Ncp-dm-ii-part-2.docx

PATHOPHYSIOLOGY OF DIABETES MELLITUS TYPE II Mandal, M. D. (2016, June 20). Diabetes Pathophysiology. Retrieved November 03, 2017, from https://www.news-medical.net/health/Diabetes-Pathophysiology.aspx

Non Modifiable factors

Modifiable factors  Physical inactivity  Diet (High CHO)

 Family history  Age ( >40 y/o)  Race (Filipino)

Destruction of beta- cells in the pancreas Insulin resistance

Failure to produce insulin Hct: 0.30 mg/dl Hgb: 101 mg/dl

Continued hepatic glucose production

Decrease glucose utilization

hyperglycemia Increase fat metabolism

Decreased transportation of glucose across cell membranes

Increase body lipid levels LDL: 167 mg/dl

Protein utilization Amino acids converted into glucose

level: 333 mg/dl

Increase renal threshold of glucose

Decreased blood flow in the extremities

Increase glucose filtered in the urine leading to increase oncotic pressure.

Decreased ATP Wasting of lean body mass Fatigue

Glucose

Polyphagi a

Polyuria Poor wound healing

Decrease blood flow Weight loss

Polydipsia

Production of glucose Poor wound healing

Weight loss Dx: Imbalanced nutrition: less than body requirements

Impaired skin integrity Pain r/t tissue trauma Risk for infection Fatigue

CUES

Disease Process: DM type II Subjective data:  “Hindi na sya ganon kalakas kumain, pakonti ng pakonti yung kinakain nya.” Claimed by the husband  Weight loss as documented in the chart.

Objective data:  Patient is seem to have dry mucous membranes, poor capillary refill, poor muscle tone, fatigability and slurring of words, NSG DX: Imbalanced Nutrition: less than body requirements

EXPLANATION OF THE PROBLEM Type 2 diabetes is characterized by a combination of peripheral insulin resistance and inadequate insulin secretion by pancreatic beta cells. Insulin resistance, which has been attributed to elevated levels of free fatty acids and proinflammatory cytokines in plasma, leads to decreased glucose transport into muscle cells, elevated hepatic glucose production, and increased breakdown of fat. A role for excess glucagon cannot be underestimated; indeed, type 2 diabetes

GOALS AND OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION CRITERIA

Long term: After 3 days of nursing interventions, patient will manifest weight gain as evidenced Absence p

Administer regular insulin by intermittent or continuous IV method: IV bolus followed by a continuous drip via pump of approximately 5–10 U/hr so that glucose is reduced by 50 mg/dL/hr.

Fully met if: absence of edema on the hand Partially met: still with edema but increase food intake. Not met: gaining weight everyday as evidence by increase edema.

Short term:  After 8 hrs of nursing intervention, the patient will demonstrate hydrated skin.

Administer glucose solutions: dextrose and half-normal saline.

Regular insulin has a rapid onset and thus quickly helps move glucose into cells. The IV route is the initial route of choice because absorption from subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate transition to carbohydrate metabolism and reduce incidence of hypoglycemia. Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia

Fully met: all mcous membranes are moisten and well hydrated. Partially me: still with cracked skin but some mucous membranes are moistened. Not met: dehydration occur

ACTUAL EVALUATION

related to insulin insufficiency



After 8 hours of nsg interventions patient will have an increase tolerance of food as manifested by disconnecting the ngt. Administer other medications as indicated.

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After 8 hours of nursing interventions, client will demonstrate lifestyle changes.

Observe for signs of hypoglycemia: changes in LOC, cold and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness.

May be useful in treating symptoms related to autonomic neuropathies affecting GI tract, thus enhancing oral intake and absorption of nutrients. Hypoglycemia can occur once blood glucose level is reduced and carbohydrate metabolism resumes and insulin is being given. If the patient is comatose, hypoglycemia may occur without notable change in LOC. This potentially life-threatening emergency should be assessed and treated quickly per protocol. Note: Type

Fully met: ngt is removed as evidenced by food is tolerated by patient when offered by mouth. Partially met: NGT is still inserted but there is an increase intake through it. Not met: Case worsen and increased demand or need of NGT.

