Foundation University COLLEGE OF NURSING Dumaguete City

Submitted to: Ms. Michelle B. Dales, B.S.N. - R.N. Level III Clinical Instructor Submitted by: Faelnar, Germaine, S.N. Real, Julie Christy, S.N. Level III - B1 & B2 Date Submitted: September 04, 2008

COURSE TITLE TOPIC PLACEMENT TIME ALLOTMENT TITLE DESCRIPTION

: NURSING CARE MANAGEMENT 101 : CARE OF THE CLIENT WITH DIABETES MELLITUS : Level III Medicine Rotation 1st Semester 2008-2009 Negros Oriental Provincial Hospital : 1.5 hours : This topic discusses on the care of the client with diabetes mellitus and its common classifications. It also touches on the endocrine system where the pancreas, which is responsible for insulin production, is located. It talks about the signs and symptoms of diabetes mellitus, the complications the clients experience, the drugs to be administered, the therapy and management of diabetes mellitus.

GENERAL OBJECTIVE: At the end of one hour and thirty minutes discussion using the various T-L Activities, the learners shall be able to gain additional knowledge, enhance skills, and acquire positive attitude and values towards caring for clients with Diabetes Mellitus. SPECIFIC OBJECTIVES Throughout the One (1) hour and thirty (30) minutes teaching with the use of various T-L activities, the learners shall: 1. discuss overview of topic briefly; CONTENT T.A. T–L ACTIVITIES REFERENCES EVALUATION After One (1) hour and thirty (30) minutes of teaching with the use of various T-L activities, the learners were able to: 5 mins Socialized discussion Shyrock, Harold. MD. (2002). Modern Medical Guide, Revised Edition. Philippines: Phillippine Publishing House. p.495. Porth, Carol Mattson. et. al. (2002).Pathophysiology Concepts of Altered Health States, 6th Edition. USA (Philadelpia) : Lippincott Williams and Wilkins. p.930. Kee, Joyce LeFever, RN MS., et. al. (1993) Pharmacology: a Nursing Process Approach, 2nd ed. USA: WB Saunders 5 mins Socialized discussion www.emedicinehealth.com Crossword Puzzle 2. define at least five (5) related terms correctly 1. discussed the overview of the topic briefly

the I. Introduction the The word diabetes is derived from the Greek word meaning “going through” and Melilitus from the Latin word for “honey” or “sweet.” Reports of the disorder dates back to the first century AD wherein it characterizes the 3Ps. Polyuria, Polydipsia, and Polyphagia. It was the discovery of insulin by Banting and Best in 1922 that transformed the disease into a manageable chronic health problem. Diabetes is a serious metabolic disorder , characterized by defects in the body’s use of carbohydrates. It also includes the disorder aside from carbohydrates, of proteins and fat metabolism resulting from an imbalance between insulin availability and insulin need.

2. define at least II. Definition of terms five (5) out of 8 related terms in A. Glucose: The simple sugar (monosaccharide) that serves their own words; as the chief source of energy in the body. Glucose is the principal sugar the body makes. The body makes glucose from

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CONTENT proteins, fats and, in largest part, carbohydrates. Glucose is carried to each cell through the bloodstream. Cells, however, cannot use glucose without the help of insulin. B. Hormone: a specific messenger molecule synthesized and secreted by a group of specialized cells called an endocrine gland. A chemical substance produced in the body that controls and regulates the activity of certain cells or organs. C. Glucagon: hormone produced in alpha cells of pancreatic islets of langerhans. Causes breakdown of glycogen into glucose, thus preventing blood sugar from falling too low during fasting. D. Insulin: A natural hormone made by the pancreas that controls the level of the sugar glucose in the blood. Insulin permits cells to use glucose for energy. Cells cannot utilize glucose without insulin. E. Metabolism – the sum of physical and chemical changes in the body by which nutrition is effected, It encompasses the total collection of chemical reactions in the body and reflects the ability of the body to capture and store energy derived from foods and to make that energy available in the appropriate form when needed. F. Hypoglycemia: abnormally low blood glucose levels. G. Hyperglycemia: an excessive amount of glucose in the circulating blood. H. Diabetes Mellitus: Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar in the blood.

