HOLY TRINITY UNIVERSITY Puerto Princesa City, 5300 Palawan Philippines In Partial Fulfillment of the Requirements in Related Learning

Experience SUMMER AFFILIATION 2010 LUNG CENTER OF THE PHILIPPINES

A CASE STUDY

“Diabetes Mellitus Type II/PTB”
Presented to: Ms. Elma Jazz E. Macrohon, R.N., M.A.N. Clinical Instructor

Presented by: Eduard L. Alcantara BSN 3rd Year – Group C

April 23, 2010

Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

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APPROVAL SHEET

This case study entitled “Diabetes Mellitus/PTB” serves as partial fulfillment of the requirements in Related Learning Experience, Lung Centre of the Philippines. It was examined and approved with the grade of _______%.

Clinical Instructor ____________________________________________ Ms. Elma Jazz E. Macrohon, R.N., M.A.N

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ACKNOWLEDGEMENT

The researcher would like to extend their sincere appreciation and heartfelt thanks to the following respectable persons who shared their time and effort for the success of this study. To the nurses and other staff of the Lung Center of the Philippines for being the place of exposure and for the learning endowed which is essential to give effective and ideal nursing care. To my dear patient and her husband for their valuable time, cooperation, and willingness to share significance information; their contributions for the enhancement of our skills in the assessment of knowledge on the disease process that are the lifeblood of this case study. To our clinical instructor for her unwavering support and guidance to us, Ms. Elma Jazz ElmaMacrohon, R.N., M.A.N. To my parents, who have always been our inspirations and the force within each one of us for their constant support in achieving and reaching our goals in our chosen career. And most of all, to our Savior and Dear Almighty God for His Divine providence and His most precious gift of wisdom and good health.

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DEDICATION

I would like to dedicate this case study to my parents and to our clinical instructor, who had inspired us in making this case study possible, for what has been imparted; for my friends who gave me their unending support; knowledge, skills and technically know-how in the field of nursing with patience and without limitation and above all, to our Almighty God for His never-ending blessings, guidance and enlightenment. E.L.A.

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TABLE OF CONTENTS Title Page---------------------------------------------------------------------------------------------------------------------------1 Approval Sheet -------------------------------------------------------------------------------------------------------------------2 Acknowledgement --------------------------------------------------------------------------------------------------------------3 Dedication -------------------------------------------------------------------------------------------------------------------------4 Table of Contents------------------------------------------------------------------------------------------------------------- 5-6

Chapter I Introduction-----------------------------------------------------------------------------------------------------------------------7 Significance of the Study -------------------------------------------------------------------------------------------------------8 Statement of the problem -----------------------------------------------------------------------------------------------------8 Scope and Delimitation --------------------------------------------------------------------------------------------------------8 Definition of Terms--------------------------------------------------------------------------------------------------------------9

Chapter II Personal Data---------------------------------------------------------------------------------------------------------------10-16
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Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

• • • • • • • •

Biographical Information Clinical and Family History Past Health History Present Medical History Present Condition Physical Assessment Summary of Findings Psychological Development (Erik Erikson)

Chapter III Laboratory Examination and Results----------------------------------------------------------------------------------17-19 • • Urinalysis Blood Glucose Test

Chapter IV Schematic Pathophysiology---------------------------------------------------------------------------------------------Narrative Pathophysiology-----------------------------------------------------------------------------------------------20-21

Chapter V Medical Management---------------------------------------------------------------------------------------------------------22 • Diet Therapy

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Chapter VI Prioritization of the Problems-----------------------------------------------------------------------------------------------23 Concept Map--------------------------------------------------------------------------------------------------------------------24 Nursing Care Plans---------------------------------------------------------------------------------------------------------25-35 Discharge Plan--------------------------------------------------------------------------------------------------------------36-37

Chapter VI Prognosis-------------------------------------------------------------------------------------------------------------------------38 Conclusion------------------------------------------------------------------------------------------------------------------------39 Bibliography----------------------------------------------------------------------------------------------------------------------40

INTRODUCTION Diabetes Mellitus Type II or formerly referred as non-insulin dependent Diabetes Mellitus (NIDDM) usually occurs after the age of 40, the pancreas retains some ability to produce insulin but this is inadequate for the body’s needs: patients may require treatment with oral hypoglycemic drugs. 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

