I.

Introduction
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. The three main types of diabetes are TYPE 1 DIABETES that results from the bodys failure to produce insulin it is also called insulin- dependent diabetes mellitus or simply IDDM, TYPE 2 diabetes which is the result from insulin resistance, it is the failure to use insulin properly, also called non- insulin dependent diabetes mellitus (NIDDM), and Gestational Diabetes which is common among pregnant women. Diabetes Mellitus (DM) or simply diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. This is the reason why diabetics need an insulin injection if the disease is already severe. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles. Diabetes Mellitus is one of the common causes of death in the Philippines because we Filipinos love to eat sweet and fatty foods. Hypertension (HPN) or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. Hypertension is classified as either primary (essential) hypertension or secondary hypertension. About 9095% of cases are categorized as "primary hypertension," which means high blood pressure with no obvious medical cause. The remaining 510% of cases (Secondary hypertension) is caused by other conditions that affect the kidneys, arteries, heart or endocrine system. We, nursing students can be a help in the preventing this kind of disease. We can also share our knowledge about the disease to the people in the community where we are exposed.

Latest Trends
There is growing excitement in the area of improved treatments for diabetes. There are significant strides being made in this avenue, including implantable insulin pumps, insulin inhalers, oral insulin medication, and new, faster acting insulin. There is also progress being made in monitoring blood glucose levels, with developments in "pain-free" testing systems, and even continuous monitoring systems, that could worn like a wrist-watch. The biggest gains, though, at this time has been islet cell transplants and gene therapy. However, these advances are only effective for those with Type 1 diabetes, and have been found to be generally ineffective for those with Type 2 diabetes.

For those with Type 2 diabetes, there is hope through identifying a protein and neuropeptide called VGF which appears to play a key role in regulating energy levels and metabolism which results in increasing the body's resistance to weight-gain. This discovery could eventually result in a "diet" medication that could help regulate weight, particularly for those that are elderly, handicapped or otherwise incapable of proper exercise.

Article Source: http://EzineArticles.com/5967420 by Gerald Perry REACTION: The islet cell transplant and gene therapy are progress that are made for monitoring blood glucose level. However, these new discovery is only applicable with patients having DM 1 only, because the main problem in DM 1 is the pancreas itself. These islet cell transplant and gene therapies may be useful to patients with type1 DM. For now, the best proven ways to control diabetes is through diet and exercise, and these methods cannot be forsaken. As a diabetic, you may look to the future with hope for an active and healthy life. Article Source: http://EzineArticles.com/5967420

Objectives of the Study

1. General Objectives The general objective of this case study is to expand our knowledge about the disease and develop our skills on how to render the best possible care to a patient suffering from diabetes mellitus type 2.

2. Specific Objectives At the end of the case study, the student nurses should be able to: a. Obtained Nursing Assessment of the patient which includes Personal History, Family Health History, History of Past and Present Illness, and Physical Examination of the patient.

b.

Identified Anatomy and Physiology and the Pathophysiologic Basis of the Disease. c. Gathered the different Diagnostic and Laboratory Procedures. d. Identified the Patient Medical Management. e. Prepared Nursing Care Plan. f. Acquired sufficient information about the disease. g. Expanded the knowledge on the physiologic effects of the disease to human body. h. Aided in the appropriate nursing interventions to give to the patient. i. Developed a sense of responsibility in caring for the patient with this kind of disease. j. Spread the information regarding the prevention of the disease. II. Demographic Data Personal History Our patients name is Mrs. S. She is a 52 years old, married, born on Aug. 17, 1959 and a Filipino citizen. She is currently residing at Sasmuan, Pampanga and a Roman Catholic. Socio-economic and cultural factors Upon interviewing the husband of the patient, she had mentioned that Mrs. S drinks beverages such as Sodas. She is a high school graduate and she worked as a Care Taker at a Fish Pond. According to him, whenever they are sick they consult a doctor.

Family Health Illness History Mrs. S is the second daughter among the four siblings, her Father is diabetic and a relative on her mother side has HPN. History of Past Illness The patient had only acquired the common illness usually during experienced during childhood such as fever and cold. In the year 2007 Mrs. S had a callus formation on her right feet, at first the patient thought it was just a boil, so she ignored it and as a remedy, she rinses it with decoction of guava leaves. Days passed the callus begin to swell and the patient thought it was odd for it has been days since she had been treating it with guava leaves decoction, her S.O brought her to Sta. Rita and found out that she has diabetes.