Fully met: Able to do diet plan for diabetes and strictly follow it as evidenced by eating behaviors and habits. Partially met: Still demand for unhealthy foods but strictly observing moderation. Not me: didn’t made any modification in the diet and lifestyle.

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After 8 hours of nursing interventions, client will manifest normalization of blood glucose level within range of 80/120 mg/dl

Auscultate bowel sounds. Note reports of abdominal pain, bloating, nausea, vomiting of undigested food. Maintain NPO status as indicated.

1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished. Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility and/or function (due to distention or ileus) affecting choice of interventions. Note: Chronic difficulties with decreased gastric emptying time and poor intestinal motility may suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment.

Fully met: Blood sugar level within range of 80/120 mg/dl. Partially met: Bloof sugar level is moderately high within the range of 150-200 mg/dl. Not met: Blood sugar is very high. 200 and above.

Weigh daily or as ordered.

Ascertain patient’s dietary program and usual pattern then compare with the recent intake. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids then progress to a more solid food as tolerated. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals and snacks.

Weighing serves as an assessment tool to determine the adequacy of nutritional intake. Identifies deficits and deviations from therapeutic needs.

Oral route is preferred when patient is alert and bowel function is restored.

Complex carbohydrates (apples, broccoli, peas, dried beads, carrots, peas, oats) decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics and individual patient

Identify food preferences, including ethnic and cultural needs.

Include SO in meal planning as indicated.

response. Note: A snack at bedtime of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response. If patient’s food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge. To promote sense of involvement and provide information to the SO to understand the nutritional needs of the patient. Note: Various methods available or dietary planning include exchange list, point system, glycemic index, or pre selected menus.

Consult dietician and/or physician for further assessment and recommendation regarding food preferences and nutritional support.

To reveal changes that should be made in the client’s dietary intake. For greater understanding and further assessment of specific foods.

CUES

EXPLANATION OF THE PROBLEM

Disease condition: Type 2 diabetes is Diabetes Mellitus type characterized by a II combination of peripheral insulin resistance and inadequate insulin Subjective data:  Patient diagnosed secretion by pancreatic with dm type II beta cells. Insulin and chronic renal resistance, which has insufficiency. been attributed to  Significant other elevated levels of free report a decreased fatty acids and verbal output. proinflammatory  Hgb: 101 mg/dl, cytokines in plasma, hct: 0.30 mg/dl, leads to decreased LDL: 163 mg/dl glucose transport into  Patient received muscle cells, elevated whole packed of hepatic glucose blood last production, and October 31. increased breakdown of fat. Objective data:  Patient is with A role for excess pitting edema glucagon cannot be grade 1+ on both underestimated; hands.  With wound on theright foot draining with

GOALS AND OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION CRITERIA

Long term: Patient’s fluid and electrolyte balance will be stabilized and intake and output will reach an approximate balance over a span of 72 hours as evidenced by decreased peripheral edema, decreased signs of dyspnea, and patient verbalizing doesn’t feel breathlessness.

Review patient’s history to determine the probable cause of the fluid imbalance.

Such information can assist to direct management. History may include increased fluids or sodium intake.

Short term:

Monitor weight regularly using the same scale and preferably at the same time of day wearing the same amount of clothing.

Sudden weight gain may mean fluid retention. Different scales and clothing may show false weight inconsistencies.