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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.1 The incidence of type 2 diabetes is rising, especially in urbanized parts of the world where sedentary lifestyles and obesity abound. In addition to weight and inactivity, race puts some people at increased risk for developing type 2 diabetes. The incidence of diabetes is rapidly increasing globally, and Asian Indians have the highest prevalence.2 The cause of continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles.3 The most common chronic complications are cardiovascular disease, peripheral vascular disease, eye disease (Retinopathy), kidney disease, skin disease (Diabetic Dermopathy) and peripheral and autonomic neuropathy.4 Dr. Tommy Ty Willing, President of the Philippine Diabetes Association (PDA), during World Diabetes day in November 2008 said that DM is prevails not only on middle-aged persons but it is now more common among elementary and highschool students. Pediatric endocrinologist Chan-Cua said the Philippines is still low on this score compared with other countries, especially Scandinavian nations like Finland, Sweden, and Norway, but we are also seeing an increase every year. My perception on this is simple – Filipinos love sweets and fatty foods. Also, our staple food is rice, which is a starchy food item. This makes diet as the primary risk factor to diabetes in the Philippines in my view.5 The researcher studied this case to identify the etiology, causes, Pathophysiology and nursing care management needed to reduce risks and other complications that might arise in the condition of the client.

SIGNIFICANCE OF THE STUDY

http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-philippines-andworldwide/ 2 http://www.sciencedaily.com/releases/2008/02/080229112210.htm March 3, 2008 3 http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-philippines-andworldwide/ 4 rd Pathophysiology made Incredibly Easy! 3 Edition 5 http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-the-philippines-andworldwide/
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This case study will serve as baseline information and future references for the nursing students and other workforce in the medicine field. This case study is important to all the researchers involved developing skills and knowledge with regards to the case. It will aid in learning more about the possible nursing care management that are necessary and other essentials. Furthermore as the case is presented it could share information to other nursing students and will be useful reference with regards to the care of Diabetes Mellitus and to the management care done to the patient with this condition. STATEMENT OF THE PROBLEM Generally, this case study entitled “Diabetes Mellitus Type II/PTB” seeks to find answers to the following queries: 1. What is Diabetes Mellitus (DM)? 2. What are the factors that precipitate and contributed to the development of DM? 3. What are the medical management for a patient with Diabetes Mellitus? 4. What are the nursing assessments, diagnoses, plans, interventions, evaluations inclusive to a patient with the said case?

SCOPE AND DELIMITATION OF THE STUDY This study is delimited in terms of problem, source of data or population, locale and time frame. Problem: This study focuses on “Diabetes Mellitus” together with the manifestations, treatment modalities of the disease and possible nursing care plans. Source of Data/ Population: The population being referred in this study is the patient, significant others, patient’s chart and admitting physician. Locale: The study was conducted on the 3-C Ward, Room Number 3301 of the Lung Center of the Philippines. Time Frame:
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The study was performed on April 16-18, 2010 at 7:00-11:00 am; though the interventions were limited for just four hours at the Ward 3-C of Room 3301 of the Lung Center of the Philippines.

DEFINITION OF TERMS DIABETIC MELLITUS- the disease where the body cannot control sugar absorption because the pancreas does not secrete enough insulin. DIABETIC DIET- a prescribed diet which is low in carbohydrates and sugar. GLUCOSE METER-is a medical device for determining the approximate concentration of glucose in the blood. GLYCOGEN – is the stored glucose in the liver and muscle. HYPERGLYCEMIA- is the excess of glucose in the blood. HYPOGLYCEMIA- low concentration of glucose in the blood. HYPOTHERMIA- a condition in which core temperature drops below that required for normal metabolism and body functions which is defined as 35.0 °C (95.0 °F). INSULIN- hormone produced by Islets of Langerhans in the pancreas that serves as precursors for glucose to provide bodily energies. POLYDIPSIA- the condition where the patient is abnormally thirst. POLYURIA- the condition where a patient passes a large quantity of urine, usually as a result of diabetes insipidus. PULMONARY TUBERCULOSIS – the infectious disease in the lungs where pulmonary infiltrates accumulate, cavities develop, and masses of granulated tissues form within the lungs. DIABETIC COMA- a state of unconsciousness caused by untreated diabetes. DIABETIC NEPHROPATHY- is the progressive damage to the kidneys seen in some people with long-standing diabetes. It is manifested as an excessive leakage of protein into the urine followed by gradual decline of the kidney function and even kidney failure. PANCREAS – The largest pure endocrine gland in the body. 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.
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TOXAEMIA – Condition produced by the presence of bacterial toxins in the blood, usually with tissue or organ damage, fever, and severe intestinal upset.