History of Present illness Few hours prior to admission the patient experience body malaise, and felt dizziness. Upon admission her vital signs were taken, with BP of 220/110 that prompted to admission.

Anatomy/Physiology Diabetes Mellitus Pancreas : The Pancreas is the one responsible for insulin production through the Islet of Langerhans. The pancreas has two main functions, the exocrine and the endocrine function. The endocrine function is more important than the exocrine function because it is the one which is responsible for controlling, regulating or maintaining the blood glucose in the body. The major endocrine cells are the alpha, beta and delta cells. The alpha cells which is responsible for the production of glucagon and the beta cells which are responsible for insulin production. Insulin : The insulin helps regulates blood sugar levels. It works by promoting the transport of glucose into cells and by inhibiting the conversion of glycogen and amino acids into glucose. The insulin which is produced by the beta cells and glucagon which is produced by alpha cells that controls the blood glucose level in the body. Role of the Insulin :

http://www.authorstream.com/Presentation/reynel89-738323-anatomy-and-physiology-ofthepancreas-dm

http://ce-preview.bmjknowledge.com/bh-oak-preview/en-us/html/topics/diabetestype-2.html

Hypertension Central Nervous System Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter. Hypothalamus; controls and intergrates activities of the autonomic nervous system and pituitary gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone. Cardiovascular System Hyperglycemia or increased blood glucose level makes the blood viscous. Blood viscosity causes the blood flow to flow slowly and ineffectively, thus, increases the workload of the heart, increasing blood pressure. Renal System Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent

vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood volume, which increases blood pressure. III.Physical Assessment: Body Parts/System General appearance Vital Signs Normal Findings Dresses appropriately No body odor Medium body build PR: (N: 60-100bpm) RR: (N: 12- 20 bpm) BP: (N: 120/ 80 mmHg) T: (N: 36- 37.7 C) Conscious Coherent Cooperative Fair complexion Generally uniform Warm to touch Capillary refill: within 2-3 seconds Skull: rounded and smooth contour Hair texture: mixture of black and black hair strands, dry, evenly distributed Scalp: fair in complexion (-) infection (-) lesions (-) tenderness Conjunctiva: bilateral blink response and symmetric firm eyeballs Pink palpebral conjunctiva Pupils: equal in size and have both brisk reaction to light and accommodation Ears Ears are shape symmetrical in Significant Findings Weak in appearance Body malaise BP: 220/110mmHg RR: 33 bpm PR: 105 bpm

Mental Status Skin

Dry skin Poor skin turgor Rough texture Nails are not well cleaned

Nails Head

Eyes

Nose

(-) Secretion External nose: symmetrical and not tender Nasal septum: intact and in midline Nasal cavity: pink colored mucosa, (+) black cilia

Mouth

(-) colds Teeth: yellowish in color,

Lips: pale and dry lips, dry mucous membrane Tongue: in midline, slightly (+) whitish coating rough with (-) whitish With 3 false teeth. coating, moves freely and (-) tenderness Neck muscles: equal in size Muscle strength: has resistance to pressure, normal head flexion (chin to chest), and head extension (chin points up) Lateral flexion: right and left Lateral rotation: right and left (-) chest pain (-) palpitation Color: fair in complexion Contour: symmetrical Palpation: soft, non-tender (-) abdominal pain Voided twice during the visit Defecated once PR () BP () CR ()

Neck

Chest Abdomen

Urinary Rectum

Extremities

Non- healing wound at the right foot.

IV. Laboratory and Diagnostic Procedures

Diagnostic/ Laboratory Procedure

Indications or Purpose Measures the total amount of Hemoglobin in the blood. It is used as a rapid indications measurement of RBC count.

Date Ordered

Results

Normal Values

Analysis and Interpretation The hemoglobin that is present in the blood is below the normal level. hgb may indicate anemia.

Hemoglobin

07/17/11

66

120-170 g/L

Hematocrit

It measures the volume of the whole blood that is composed of RBC.

07/17/11

0.20

0.40 0.52/L

The hematocrit that is present in the blood is below the normal level. hct may also indicate anemia.

Platelet count

A test to measure how many platelets you have in your blood. Platelets help the blood clot.

07/17/11

480 x 109/liter

150-450 x 109/liter

Number of platelet in the blood exceed beyond the normal range

They are smaller than red or white blood cells.

