I.

INTRODUCTION

Diabetes mellitus it is the group of metabolic disease characterized by elevated level of glucose in the blood (hyperglycemia) resulting from defect in insulin secretion, insulin action or both. Normally a certain amount of glucose circulates in the blood. The major source of this glucose is the absorption of ingested food in the GI tract and formation of glucose by the liver from food substances. Diabetes mellitus (commonly called diabetes) is a condition found in 16 million Filipinos. About half of these people do not know they have diabetes and are not under care for the disorder. Diabetes is not a single disease but rather a syndrome of hyperglycemia and glycosuria, accompanied by varying degrees of ketosis and acidosis, with or without weight loss. It has several causes and mechanisms of inheritance. As diabetes is a condition characterized by metabolic abnormalities (the most evident is hyperglycemia, an elevated concentration of glucose in the blood), the treatment of it must also prevent or reduce the risk and severity of other long term complications involving multiple organs, the eyes, kidneys, nerves and blood vessels. These complications result from a deficiency of the hormone insulin or a reduction in the effectiveness of insulin. The longer the duration of diabetes, and the worse the long-term blood glucose control, the more likely are the complications to occur. There are two major forms of diabetes: Type 1, insulin-dependent (IDDM), and Type 2, non insulin dependent (NIDDM). Type 1 diabetes is characterized by an absolute deficiency of insulin caused by beta-cell destruction of the Islets of Langerhans in the pancreas. Type I diabetes usually appears before the age 40. Typical symptoms are thirst, fatigue, cramps, excessive urination, increased appetite, and weight

loss.Treatment requires administration of insulin, diet coordinated with insulin dosage schedule, and regular physical exercise. Dietary treatment is primary

therapy in Type 2 diabetes and is vital treatment to Type I diabetes. Presently, there is no known method to prevent the development of this form of the disease. Type 2 diabetes, usually appears in midlife, among people who are overweight or obese. Its onset is gradual, and many people have a long history of mild symptoms, or display no symptoms at all. In type 2 diabetes, the pancreas usually produces insulin, but for some reason, the body cannot use the insulin effectively. The end result is the same as for type 1 diabetes--an unhealthy buildup of glucose in the blood and an inability of the body to make efficient use of its main source of fuel. Obesity is strongly associated with the onset and severity of Type 2 diabetes. New cases of this condition can be reduced by approximately half by preventing obesity in middle-aged adults. The risk of diabetes increases with the degree of obesity and its duration, as well as the distribution of body fat; upper body fat is more associated with Type 2 diabetes than is lower body fat. Significant caloric reduction lowers blood glucose levels even before weight loss occurs. Once desirable weight is achieved, control of blood sugar levels can be accomplished by consuming just enough energy to maintain it. As weight falls to desirable levels, improvements in cardiovascular disease risk factors, hypertension and high blood lipid levels, also occur.

II.

STATEMENT OF THE PROBLEM

A case of Mrs. Natividad Rasonabe, Female, and a 71 year old widow, roman catholic, from Alae, Manolo Fortich Bukidnon, was admitted for the 1st time in Northern Mindanao Medical Center last October 9, 2007 at 4:30 in the afternoon due to side body weakness. She was later diagnosed having Cardiovascular Disease and Diabetes Mellitus Type II. Her vital signs upon admission were BP- 140/90, HR-80bpm, RR-20cpm, and Temperature-37.1C.. She was given precautions of CHO=270g, CHON=135g, Fats=20g.

III.

MEDICATIONS glyburide Classification: sulfonylureas, 2nd generation Dose/frequency/route: 5mg PO,OD Action:sstimulate insulin release from functioning beta cells in the pancreas;may improve insulin binding to insulin receptor sites or increase the number of insulin receptor

Ranitidine Classification: Anti ulcer agents Dose/ Frequency/ Route: 50 mg IVTT every 8 hours Action: inhibits the action of histamine at the H2 receptor site located primarily in the gastric parietal cells, resulting inhibition of gastric acid secretion. Indication: management of gastric hypersecretion states Contraindication: hypersensitivity Side effects: dizziness, drowsiness, headache Precaution: assess pt. for epigastric or abdominal pain and frank or occult blood in the stool, emesis or gastric aspirate. Report promptly

IV.

DIETARY MANAGEMENT Calories Should be prescribed to achieve and maintain a desirable body weight. Should comprise 60% of calories. Unrefined should replace all refined carbohydrates. Should follow the RDA of 0.8 g per kg of body weight for Protein adults. Some reduction in protein intake may prevent or delay the onset of the kidney complications of diabetes. Should comprise less than 30% of total calories. Fat Replacement of saturated fats for polyunsaturated fats to reduce the risk of CHD. Should be limited to 300 mg or less per day to reduce

Carbohydrate

Cholesterol cardiovascular risk.