CHAPTER II PERSONAL DATA A. Biographical Information Name: Mrs. Constellation Age: 54 years old, 4 months, 55 days Sex: Female Address: 59 Mercury St., Constellation Homes, Novaliches, Caloocan Educational Background: College Graduate (BS Commerce) Religion: Roman Catholic Civil Status: Married Occupation: Self-employed/Dependent/Housewife Usual Source of Medical Care: Doctor/Health Care Professional Date & Time of Admission: April 12, 2009; 7:00 AM Admitting Diagnosis: DM/PTB? Chief Complaints: Increased blood Sugar Attending Physician: Newell R. Nacpil, MD Sources of Data: Patient’s Subjective and Objectives Cues, Chart, SO B. Clinical and Family History Name of Father: Papa Star Disease within the Family: Diabetes Mellitus, Cardiac Arrest, Bronchial Asthma Name of Mother: Mama Starry Disease within the family: Pulmonary Tuberculosis, Hypertension Number of children in the family: 4 Death in the family: 1st and 4th Child Cause: Toxaemia Immunization status: Unrecalled C. Past Medical History

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She was born on December 5, 1955 via normal spontaneous delivery. Her childhood illnesses are cough, colds, and influenza. She experienced having Caesarean delivery five times. She experienced having Hysterectomy when she was 46 years old because of Myoma. She doesn’t have any allergy on food, medications or pollens. She admitted that her father had died due to Cardiac Arrest (Stroke CVA) and her mother has pulmonary tuberculosis. She said that some of her relatives had Diabetes Mellitus. She was once admitted on February 2009 at Novaliches Hospital for 3-4 days because of the increased on her blood sugar. D. Present Medical History Two weeks prior to admission she finished washing their clothes and found a blood stain on the floor. She suspected but unsure that it came from her mouth and got worried. After that incident she immediately got the idea of having a check-up. After days, she forgot the planned check-up. On April 11, 2010 she checked her blood sugar through glucose meter and it showed increased in her blood sugar. She immediately went to a clinic under the service of Dr. Cheng, but the said doctor was absent during that time so she went on the clinic of Dr. Nacpil. On the said clicnic, she was confirmed having an increased blood sugar. In addition to that, through the use of X-ray it was confirmed that she has pulmonary tuberculosis and was given appropriated medications. Dr. Nacpil referred her to the Lung Center of the Philippines. She was admitted on April 12, 2010 at 7 o’clock in the morning. She is confined at Ward 3-C Private Room 3301 and administered insulin and Fixcom for her PTB. She is ordered to have strict Diabetic Diet. E. Present Condition a. Perception and expectation of illness/hospitalization The client came to the hospital because of the significant change in her blood sugar and her worry about the unconfirmed PTB. She expects that she’ll be home after 2 days of confinement. She still lives with her mother and her husband and children who she considers important persons in her life. She spends her time by watching the television and cross-stitching. After hospitalization she expects to have a general strictness on her lifestyle.

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b. Specific Basic Needs i. Comfort / Rest needs Before Hospitalization: • Her usual length of sleep is 6-7 hours a day, usually from 10pm to 4 or 5 am; stated that at times he takes a nap in the afternoon; able to take a bath daily; able to routinely perform oral care, brushes her teeth three times daily after meal. • She also takes a bath every day after breakfast. At the course of illness and during Hospitalization: • She experienced headache and consulted the physician immediately and cannot do her ADL’s. ii. Safety needs Before Hospitalization: • The client doesn’t experience difficulty in moving about. She wears eyeglasses and don’t have hearing difficulty. During hospitalization: • She is confined in a bed with side rails and SO’s at her side –mother, her husband and her children. They are the most important persons in her life. She also wears eyeglasses and said she cannot see clearly when she is far as 2-3 feet away. iii. Fluids and Nutrition Before Hospitalization: • Prior to admission, her usual meal is composed of ½ to 1 cup of rice, 1 piece of medium-sized fried fish, a cup of coffee with sweetener in the morning; ½ to 1 cup of rice with viand of vegetables at lunch time; ½ to 1 cup of rice with 2 medium-sized pork adobo at dinner time; she prefers vegetables and fruits. She drinks 9-11 glasses of water in a day approximately 2,640cc (240cc x 11). • As verbalized, “Mahilig ako sa gulay at prutas… nagdidiyeta na rin ako…”

During hospitalization: • The Doctor ordered a Diabetic diet with calorie intake of approximately 2000cal/day; consumes approximately 3,000cc oral fluids/day.