Erythrocytes

A decrease in RBC indicates inadequate oxygen supply of the blood. An increase in leukocyte or WBC result indicates that there is an infection in the body.

07/17/11

2.33

4.0-5.0 x1012/liter

in RBC result may indicate anemia.

Leukocytes

07/17/11

10.7 5-10 x109/liter in WBC result means that there is an infection.

Diagnostic/ Laboratory Procedure

Indications or Purpose

Date Ordered

Results

Normal Values

Analysis and Interpretation

Segmenters

07/17/11

0.88

0.50-0.70

The presence of segmenters in the blood exceed the normal

range Determine if there is enough cell that produces antibodies and other chemicals responsible for destroying microorganisms; contributes to allergic reactions, graft rejection, tumor control, and regulation of the immune system

Lymphocytes

07/17/11

0.12

0.20-0.40

The presence of lymphocytes in the blood below the normal range

Nursing Responsibilities: Explain the purpose to the patient. Tell patient that fasting is required. Apply pressure or a pressure dressing to the venipuncture site Observe the venipuncture site for bleeding Instruct patient to apply warm compress if hematoma occurs on puncture site. Document procedure done. Follow up results

CUES

NURSING DIAGNOS IS

SCIENTIFIC EXPLANATION

OBJECTIVES

NURSING INTERVENTION

RATIONAL E

EVALUATIO N

S>

Activity Intolerance r/t body weakness as evidenced by decreased hemoglobi n and hematocrit on CBC result.

O>

Appears weak Abnormal Heart Rate, pallor

A decrease in hemoglobi n and hematocrit result on CBC indicates that the blood concentrati on has decrease in oxygen supply that leads to body weakness.

After 8 hours of nursing intervention, the patient will be able to identify alternative ways to maintain desired activity level.

Provide positive atmosphere, while acknowledging the difficulty for the client. Instruct SOs in monitoring response to activity and in recognizing signs and symptoms. Instructed the patient to limit activities and rest periods. Demonstrated relaxation

Helps minimize frustratio n and channels energy Indicate need to alter activity level

After 8 hours of Nursing Intervention, goal was met as evidenced by patients verbalization of understanding of present situation and willingness to participate in care.

techniques.

CUES

NURSING DIAGNOS IS

SCIENTIFIC EXPLANATION

OBJECTIVES

NURSING INTERVENTION

RATIONAL E

EVALUATION

S>

>High blood Risk pressure (HBP) for or hypertension prone behavio means high r pressure related to (tension) in the lack of arteries. Arteries knowledge are vessels that about the carry blood from disease the pumping heart to all the tissues and organs of the

>After 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment.

>Explain hypertension . >Assist the patient in identifying modifiable risk factors like diet high

>Provides basis for understandin g elevations of BP, and clarifies misconceptio ns

Bakit kaya madalas ako mahilo?

>After 8 hours of nursing interventions, the patient was able to verbalize understanding of the disease process and treatment.

O> V/S taken as follows: T: 37.3 P: 105 R: 33 BP: 170/100

in sodium, saturated and also fats and cholesterol. understandin g >Reinforce the importance of that high BP can

body.

adhering to treatment regimen

exist without symptom or even when feeling well.

>Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "prehypertension",

and keeping follow up appointments.

CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

OBJECTIVES NURSING RATIONALE INTERVENTIO N

EVALUATION

S O not healing wound in the right foot. -Long and dirty both finger & toe nails. -Not well groomed.

Risk for infection related to chronic disease

Decreased leukocyte function circulatory changes, and delayed healing.

-The patient will be able to identify interventions to prevent/reduce risk for infection.

Demonstrate techniques, lifestyle changes to promote healthy environment. -Achieve timely wound healing.

To prevent the patient to have further infection that might cause by being wounded.

-The patient or -Advice patient the SO will to prevent or clean and cut patients nails. avoid being wounded. -The SO will clean the patients body. -The patient will be able to understand all the health teachings imparted r/t having

Patient and SO showed understandi ng about the teachings regarding delayed healing of wounds that can cause infection.

infection.

CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

OBJECTIVES

NURSING INTERVENTION

RATIONALE

EVALUATION

S- pane kung danupan as verbalized by the patient.

O-

Imbalance nutrition more than body requireme nts related to excessive intake in relationshi p to metabolic need

- stimulation of hunger mechanism via hypothalamus.

