, drug toxicity, overwhelming infection, autoimmune disease

LABORATORY INTERPRETATION LABORATORY TEST

Segments

RESULT

July 1 - 0.60

NORMAL RANGE

INTERPRETATION

50-65%

HIGHER: Cushing’s syndrome, eclampsia, gout, inflammatory disease, ketoacidoses, myelocytic, leukemia, stress acute infection.

July 4 - .72 July 5 - 0.84

Lymphocyte

July 1 - 0.40 July 4 - 0.28 July 5 - 0.16

20%-40%

LOWER: addison’s disease, aplastic anemia, overwhelming infection, radiation therapy. HIGHER: chronic infections, hepatitis, lymphocytic leukemia, mononucleosis, multiple myeloma, viral infections.

LABORATORY INTERPRETATION CT Scan Impression:  Old Thalamic Infarct Right  Generalized Athropy Cardiac Evaluation Interpretation: 







Eccentric left ventricle with hypokinesia of all left ventricular segments except for the posterobasal and basal lateral left ventricular free wall. There is Doppler evidence of reduced systolic and diastolic compliance. Normal right ventricular dimension with adequate wall motion and contractility. Dilated left atrial dimension.







 

Thickened mitral valve leaflets and chordae with low flow configuration; mitral annular calcification. Calcified aortic cusps with slight restriction of motion; aortic annular calcification. Structurally normal tricuspid valve and pulmonic valve with good opening and closing motion. Normal main pulmonary artery and aortic root dimension. Calcified antero-postero aortic wall.

Chest X-ray Roentgenological Report Impression: 

Atheromatous aortic knob.

DISCHARGE PLAN Make sure the pt. and family have information on referrals for follow-up counseling.  Determine evaluation needs to be made before the pt. is discharged or leaves the agency .  Determine the appropriate quantities of the prescribed medications to lend home with the pt. 

HEALTH TEACHINGS Inform the patient the importance of follow-up appointments  Promotion of health from illness.  Healing process from treatment. Encourage communication of patient  Assess the motional state of the patient, self-esteem, confirming or justifying any fears patient may have concerning recurrences of cancer.  Have patient talk about activities they enjoyed before treatment.  Explain they are getting their life back while adapting to reality of having cancer and possibilities of recurrences.  Encourage patient to perform range of motion exercise in the affected parts as frequently as the patient’s condition warrants limit.

OUT PATIENT DISCHARGE 

Follow-up check-up in the outpatient department.

Diet 

High fiber, low-fat, low salt, and low sugar diet.

Thank You!!!!