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REFERENCES Price, Sylvia A. et al. (2003). Pathophysiology Clinical Concepts of Disease Processes, 6th Edition. p.950. www.wikepedia.com Blackwell's Nursing Dictionary, 2nd ed.(2005). Blackwell Publishing Ltd. p.179,286,289, 304, 358,253

EVALUATION A. Glucose: The simple sugar (monosaccharide) that serves as the chief source of energy in the body. B. Glucagon: hormone produced in alpha cells of pancreatic islets of langerhans. C. Insulin: A natural hormone made by the pancreas that controls the level of the sugar glucose in the blood. D. Hypoglycemia: abnormally low blood glucose levels. E. Hyperglycemia: an excessive amount of glucose in the circulating blood.

SPECIFIC CONTENT OBJECTIVES 3. pinpoint the III. Anatomy and Physiology of the Endocrine System gland responsible for diabetes A. Endocrine System mellitus correctly; The Endocrine System and Nervous System have similar regulatory functions. The nervous system sends electrical messages to control and coordinate the body while the endocrine system has a similar job, but uses chemicals to “communicate”. These chemicals are known as hormones. The glands in the endocrine system are ductless, which means that their secretions (hormones) are released directly into the bloodstream and travel to elsewhere in the body to target organs, upon which they act. 1. Glands of the Endocrine System

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EVALUATION

Seeley, Rod R. et al. (2005). Essentials of Anatomy and Physiology, 5th ed. New York: Mc-GrawHill Companies, Inc. pp. 272 – 296. http://en.wikipedia.org/wiki/ Endocrine_system

2. Functions of the Endocrine System The main regulatory functions of the endocrine system include: a. Water balance – The endocrine system regulates water balance by controlling the solute concentration of the

SPECIFIC OBJECTIVES blood.

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b. Uterine contractions and milk release - .regulates uterine contractions during delivery of the newborn and stimulates milk release from breasts in lactating females. c. Growth, metabolism and tissue maturation – regulates the growth of many tissues, such as bone and muscle, and the rate of metabolism f many tissues which helps maintain a normal body temperature and normal mental functions. d. Ion regulation – it regulates sodium, potassium and calcium concentrations in the blood. e. Heart rate and Blood pressure regulation – the endocrine systems helps regulate the heart rate and blood pressure and helps prepare the body or physical activity. f. Immune system regulation reproduction and function of immune cells. helps control the

g. Reproductive functions control – controls the development and the functions of the reproductive system in males and females. h. Blood glucose control – regulates blood glucose levels and other nutrients levels in the blood. 4. differentiate the IV. Classification of Diabetes Mellitus two types of Diabetes Mellitus A. Type 1 Diabetes: also known as IDDM or Insulinaccurately in their dependent diabetes mellitus, occurs mainly in children and own words; young adults and the onset is usually sudden. The deficiency 10 mins Socialized Discussion Waugh, Anne. et.al. (2002) Ross and Wilson. Anatomy and Physiology in Health and Illness, 9th Edition. Elsevier Science Ltd. pp. 234- 236. 4. differentiate the two types of Diabetes Mellitus accurately in their own words;

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CONTENT or absence of insulin is due to the destruction or dysfunction of beta cells by the cells of the immune system. The causes are unknown but there is a familial tendency, suggesting genetic involvement. In many cases an autoimmune reaction has occurred in which antibodies to beta cells are present. As of today, this type is not curable. B. Type 2 Diabetes: this is the non-insulin dependent type or NIDDM that occurs later in life, the body has an adequate supply of insulin , but a defect has developed in the mechanism by which insulin enables cells to make use of glucose. The pancreas secretes insulin, but the body is partially or completely unable to use the insulin. This is sometimes referred to as insulin resistance. The body tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they do not continue to secrete enough insulin to cope with the higher demands.

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REFERENCES Shyrock, Harold. MD.p.497.

EVALUATION Type I Diabetes is also known as Insulin-dependent diabetes mellitus. Type II is the non insulin-dependent diabetic mellitus.