-The patient will be able to develop carbohydrate/fat portion and appetitereduction plan to support continuation of behavioral changes. -Assist client to choose nutritious foods.

-Discuss clients motivation for weight loss. -Provide information regarding specific nutritional needs. -Encourage client to start with small changes to slowly change eating habits.

-For own satisfaction/selfesteem.

The patient and the SO had knowledge about proper food intake and a balanced diet with the restriction of too much sweets.

IX. Drug Study Generic Name Potassium Chloride Brand Name Kalium Durule Classification Potassium Salt Indication Contraindicati on Hypokalemia Patients with cardiac disorders and severe renal impairment. Side Effects Paresthesia of the limbs, flaccid paralysis, nausea, vomiting, abdominal pain, hypotension. Nursing Responsibilities - Monitor v/s - Check potassium level after repeated doses. - Inform patient of short- term need for drug and answer any questions and address concerns. - Review potential adverse reactions and instruct patient to promptly report any occurrences.

Metronidaz ole

Amebicide, Anti- bacterial, Antibiotic, Anti- protozoal

Acute infection with susceptible

Contrain dicated with hyperse

- headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures, peripheral neuropathy, fatigue.

- administer oral doses with food. - apply topically after cleansing the area.

anaerobic bacteria. Acute intestinal amebiasis. Amebic liver abscess. Trichomonia sis (acute and partners of patients with acute infection)

Amlodipine

Norvasc

Anti- angina, AntiHypertensive, calcium channel blocker

Angina pectoris due to coronary artery spasm. Chronic stable angina, alone or in combination with other drugs.

nsitivity to metroni dazole; pregnan cy Use cautious ly with CNS diseases, hepatic disease, candidia sis, blood dyscrasi as, lactation . Contrain dicated with allergy to amlodipi ne, impaired hepatic or renal function, sick sinus

- unpleasant metallic taste, anorexia, n/v, diarrhea, GI upset, Cramps. - dysuria, incontinence, darkening of the urine. -thrombophlebitis (IV); redness, burning, skin irritation.

Advice the patient that cosmetics may be used over the area after application. - reduce dosage in hepatic disease.

Dizziness, lightheadedness, headache, asthenia, fatigue, lethargy. Peripheral edema, arrhythmias. Flushing, rash. Nausea, abdominal discomfort

Monitor patient carefully (BP, Cardiac rhythm, and output) While adjusting drug to therapeutic dose; use special caution if patient has heart failure.

Metformin

Antidia betic

Adjunct to diet to lower blood glucose with type 2 diabetes mellitus in patients 10 year and older; ER in patients 17 year and older. As part of combination when either drug alone cannot control glucose levels in

syndrom e, heart block, lactation . Use cautious ly with heart failure; pregnan cy. Contrain dicated with allergy to metform in; heart failure; diabetes complic ated by fever, severe infection s, severe trauma, major surgery, ketosis, acidosis, coma,

Hypoglacemia, lactic acidosi, anorexia, n/v, epigastric discomforts, heart burn, diarrhea, flatulence, allergic skin reation, eczema, pruritus, erythema, urticaria.

Monitor urine or serum glucose level frequently to determine effectiveness of drug and dosage.

patients with type 2 DM.

Glibenclam ide

Antidiabetic

Indicated as adjunct to diet to lower the blood glucose in patients with non-insulin dependent diabetes mellitus type 2 whose hyperglycem ia cannot be control by

type 1 diabetes, serious hepatic and renal impairm ent,, uremia, thyroid or endocrin e impairm ent, glocosur ia, hypergly cemia. Diabetes Mellitus complic ated by fever, trauma or gangren e and in patients with impaired renal or hepatic

Monitor kidney and liver function. Instruct patient to avoid doing activities that needed concentration such as driving. Instruct the patient to increase OFI.

diet alone.

Furosemide

Lasix

Loop diuretic

Oral, IV: edema associated with heart failure, cirrhosis, renal disease.

function or serious impairm ent of thyroid or adrenal function. Diabetes mellitus in patients with the history of metaboli c decomp ensation ; pregnan cy. Contrain dicated with allergy to furosemi de, sulfona mides; allergy

Dizziness, vertigo, paresthesis, headache, drowsiness, fatigue, blurred vision, orthostatic hypotension, thrombophlebitis. Nausea, anorexia, vomiting and oral and gastric irritation.