Sweeteners

Both nutritive and non-nutritive sweeteners are acceptable in diabetes management. Should not exceed 3g per day, to minimize symptoms of hypertension. Should be moderate and may need to be restricted entirely

Sodium (Salt)

Alcohol

by persons with diabetes and insulin-induced hypoglycaemia, neuropathy, poor control of blood sugar, blood lipids, or obesity. Often deficient in diabetics. May help to control blood

Vitamin C

cholesterol levels and reduce the chances of other complications.

Selenium

Selenium has been shown to reduce the risk of CHD and

hypertension. Potassium Potassium regularly produces a decline in blood pressure. Chromium Chromium is a constituent part of glucose tolerance factor in the prevention of diabetes. Lost in urine due to the diuretic effect of high blood sugar. Studies suggest that a deficiency in magnesium may worsen Magnesium the blood sugar control in Type 2 diabetes. Scientists believe that a deficiency of magnesium interrupts insulin secretion in the pancreas and increases insulin resistance in the body's tissues. Is also used extensively for the treatment of CHD. A recent study found that when people with diabetes were given vanadium, they developed a modest increase in insulin Vanadium sensitivity and were able to decrease their insulin requirements. Currently researchers want to understand how vanadium works in the body, discover potential side effects, and establish safe dosages. Computation of DBW: 53 tall = 5 x 12 = 60+3 = 63 inches = 63 x 2 = 160.02 cm DBW = 160.02 100 = 60.02 kg = 60.02 x .10 = 6.002 = 60.02 6.002 = 54 kg

1.) Ht

 Computation of TER:

2.)

54 kg x PA = TER 54 kg x 35 = ? = 1890 kcal/ day

3.)

CHO = 1,890 x .60 = 1134 kcal Chon = 1,890 x .15 = 283.5 kcal Fats = 1,890 x .25 = 472.5 kcal

4.)

CHO = 1134 / 4 = 283.5 g/day Chon = 283.5 / 4 = 70 g/day Fats = 472.5 / 9 = 52.5 g/day

Diet Prescription: Kcal 1,890 kcal CHO 283.5 g/day Chon 70 g/day Fats 52.5 g/day

Menu for The Day

Exchanges 2 starch 3 meat Breakfast 2 slices bread 2 oz sliced turkey and 1 oz lowfat cheese 1 vegetables Lettuce, tomato, onion 1 fat 1 fruit Free items (optional) 1 tsp mayonnaise 1 tbsp salad dressing 1 medium apple 1 cup watermelon Green salad cup plum tomatoes 1 tsp olive oil 1 cup fresh strawberries Iced Tea Mustard, pickle, hot pepper Diet Soda 1 tbsp catsup, pickle onions Ice water with lemon Garlic, basil Lunch Hamburger Bun 3 oz lean beef patty Dinner 1 cup cooked pasta 3 oz boiled shrimp

V.

Other Recommendation As we all know diabetes mellitus is a chronic illness requires a lifetime of

special self-management behavior, because diet, physical activities and physical and emotional stress affect diabetic control, patient must learn to balance a multitude of factors. We told her that she need to have a daily self care skills to prevent acute fluctuation in blood glucose and she must also incorporate in her lifestyle to prevent long term diabetic complication. We also recommend our patient that she need to have eat nutritious food, know the effect of the medicine and the side effect, exercise daily, have a blood glucose monitoring and medication adjustment.

We advice her to refrain eating from high calories and high fat dessert like cookies, cakes doughnuts, ice cream. Its because high fat foods may slow the absorption of glucose. In return it may be able to cause very high blood glucose levels for several hours after the reaction it may contribute to weight gain.

We encouraged Mrs. Rasonabe to take her medications on the right day at the right time with the right dose and to instruct to proper route and frequency. We encouraged her for the compliance of the medication to the regimen and follow the instruction of the physician and cooperate with the health personnel related to the treatment of her illness. Also, the client is advised to go back to have the follow up appointments with the physician for the status of his health and for the supervision of her glucose level.

And for her exercise we explain it to her that it is important that she must have her daily exercise, because it can lower down the blood glucose and it can reduce cardiovascular risk factor. It also improves circulation and muscle tone. We told her to have weight lifting, it can increase lean muscle mess, and it can increase the resting of metabolic rate. And have daily walking exercise for 30 min.