Porth, Carol Mattson. et. al. p. 936. www.emedicinehealth.com

5. enumerate 6 out V. Common Signs and Symptoms of Diabetes Mellitus of the 10 signs and symptoms of A. Polyuria: excessive urination. Another way the body tries Diabetes Mellitus to get rid of the extra sugar in the blood is to excrete it in the urine. correctly ; This can also lead to dehydration because excreting the sugar carries
a large amount of water out of the body along with it.

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Lecture discussion Match Me! Game

Porth, Carol Mattson. et. al. 5. Give 6 out 10 p.936. signs and symptoms of diabetes mellitus. A. Polyuria B. Polydipsia C. Polyphagia D. Weight loss E. Blurred Vision F. Fatigue

B. Polydipsia: excessive thirst. The body encourages more water consumption to dilute the high blood sugar back to normal levels and to compensate for the water lost by excessive urination. C. Polyphagia: excessive hunger. One of the functions of insulin is to stimulate hunger. Therefore, higher insulin levels lead to increased hunger and eating. Despite increased caloric intake, the person may gain very little weight and may even lose weight.

www.emedicinehealth.com

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CONTENT D. Unexplained Weight loss: People with diabetes are unable to process many of the calories in the foods they eat. Thus, they may lose weight even though they eat an apparently appropriate or even excessive amount of food. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss. E. Blurred Vision: Blurred vision develops as the lens and retina are exposed to hyperosmolar fluids or very high blood glucose levels. F. Fatigue: In diabetes, the body is inefficient and sometimes unable to use glucose for fuel. The body switches over to metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. The end result is feeling fatigued or constantly tired. G. Paresthesias: is a sensation of tingling, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb being "asleep." H. Infections: Certain infection syndromes, such as frequent yeast infections of the genitals, skin infections, and frequent urinary tract infections, may result from suppression of the immune system by diabetes and by the presence of glucose in the tissues, which allows bacteria to grow well. They can also be an indicator of poor blood sugar control in a person known to have diabetes. I. Poor wound healing: High blood sugar levels prevent white blood cells, which are important in defending the body against bacteria and also in cleaning up dead tissue and cells, from functioning normally.

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SPECIFIC CONTENT OBJECTIVES 6. classify the VI. Complications of Diabetes Mellitus different complications of A. Acute Diabetes Mellitus appropriately; 1. Diabetic Ketoacidosis: diabetic ketoacidosis occurs when ketone production by the liver exceeds cellular use and renal excretion. The most serious complication of type 1 diabetes. This develops due to increased insulin requirement or increased resistance to insulin due to some added stress such as pregnancy, microbial infection, infarction, cerebrovascular accident. Severe hyperglycemia is developed. a. Management: This can be treated by restoring water and electrolyte balance. IV therapy by means of unmodified insulin to allow glucose utilization and antibiotics to overcome infections. 2. Hyperglycemic Hypersmolar Nonketotic Syndrome: occurs most often in older individuals with type 2 diabetes. Because of relative but not absolute insulin deficiency, hyperglycemia develops without ketosis. It is caused by severe dehydration due to the continuous removal of sugar in urine known as hyperglycaemic diuresis. The patient may become unconscious and may die if the condition is not quickly reversed. The major difference between HHNK and DKA is the lack of ketosis with HHNK. a. Management: The treatment of HHNK consists of rehydration, electrolyte replacement, IV of large amount of bicarbonates and half a dose of regular insulin. 3. Hypoglycemia: also known as insulin reaction or insulin shock which is mainly a complication of insulin therapy. Insulin-dependent diabetic patients may occasionally receive insulin in amounts larger than that needed to maintain normal glucose levels with resulting hypoglycaemia.

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EVALUATION 6. Give at least one two (2) complications of diabetes mellitus and classify; A. Hypoglycemia: acute B. Diabetic neuropathy: chronic

www.wikepedia.com Waugh, Anne. et.al. p.235.