Reduce dosage if given with other hypertensives. Give early in the morning. Monitor I and O. Monitor BP Monitor weight.

ketostaril

Essenti al amino acid

For human protein metabolism and for chronic renal failure.

to tartrazin e (in oral solution) ; anuria, severe renal failure; hepatic coma; pregnan cy; lactation . Use cautious ly with SLE, gout, diabetes mellitus. Hyperca lcemia Allergy and hyperse nsitivity to ketosteri l Caution use for

Hypercalcemia

Evaluate for any contraindication Take drug as prescribed Warn the patient about possible side effects and how to recognize them. Give with food if GI upset occurs.

patient with phenylk etonuria.

Frequently assess for hypercalcemia.

X.

Discharge Planning

Actual SOPIE and Discharge Summary S ok naku as verbalized by the pt. O - Received pt. lying on bed with an IVF of PNSS 1L regulated as KUD infusing well conscious and coherent -V/S are normal A- Home maintenance and management P- After a series of nsg. intervention

I- seen on rounds by ROD, MGH

E - Goal met, as evidenced by, pt. showed willingness to comply on the health teachings and discharge instructions given

METHOD M-Amlodepine 10g 1tab BID metformin 500mg 1tab BID kalium durule 1cap TID metronidazole 500mg glibenclamide

E - Advised pt. to do activities of daily living as tolerated - Advised pt. to perform light exercises such as brisk walking - Explained to the pt. that Regular exercise can improve the functioning of the cardiovascular system, improve strength and flexibility, improve lipid levels, improve glycemic control, help decrease weight, and improve quality of life and self-esteem. - Encouraged pt. to include 5 to 10 minutes warm up and cool down sessions in the exercise program.

T - Advised pt. to take medication as ordered by the physician

H - Health teachings provided such as: - Monitor blood glucose level daily - Observe signs and symptoms of hypoglycemia and hyperglycemia - Take medicines exactly as directed - Emphasized proper hygiene O - Advised pt. to come on July 23 for OPD follow-up check-up at 8am D - Advised pt. to eat food rich in fiber and protein and advised to decrease sugar intake- - Encouraged to maintain a healthy diet consisting of multiple servings of fruits, vegetables, whole grains, low-fat dairy products, fish, lean meats, and poultry.

Conclusion and Recommendations The success of any diabetic regimen depends upon the patients willingness to adhere to the care plan given. Essentially, learning to live with diabetes is like any other form of learning. Patients must obtain a grasp of unfamiliar factual material (nature of the disease), learn to perform certain procedures (insulin injection) and permanently change certain behavior patterns (eating habits, lifestyle, and recreational activities). Like a student, patient needs scheduled classes, planned instruction, reading materials which are geared to educational level, demonstrations of procedures and the opportunity to perform these procedures with supervision. Learning is a continuing process and patients are given with the most basic facts regarding diabetes. As student nurses, it is recommended to encourage patients to continuously read and learn about their disorder and to keep abreast of new developments in the field. Knowledge and confidence go hand in hand. The more the patient knows about diabetes, the easier it will be for them to accept the condition, control the disorder and live a normal productive life. As for us student nurses, we are tasked to learn the different interventions that should be given in a client who has diabetes mellitus in order for us to provide our clients with the necessary care that they need. Studies about different treatment modalities with regards with this disease do not cease as members of the medical and research fields exert effort to always find ways to alleviate the modes of living of the people. But this has always been a challenge. We may be too young to do such sensitive researches, yet it does not follow that we are excused of

the responsibility. We need to provide intensive and good nursing care for our clients. They may be very difficult to handle but let us not deprive them of the care, respect and compassion that they all deserve. Proper nursing management must be administered to help the patient cope with his condition. Health teaching should be given in order for the patient to realize the effects of her disease or condition. A student nurses we should check and correct the lifestyle the patient has to lessen the occurrence of such disease.

XI.

Bibliography

Nursing Crib Mosbys Pocket Dictionary of Medicine, Nsg and Health Proffession Edition II Nurses Pocket Guide by: Marilyn E.Doenges Mary Frances Moorhouse Alice C. Murr 2010 Lippincotts Nursing Guide by: Amy Karcch Essesential of Human Anatomy and Physiology 8th edition by: Eleaine N. Marieb Medical Surgical Nursing 8th edition by: Joyce M. Black, Jane Hokanson Hawks.