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Breakfast

Lunch

Dinner

Snacks

Total Kcal Intake per day 1,627.6 KCal

1 cup rice (200 Kcal) 1 cup coffee with sugar alternative (20.6Kcal) 1 slice Papaya (40 Kcal)

1 cup rice (200 Kcal) 1 serving fish stew (89 Kcal) 1 mediumsized banana (40 Kcal) Calamansi juice (60 Kcal)

1 cup rice (200 Kcal) 1 serving Beef Steak (118Kcal) 1 glass lemonade (60 Kcal)

2 glass juice (120 Kcal) 2 slice bread (200 Kcal) 8 pcs (30g/4pcs) Crackers 280 Kcal (140Kcal x 2)

iv. Elimination Before Hospitalization: • Usually defecates once every 2 to 3 days, usually in the morning, to a hard formed stool, yellowish - brownish in color; nocturia noted, urinates about 12-15 times a day with no difficulty reported. Urine is slightly hazy in color and approximately 70cc/hour. During Hospitalization: • Defecates once a day, with no definite time, to a soft formed stool, yellowish in color approx. 220cc a day; urinates about 11-12 times approximately 60-70cc/urination day with no difficulty reported. Urine is slightly (yellow to orange). v. Oxygenation Before Hospitalization: • Prior to admission no reports of DOB and SOB; home described as surrounded with trees; She doesn’t smoke but her husband smokes as a way of hobby at least once a month or nothing at all.

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During Hospitalization: • Upon admission at the 3-C Ward, revealing a normal RR ranging from 2022 cpm; (-) DOB; (-) SOB (April 13 to 15, 2009);

vi. Others i. Sexuality: o Generally Feminine in the way he acts, speaks and dress. ii. Allergies: o Reported (-) drug allergy; (-) asthma; (-) food; (-) dust. iii. Communication: o He communicates using Tagalog as their dialect. Responsive to the questions asked and able to comprehend. She is also able to speak Ilocano dialect and English. F. Physical Assessment MENTAL STATUS Conscious and coherent with fast response to external stimuli; GCS of 15/15 (E=4; V=5; M=6) as of April 13-15, 2010. o Impression: Congruent affect and happy mood, and with good feminine appearance and grooming. o Speech: Speaks clearly and speaks logically. o LOC: Alert and understands written and spoken language and responds appropriately. o Orientation: Oriented on the person near, place, and time. Approximately 3-4 inches in length with minimal white hair strands; Hair dry; well distributed in the scalp Head Normocephalic; (-) pediculosis capitis; (-) mass; (-) lesion or Face tenderness. Symmetrical facial structures; CNV Trigeminal nerve tested using cotton functioning well; CNVII facial functions tested through food functioning well. Eyes Eyebrows and eyelids are intact, arched along bony prominences above orbits; lashes present on upper and lower lids; (-) swelling of lacrimal gland or duct; with pale palpebral conjunctivae noted; with symmetrical pupils equally round and reactive to light accommodation; with pupillary size of 3 mm on both eyes; (+) medial movement of both eyes, symmetric movement of eyelids; (+) blurring of vision in both eyes wearing no glasses when reading. Ears Same color with the facial skin; top of pinna in line with the outer canthus of the eye; (+) moderate amount of cerumen on both ears; responsive to sound stimuli (CN VIII – Vestibulocochlear intact)
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Nose

Symmetrical; with patent nares, (-) nasal flaring noted; septum at midline, straight and intact; mucosa is dry and pale pink in color; able to distinguish odor (CN I – Olfactory Intact)

Throat/Mouth

able to stick out tongue and; (+) white curd like patches at the tongue surface; (+) gag and swallowing reflexes, able to speak and cough, able to distinguish taste ( CN IX – Glossopharyngeal intact Heart: and CN X – Vagus intact) Chest and Lungs: (-) palpable lifts and heaves; (-) murmurs; Cardiac rate 72-78 bpm. Inspection: With symmetrical lung expansion during respiration; diaphragmatic breathing noted, RR-20-22 cpm with regular rhythm; spine vertically aligned; spinal column is straight; right and left shoulder are at the same height. Palpation: o posterior – skin intact; (-) palpable masses; full symmetric lung expansion noted; bilateral symmetry of tactile fremitus is noted; most palpated at the apex of the lungs o anterior – uniform temperature on the anterior thorax noted; skin intact; (-) palpable mass on all quadrants of the breasts including the axilla; with full and symmetric lung expansion noted Percussion: Resonant sound heard on anterior and posterior intercostals spaces upon percussion Auscultation: (-) bronchial sound heard on both lung apex is noted; ()bronchovesicular sound heard on the mid-line of the lungs is noted; (-)vesicular breath sounds heard on both lung bases is noted upon auscultation.

Abdomen:

Genito-urinary: Skin and Extremities:

I – flat abdomen noted; (+) symmetric movement during respiration. A – with 2-3 borborygmic sound/min in all quadrants. P – dull sound heard at the first quadrant; tympanic sound percussed in 3rd and 4th quadrants. P – soft to touch, non-tender, with smooth, consistent contour.