Fully met: patient is able to reach the target input and output, absence of edema and regular breathing. Partially met: she is back to feeling of normal, which includes feeling short of air, deep breathing, and use of accessory muscles and belly to breathe, however is still retaining large volumes of fluid. Not met: conditions didn’t get any better. Fully met: olume as evidenced by weight loss, decreased peripheral edema, clear lung sounds, and normal heart



After 8 hours of nursing interventions, patient will demonstrate

ACTUAL EVALUATION

purulent discharges.  Seen to have dry mucous membranes Nursing dx: Excess fluid volume related to compromised regulatory mechanism



reduced extracellular fluid volume as evidenced weight loss, decreased peripheral edema, clear lung sounds, and normal heart sounds each day until discharge.

Monitor input and output closely.

Dehydration may be the result of fluid shifting even if overall fluid intake is adequate.

After 2 days of NSG interventions, patient’s complication will be prevented or minimized by discharge date was met.

Assess weight in relation to nutritional status.

In some patient with heart failure, the weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.

Record intake if patient is on fluid restriction.

sounds each day until discharge was partially met. The patients lung sounds were clear, and heart regular rhythm despite rate being high at times Partially met: Still with edema. Not met: edema worsen.

Fully met: patient is discharged with normal and stabilized glucose level and without any complications such as infection. Partially met: With risk for complication but can be prevented with drugs and interventions. Not met: Complication cannot be Patients should be prevented, arised reminded to include items that are liquid at as a new problem room temperature such thereby causing an extension to ward as gelatin, sherbet, soup, and frozen juice confinement. pops.

Monitor and note BP and HR.

Sinus tachycardia and increased BP are evident in early stages.

Review chest x-ray reports.

The x-ray studies show cloudy white lung fields as interstitial edema accumulates.

Assess urine output in response to diuretic therapy.

Recording two voids versus six voids after a diuretic medication may provide more useful information. Medications may be given intravenously because FVE in the abdomen may interfere with absorption of oral diuretic medications.

Note for presence of edema by palpating over the tibia, ankles, feet, and sacrum.

Edema occurs when fluid accumulates in the extravascular spaces. Dependent areas more readily exhibit signs of edema formation. Edema is graded from trace (indicating barely perceptible) to 4 (severe edema). Pitting edema is

manifested by a depression that remains after one’s finger is pressed over an edematous area and then removed. Measurement of an extremity with a measuring tape is another method of the following edema. Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and orthopnea.

These signs are caused by an accumulation of fluid in the lungs.

Assess for bounding peripheral pulses and S3.

These assessment findings are signs of fluid overload.

Check for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately.

Distended neck veins are caused by elevated CVP. Ascites occurs when fluid accumulates in extravascular spaces.

Review serum electrolytes, urineos molality, and urine specific gravity.

All are indicators of fluid status and guide therapy.

Consider the need for an external or indwelling urinary catheter.

Treatment focuses on diuresis of excess fluid. Urinary catheters provide a more accurate measurement of the response to diuretics.

Check for excessive response to diuretics.

Significantly increased response to diuretics may lead to the fluid deficit.

Instruct patient, caregiver, and family members regarding fluid restrictions, as appropriate.

Information and knowledge about condition are vital to patients who will be co-managing fluids.

Limit sodium intake as prescribed.

Restriction of sodium aids in decreasing fluid retention

Monitor fluid intake.

This enhances compliance with the regimen.

Take diuretics as prescribed.

Diuretics aids in the excretion of excess body fluids.

Elevate edematous extremities, and handle with care.

Elevation increases venous return to the heart and, in turn, decreases edema. Edematous skin is more susceptible to injury.

Consider interventions related to specific etiological factors (e.g., inotropic medications for heart failure, paracentesis for liver disease).

Knowledge of etiological factors gives direction for subsequent interventions.

Educate patient and family members regarding fluid volume excess and its causes.

Information is key to managing problems.

Explain rationale and intended effect of the treatment program.

Follow-up care will be the patient’s or caregiver’s responsibility. Information is necessary to make correct choices in the future.

Educate patient and family members the importance of proper nutrition, hydration, and diet modification.

Knowledge heightens compliance with the treatment plan.