www.diabetesmellitusinformation.com

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CONTENT Management: Administering quickly absorbed glucose source such as softdrinks, orange juice, pinch of cake frosting, foods rich in vitamins C, E and B complex and glucose containing tablets. IM of glucagon. B. Chronic 1. Diabetic nephropathy- kidney damage from diabetes. The diseased small blood vessels in the kidney. As the disease progress, the kidney stops filtering and cleaning the blood leading to accumulation of toxic waste products in blood. a. Management: Controlling high blood pressure ,dialysis. 2. Diabetic retinopathy: diabetic retinopathy is the leading cause of blindness and is cause by an underlying microangiopathy a. Management: Controlling high blood pressure , blood sugar level, eating raw natural foods, rich in vitamin A foods and exercise of the eyes. 3. Diabetic neuropathy: A family of nerve disorders caused by diabetes. It involves temporary or permanent damage to nerve tissues. Diabetic neuropathies cause numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Neurologic problems in diabetes may occur in every organ system, including the digestive tract, heart, and genitalia. People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater is the risk. a. Management: Controlling, blood sugar level, analgesics, regular foot examination, oral and topical medications.

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SPECIFIC CONTENT OBJECTIVES 7. name at least VII. Medical Management for Diabetes Mellitus one (1) drug and one (1) laboratory A. Drugs test in the medical management of 1. Insulin: Regular and NPH insulin; can be classified as diabetes mellitus intermediate and long acting insulin. concisely; a. Action: Increases glucose transport across muscle and fat cell membrane to reduce glucose level. Helps convert glucose to glycogen; b. Indication and dosage: This is for type 1 diabetes mellitus Many people with type 2 diabetes eventually require insulin therapy.varies according to the clients’ blood sugar. c. Side effects: hunger, tremors, weakness, headache, lethargy, fatigue, redness, irritation or swelling at insulin injection site, flushing, confusion, agitation. d. Adverse effects: urticaria, tachycardia, palpitations, hypoglycaemic reaction, rebound hyperglycemia (somogi effect), lipodystrophy, life threatening adverse reactions are shock and anaphylaxis. 2. Sulfonylureas: Dymelor

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REFERENCES Kee, Joyce LeFever, RN MS., et. al. p. 635-637.

EVALUATION 7. Name at least one (1) drug and one (1) laboratory test in the medical management of diabetes mellitus;

(2008) Nursing 2008 Drug Handbook, 28th Edition. New York: Lippincott A. Sulfonylureas Williams & Wilkins. p. 795 – (Dymelor) 828. B. Benedicts Test

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a. Action: These drugs stimulate the pancreas to make more insulin. This increases the insulin cell receptors, thus increasing the cells’ ability to bind insulin for glucose metabolism. b. Indication and dosage The sulfonylureas are used in the treatment of type 2 diabetes or NIDDM. metabolism. P.O.: 250 to 1,000mg daily

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CONTENT in 1 or 2 divided doses. Maximum dosage is 1.5 grams daily and maintenance is 1000 mg daily. c. Side effects: Nausea, vomiting, diarrhea, rash, pruritis, headache and photosensitivity. d. Adverse effects: Hypoglycemic reaction, life threatening adverse effects are aplastic anemia, leukopenia, thrombocytopenia. 3. Nonsulfonylureas: expanding knowledge of glucose metabolism has revealed new mechanisms for the management of NIDDM or type 2 diabetes. These new drugs, metformin and acarbose, use different methods to control serum glucose levels following a meal. Unlike the sulfonylureas, which enhance insulin release. Metformin (Glucophage) a. Indication and dosage: for NIDDM when no response to Sulfonylureas. Take with meals. May be combined with sulfonylurea (dose reduction of metformin would be needed). PO: Initial:500. mg, daily b.i.d.; increase dose gradually; max:2500 mg/daily. b. Adverse effects : diarrhea, nausea, vomiting, abdominal bloating, flatulence, anorexia, taste perversion, anemia, lactic acidosis, hypoglycaemia. 4. Hypoglycemic a. Action: Raises glucose level by promoting catalytic depolymerization of hepatic glycogen to glucose. Relaxes the smooth muscle of the stomach, duodenum, small bowel and colon.