Unable to assess.
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Cool skin; With body temperature of 33.1⁰C. Capillary refill of 2-3 seconds; fair in complexion; good skin turgor; muscle grade of 5/5 on upper extremities; muscle grade of 5/5 on lower extremities. Cranial Nerves Assessment I. II. Olfactory Nerve Optic Nerve wearing eyeglasses. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Oculomotor Trochlear Abducens Trigeminal Facial Acoustic Glossopharyngeal Vagus Spinal Accessory Hypoglossal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Unable to smell mild smells Blurry vision when not

General condition: Conscious and coherent; with stable vital signs SUMMARY OF FINDINGS SIGNIFICANT TO NURSING CARE 1. S: None O: Cool skin; with body temperature of 33.1⁰C. Nursing Diagnosis: Hypothermia R/T decreased metabolic rate 2. S : None O: Fluctuating blood glucose level. Nursing Diagnosis: Unstable blood Glucose R/T Diabetes Mellitus 3. S: As verbalized, “Mahilig ako sa gulay at prutas… nagdidiyeta na rin ako…”
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O: Prior to admission, her usual meal is composed of ½ to 1 cup of rice, 1 piece of mediumsized fried fish, cup of coffee with sweeter in the morning; ½ to 1 cup of rice with viand of vegetables at lunch time; ½ to 1 cup of rice with 2 medium-sized pork adobo at dinner time; she prefers vegetables and fruits. Nursing Diagnosis: Imbalanced nutrition: less than body requirements R/T Insulin deficiency 4. S: “Medyo may kalabuan ang paningin ko...” as verbalized. O: (+) blurring of vision in both eyes wearing no glasses when reading. Nursing Diagnosis: Disturbed Sensory Perception R/T Diabetes Mellitus 5. S: NONE O: presence of DM and PTB; exposed to visitors Nursing Diagnosis: Risk for infection R/T chronic disease (DM and PTB?)

PSYCHOSOCIAL THEORY BY ERIK ERIKSON Age Middle Adulthood: Book Profile Life Profile Remarks Erikson states that the significant The client was She task is to perpetuate culture and able to establish successfully 35 to 55 or 65 transmit values of the culture her own family accomplished Ego Development through the family (taming the and nurtured her this stage. kids) and working to establish a own Outcome: stable Generativity vs. Selfcomes through care of others and needs. absorption or production of something that Stagnation contributes to the betterment of Basic Strengths: Production and Care society, which Erikson calls environment. Strength according to their children

generativity, so when we're in this

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stage we often fear inactivity and meaninglessness. If we don't get through this stage successfully, we can become self-absorbed and stagnate.

CHAPTER III Laboratory Examinations and Results DIAGNOSTIC PROCEDURES 1. Urinalysis Definition: An array of tests performed on urine and one of the most common methods of medical diagnosis. Rationale: To determine urine compositions and possible abnormal components (such as protein, glucose and/or infection).
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Date ordered: April 12, 2010 DIAGNOSTIC PROCEDURE Colour RESULT Light Yellow NORMAL VALUES Pale to amber INTERPRETATION Within normal limitations. RATIONALE The intensity of the color generally indicates concentration of urine. Pale or colourless urine indicates dilute and yellow indicates urine is concentrated. Determines the clouding of urine; also called opacity or turbidity. Determine presence of glucose ion urine that may indicate DM, kidney damage.

Transparency

Slightly Hazy

Clear

Abnormal; (+) clouding in the urine output. Above normal. Indicates presence of glucose ion in urine and indicates presence of DM and kidney damage. Normal; Indicative of adequate defense mechanism against possible pathogens in the genitor-urinary infection. Indicative of negative existing dehydration

Glucose

(+1)

(-)

pH

6.5

4.5 – 8.0

To measure or determine the acidity or alkalinity of urine.

Specific gravity

1.012

1.005-1.035

Protein

(-)

(-)

Within normal limitations.

To measure the amount of substance dissolved in the urine. These tests also determine how well the kidneys are able to adjust the amount of water in the urine. Protein is normally not found in the urine. Fever, hard
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Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

Nitrite

(-)

(-)

Within normal limitations.

RBC

0-2/HPF

2-3/HPF

Epithelial

Few

None

Below normal result which means insufficient haemoglobin supply in the body. Presence of contamination.

exercise, pregnancy, and some diseases, especially kidney disease, may cause protein to be in the urine. Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary nitrates to nitrites. Nitrites in urine show a UTI is present. To determine the amount of oxygen being transported in the body It is normal not to have any epithelial cells present in a urine sample or to have occasional numbers of any of the three cell types. Large numbers of squamous cells may indicate contamination of the urine specimen, but large numbers of either the transitional or renal tubular cells may indicate a serious disease process. Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and
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Bacteria

Moderate

None

Presence of bacterial infection.

Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

Mucus Thread

Few

None

Normal

because of their ability to rapidly multiply in urine standing at room temperature. This is a common finding in urine since the entire urine system is filled with mucus.

5. Blood Glucose Test Definition: A blood glucose test measures the amount of sugar (glucose) in a sample of your blood. Rationale: Your doctor may order this test if you have signs of diabetes. It is also used to monitor patients who have the disease. Date April 12, 2010 Time 12 pm 2 pm 6 pm 12 midnight 6 am 11 am 6 pm 12 midnight 6 am 12 midnight 12 midnight 6 am Glucose Result Patient ate 334 mg/dL 210 mg/dL 223 mg/dL 186 mg/dL 260 mg/dL 147 mg/dL 169 mg/dL 169 mg/dL 160 mg/dL 193 mg/dL 186 mg/dL

April 13, 2010

April 14, 2010 April 15, 2010

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CHAPTER IV Schematic Pathophysiology and Narrative Pathophysiology NARRATIVE PATHOPHYSIOLOGY This section narrates the disease process of Diabetes Mellitus Type II/PTB. Mrs. Constellation’s condition is affected by predisposing factors such as family history and of old age of 54 years old. The highest incidence of DM Type II occurs in those persons with family history and in individuals ages 40 and above. Her diet also contributes to the illness process. When there is increased glucose in the blood, there will be increased absorption of glucose which will result to increase of its absorption in the GI tract, specifically in the colon.
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The stimulation of the production of glucose happens when the pancreas specifically the A cell, B cell, and D cell works together. The A cell increases the secretion of glucagon, B cell decreases the production of insulin which the D cells inhibits A cell and B cell processes. When there is increased absorption of glucose insulin deficit happens. Insulin deficits happen when there is the decreased secretion of insulin and there is insulin resistance. This will result to increased basal hepatic glucose production mainly in the liver resulting to decreased glucose metabolism and decreased insulin-stimulated glucose uptake. When there is decreased glucose metabolism there will be decreased in the flow of blood in the lymphatic system (perfusion) resulting in decreased immune system functioning which then increases the risk for infection. M. tuberculosis can be spread or transmitted through cough or sneezes of other people. Because of the lowered immune system response the process of invasion and proliferation of bacteria happens. The PTB is asymptomatic because of its early stage. The decreased of insulin-stimulated glucose uptake results to the abnormal metabolism of Carbohydrates, Protein and Fats thus affecting the lipid metabolism. If there is a problem in the lipid metabolism hypoglycemia happens which will result to hypothermia because of the decreased energy production or metabolism. Another, if there abnormal metabolism of Carbohydrates, Protein and Fats thus affecting the lipid metabolism which results to unstable blood glucose. When hyperglycemia occurs it will result to thickening of the capillary basement membrane resulting to capillary closure, demyelinization of the optic nerve, and aberrations of myelin sheath which affects the eyesight causing impaired visual perception specifically disturbed visual perception. When there is increased glucose in the blood stream meaning that there is decreased glucose in the cell/s which will cell starvation. When these happens polyphagia or excessive eating occurs because of the stimulation of the hypothalamus which is the satiety center causing excessive thirst and hunger which will result to increased food and water intake. When there is cell starvation there will be negative feedback mechanism which decreases the fat and protein in the body which caused imbalanced nutrition.
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When there is hyperglycemia, there will be glucosuria or the excess glucose spills in the urine resulting polyuria which result to flushing of excess glucose and ketones in the blood stream resulting to polydipsia and polyphagia.

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CHAPTER V Medical Management A. Diet Type of Diet NPO Date Ordered April 12, 2010 Rationale To prevent any alterations in diagnostic test done to the patient. To eat specific portions of Carbohydrates and Proteins at specific times throughout the day by a diabetic person to make sure that the diet is stabilizing blood sugar levels.

Diabetic Diet

April 13, 2010

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CHAPTER VI PRIORITIZATION OF NURSING PROBLEMS/NURSING CARE PLANS

ACTUAL OR ACTIVE PROBLEM: Problem No. Problem Date Identified Date Resolved Remarks

The temperature 1 Hypothermia R/T decreased metabolic rate April 13, 2010 April 14, 2010 increased but not in its normal level.

2

Unstable blood Glucose R/T Diabetes Mellitus Disturbed Visual Perception R/T Diabetes Mellitus

With latest blood April 13, 2010 April 15, 2010 sugar level of 186 mg/dL. The client can’t

3

clearly see an April 13, 2010 April 14, 2010 object 2-3 feet away.

4

Imbalanced nutrition: less than body requirements R/T Insulin deficiency

The client experiences April 14, 2010 April 15, 2010 fluctuation of blood sugar level.