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CONTENT b. Indication and dosage: Adults and children who weigh more than 20 kg or 44 lbs.: 1 mg IV , IM, or subcutaneously. Children who weigh 20 kg or less: .5 mg or 20 to 30 mcg/kg. IV, IM, or subcutaneously: maximum dose 1 mg. May repeat in 15 minutes, if needed. IV glucose must be given if patient fails to respond. b. Adverse effects : nausea, vomiting, bronchospasm, respiratory distress, hypersensitivity reactions. d. Nursing considerations: Use drug only in emergency situations. Monitor glucose level before, during, and after administration. Alert: arouse patient from coma as quickly as possible, and give additional carbohydrates orally to prevent hypoglycaemic reactions. B. Laboratory and Diagnostic Tests 1. Blood Tests: Blood glucose measurements are used in both diagnosis and management of diabetes. a. Fasting Blood Glucose Test- the fasting blood glucose has been suggested as the preferred diagnostic test because of ease of administration, convenience, patient acceptability, and cost. Glucose levels are measured after food has been withheld for 8-12 hours. If the fasting plasma glucose level is higher than 126 mg/dl, on two occasions diabetes is diagnosed. A fasting plasma glucose level below 110 mg/dl, is normal. A level between 110 mg/dl to 126 mg/dl, is significant and is defined as impaired fasting glucose. b. Random Blood Glucose Test: a random blood glucose is one that is done without regard to meals or time of day random blood glucose concentration that is unequivalent elevated (>200 mg/dl,) in the presence of classic symptoms of

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CONTENT diabetes such as polydipsia, polyphagia, polyuria, and blurred vision is diagnostic of diabetes mellitus of any age c. Glucose Tolerance Test: the oral glucose tolerance test ensures the body’s ability to store glucose by removing from the blood. In men and women, the test measures the plasma glucose response to 75 g of concentrated glucosylution at selected intervals, usually 1 hour to 2 hours. Persons with diabetes lacks the ability to respond to an increase in blood glucose by releasing adequate insulin to facilitate storage, blood glucose levels rise above the served in normal people and remain elevated for long periods. d. Capillary Blood Tests and Self-Monitoring of Capillary: These methods use a drop of capillary blood obtained by pricking the finger or forearm with a special needle or lancet. Small trigger devices make use of the lancet usually painless. The drop of capillary blood is placed on absorbed by a reagent strip, and glucose levels are defined electronically using a glucose meter e. Glycosylated Hemoglobin Test: is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months. 2. Urine Tests a. Benedicts test :determines the presence of sugar in the body. b. Urine test for ketones: a urine test to determine if your blood glucose is dangerously high and if you are producing substances called ketones. Ketones are the by-product of the fat burning process that occurs in the absence of insulin. When a person with diabetes has a high blood glucose, if there is not enough insulin around (type 1 diabetes) or if their body is unable to utilize the insulin properly (type 2 diabetes) and break

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CONTENT down glucose, the body turns to fat stores to create energy for the cells. While ketones can be a source of energy for many cells, they can be toxic in large amounts and cause a lifethreatening emergency condition called ketoacidosis.

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8. itemize the VIII. Nursing Care Management for Patients with Diabetes Nursing Care Mellitus Management for Diabetic patients A. Assessment thoroughly; 1. Vital Signs 2. Client’s level of knowledge 3. Lab results 4. Blood Sugar 5. Skin 6. Blood Pressure 7. Eyesight 8. Urine Output 9. Activity 10. Diet 11. Weight 12. Fluid Intake B. Diagnoses 1. Self-care Deficit: potential self-care deficit related to physical impairments or social factors 2. High Risk for Injury 3.Altered Nutrition: imbalanced nutrition related to imbalance of insulin, food, and physical activity 4. Risk for Infection 5. Risk for Impaired Tissue Integrity 6. Knowledge Deficit: deficient knowledge about diabetes self-care skills/information 7. Risk for Impaired Adjustment 8. Risk for Disturbed Sensory Perception

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8. Give at least 3 the Nursing Care Management for Diabetic patients?

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CONTENT 9.Compromised Family Coping 10. Anxiety- related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications 11.Risk for Fluid Volume Deficit- related to polyuria and dehydration C. Interventions 1. Dependent a. Insulin Therapy: insulin regimens vary from 1 or more injections per day. Usually there is a combination of a short-acting insulin and a longer-acting insulin. The goal of all but the simplest, one injection insulin regimens is to mimic this normal pattern of insulin secretion in response to food intake and activity patterns. In people without diabetes, insulin secretion compensates for varying amounts of food intake and exercise. In contrast, individuals with diabetes are unable to secrete sufficient quantity of insulin to maintain their blood glucose level. As a consequence, blood glucose rise to high levels in response to meals, and levels are high in the fasting state. Patients with severe insulin insufficiency require injections of insulin in addition to a meal plan. b. Medications – the use of antidiabetics help patients blood glucose level return to its normal balanced state. 2. Independent a. Exercise and Limitations in Activity: exercise appears to facilitate the transport of glucose into cells and to increase sensitivity to insulin. However, patients with diabetes complications should limit their activity and is advised to consult the doctor before taking up an exercise regimen or doing any activity.