HIGH RISK OR POTENTIAL:

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Problem No. 1

Problem Risk for infection R/T chronic disease (DM and PTB?)

Date Identified April 13, 2010

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1.
Perception R/T Diabetes Mellitus

3. Disturbed Visual

Hypothermia R/T decreased metabolic rate

Demographic Profile Name: Mrs. Constellation Gender: Female Age: 54 years old Marital status: Married Religion: Catholic Occupation: Selfemployed/Dependent/Housewife Educational Background: College Graduate (BS Commerce) Vital Signs: BP: 120/80 mmHg RR: 20 cpm PR: 72 bpm Temperature: 33.1 ⁰C

CONCEPT MAP
4. Imbalanced nutrition: less 5. Risk for infection
R/T chronic disease (DM and PTB?) than body requirements R/T Insulin deficiency

2.

Unstable blood Glucose R/T Diabetes Mellitus

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NURSING CARE PLAN PROBLEM #1 Statement of Problem STG: At the end of 2 hours, will be able to demonstrate measures that will enhance normothermia. INDEPENDENT Planning Nursing Intervention Outcome

Assessment

SC: “Ayos naman ang Hypothermia R/T pakiramdam ko pero decreased metabolic parang sa bawat oras ng rate pagkuha sa temperatura ko nasa 33 hanggang NANDA Definition: Body temperature below 35⁰C.” normal range. LTG: At the end of 3 days, will be able to continually demonstrate measures that will manage normal range of temperature.

OC:

Etiology: The cause of lower body Body temperature is because temperature the decreased below normal of metabolic rate range secondary to DM. Cool skin Temperature: Theory: 35.4⁰C (April 13, Background According to Virginia 2010), 33.1⁰C (April 14, Henderson the unique function of the nurse to 2010: 8:00am) 34.1⁰C (April 14, assist the individual, sick well, in the 2010: 10:00 am), or

Unable to measure temperature due to the 1) Established trust and end of duty. rapport. ®To gain trust and STG: partially met rapport for effective (April 14, 2010: 8:00 am assessment and 33.4⁰C then at 10:00 am intervention. 34.1⁰C) 2) Monitored vital signs LTG: partially met especially the temperature. (R) For baseline data and to plan effective interventions. 3) Provided warm liquids. (R) To enhance warming effect on the body and promote good circulation. 4) Encouraged to have moderate movement or
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Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

33.1⁰C (April 15, performance of those 2010) activities contributing to the health or its recovery (or to a peaceful death); that he would perform unaided if he has the necessary strength, will or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.

exercise. ® To increase the body temperature because it helps in metabolism. 5) Measured urine output. ® Oliguria/renal failure can occur due to low flow state and/or following hypothermic osmotic diuresis. 5.) Monitored laboratory studies, such as ABGs (respiratory and metabolic acidosis); electrolytes; CBC (increased hematocrit, decreased white blood cell count); cardiac enzymes (myocardial infarct may occur owing to electrolyte imbalance, cold stress catecholamine release, hypoxia, or acidosis); coagulation profile; glucose; pharmacological profile (for possible cumulative drug effects). ® To measure or identify
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Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

Assessment alterations. 6.) Provided wellbalanced, high-calorie diet/feedings. ® To replenish glycogen stores and nutritional balance. 7.) Discussed signs/symptoms of early hypothermia. ® To facilitate recognition of problem and timely intervention.

Statement of Problem

Planning

Nursing Intervention

Outcome

PROBLEM #2

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S: (none) NANDA Definition: Variation of blood glucose/sugar levels from the normal range. Etiology: Unstable blood sugar occurs because of DM. Background Theory: According to Lydia Hall’s Key Concepts of Three Interlocking Circles Theory “Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team.” LTG: at the end of 3 days will be able to maintain optimal wellbeing. STG: met With latest blood sugar glucose of 186 mg/dL. LTG: partially met

Unstable blood Glucose R/T Diabetes Mellitus

O:

o Weakness o Diabetes Mellitus o Fluctuating blood sugar levels: 334 mg/dL; 210 mg/dL, 223 mg/dL, 186 mg/dL, 260 mh/dL, 147 mg/dL, 169 mg/dL, 169 mg/dL, 160 mg/dL, 193 mg/dL,

STG: at the end of 2 hours nursing intervention, will be able to participate to normalize blood sugar level. 1.) Determined nutritional status and potential for delayed healing or tissue injury exacerbated by malnutrition. ® To plan for appropriate nursing care plan. 2.) Determined individual factors that may contribute to unstable Glucose. ® To know the mere cause. 3.) Provided information on balancing food intake, antidiabetic agents, and energy expenditure. ® To facilitate client’s understanding. 4.) Reviewed client’s
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Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

diet, especially carbohydrate intake. ® Glucose balance is determined by the amount of carbohydrates consumed, which should be determined in needed grams/day. 5.) Emphasized importance of checking expiration dates of medication, inspecting insulin for cloudiness if it is normally clear, and monitoring proper storage and preparation (when mixing required). ® Affects insulin absorbability. 6.) Checked injection sites periodically.
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Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