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Smeltzer, S., Bare, B. (2004). Medical Surgical Nursing, Vol. 2, 10th ed. New York: Lippincott Williams & Wilkins. pp. 1163.

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CONTENT b. Diabetes education: patients with diabetes mellitus can lead to a relatively normal life if they are well informed about their disease and its management. Patients can learn to administer their own insulin, monitor their blood glucose level, and use this information to regulate their insulin dosage and plan their diet and exercise to minimize hyperglycemia and hypoglycemia. 3. Collaborative a. Meal Planning - the meal planning of diabetic patients is aimed at controlling the number of calories and the amount of carbohydrates ingested daily. The recommended number of calories varies, depending on the need for maintaining, reducing, or increasing body weight. The meal plan should be developed in consultation with a registered dietitian and based on a patient’s diet history, food preferences, lifestyle, cultural background, and physical activity. b. Glucose Monitoring – various self-monitoring of blood glucose (SMBG) methods are available. Most involved obtaining a drop of blood from fingertip, applying the blood to a special reagent strip, and allowing the blood to stay on the strip for the amount of time specified by the manufacturer. The meter gives a digital readout of the blood glucose value. c. Planning of Care - must be done with the patient to fit his lifestyle. Self-care at home should include diet, exercise, alcohol use, smoking, self monitoring.

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EVALUATION

Price, Sylvia A. p. 946.

9. evaluate the IX. Open Forum presentation objectively

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9. Do you have any questions, clarifications and comments?

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EVALUATION 10. get a seventy-five percent (75%) out of one hundred percent (100%) level of competency. 1. It is a serious metabolic disorder , characterized by defects in the body’s use of carbohydrates. (Diabetes Mellitus) 2. Give the 3 P’s of diabetes mellitus (Polyuria, polydipsia, Polyphagia) 3-6. Give and Differentiate the two common types of diabetes mellitus. (Type I – insulin dependent and Type 2 – noninsulin dependent).

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EVALUATION 7. Is also known as insulin reaction or insulin shock which is mainly a complication of insulin therapy. (Hypoglycemia) 8. What is the gland in the endocrine system that is responsible for insulin production? (pancreas) 9 -10. What are the two hormones produced by this gland? (insulin and glucagons)

BIBLIOGRAPHY: BOOKS: (2005). Blackwell's Nursing Dictionary, 2nd ed. Blackwell Publishing Ltd. (2008) Nursing 2008 Drug Handbook, 28th Edition. New York: Lippincott Williams & Wilkins. p. 795 – 828. Seeley, Rod R. et al. (2005). Essentials of Anatomy and Physiology, 5th ed. New York: Mc-Graw-Hill Companies, Inc. Kee, Joyce LeFever, RN MS., et. al. (1993). Pharmacology: a Nursing Process Approach, 2nd ed. USA: WB Saunders Company. Price, Sylvia A. et al. (2003). Pathophysiology Clinical Concepts of Disease Processes, 6th Edition. Porth, Carol Mattson. et. al. (2002). Pathophysiology Concepts of Altered Health States, 6th Edition. USA (Philadelpia) : Lippincott Williams and Wilkins. Shyrock, Harold. MD. (2002). Modern Medical Guide, Revised Edition. Philippines: Phillippine Publishing House. Smeltzer, S., Bare, B. (2004). Medical Surgical Nursing, Vol. 2, 10th ed. New York: Lippincott Williams & Wilkins. pp. 1163. Waugh, Anne. et.al. (2002) Ross and Wilson. Anatomy and Physiology in Health and Illness, 9th Edition. Elsevier Science Ltd. INTERNET SOURCES: http://www.diabetesmellitus-information.com http://www.emedicinehealth.com http://www.wikipedia.com

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