® Insulin absorption can vary from day to day in healthy sites and is less absorbable in lypohypertrophic (lumpy) tissues. COLLABORATIVE 1.) Consulted with dietitian about specific dietary needs based on individual situation (e.g., growth spurt, pregnancy, change in activity level following injury). ® To have adequate intake.

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PROBLEM #3

Assessment

Statement of problem

Planning

Nursing Intervention

Outcome

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SC: (none) INDEPENDENT

OC: Was met

Imbalanced nutrition: less than body requirements R/T Insulin deficiency STG: “Naiintindihan ko na ang kalagayan at kondisyon ng pangangatawan ko ngayon.”

o NANDA Definition: The state in which an individual is experiencing an intake of nutrients insufficient to meet metabolic needs. LTG: At the end of 3 days will be able to normalize eating habits and laboratory values. 2.) Identified food preferences, including ethnic/cultural needs. Etiology: The client is experiencing imbalanced nutrition because of the alterations of insulin production.

STG: At the end of 1 hour nursing intervention will be able to verbalize the causative factors. 1.) Ascertained patient’s dietary program and usual pattern; compare with recent intake. ® Identifies deficits and deviations from therapeutic needs.

o o

Pale conjunctiva noted Weakness Fluctuating blood sugar levels:

LTG: The goal was met with latest blood sugar level of 186 mg/dL.

334 mg/dL; 210 mg/dL, 223 mg/dL, 186 mg/dL, 260 mh/dL, 147 mg/dL, 169 mg/dL, 169 mg/dL, 160 mg/dL, 193 mg/dL, Background Theory: According to Dorothy Johnson “each individual has patterned, purposeful, repetitive ways of acting that comprises a behavioral system specific to that individual.” ® If patient’s food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge. 3.) Observed for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness. ® To make appropriate nursing intervention. 4.) Health teaching about the Diabetic Diet. ® To gain cooperation and
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o

Weight = 60.7 kg

Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

appropriate plan of nursing care. COLLABORATIVE 1.) Performed fingerstick glucose testing. ® For monitoring. 2.) Performed other laboratory diagnostic procedures as ordered by AP. ® For monitoring and accurate diagnosis of the client’s case. 3.) Consulted with dietitian for initiation of resumption of oral intake. ® Useful in calculating and adjusting diet to meet patient’s needs; answer questions and assist patient/SO in developing meal plans.

PROBLEM # 4

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Assessment

Statement of the problem

Planning

Nursing intervention

Outcome

SC: Medyo may kalabuan ang paningin ko...” STG: At the end of 1 hour nursing intervention, will be able to regain usual level of cognition. 1.) Identified client with condition that can affect sensing, interpreting, and communicating stimuli.

Disturbed Visual Perception R/T Diabetes Mellitus

STG: met LTG: partially met.

OC: LTG: At the end of 3 days nursing intervention will be able to be free of injury. (R) To plan for an appropriate nursing care plan. 2.) Monitored drug regimen. ® To identify medications with effects or drug interactions that may cause/exacerbate sensory/ perceptual problems. 3.) Evaluated sensory awareness: Stimulus of hot/cold, dull/sharp, smell, taste, visual acuity and hearing; gait/mobility, and location/function of body parts. ® To evaluate client’s response. 4.) Explained procedures/activities, expected sensations, and outcomes. ® For cooperation. 5.) Placed call bell/other
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o o

Wears eyeglasses Blurry vision

NANDA Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. Etiology: The client experiences blurry vision because of the presence of Diabetes Mellitus. Background theory: According to Dorothea Orem “Nursing is a service of deliberately selected and performed actions to assists individuals or groups to maintain self care including structural integrity, functioning and development."

Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

communication device within reach and be sure client knows where it is/how to use it. ® For immediate response of the health care provider. 6.) Assisted client/SO(s) to learn effective ways of coping with and managing sensory disturbances, anticipating safety needs according to client’s sensory deficits and developmental level. ® To facilitate client’s effective response.

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PROBLEM #5

Assessment Risk for infection R/T chronic disease (DM and PTB?)

Statement of Problem

Planning

Nursing Intervention

Outcome

SC: (none)

OC: LTG: At the end of 2 days, will be able maintain in demonstrating measures in preventing infection.

NANDA Definition: The state in which an individual is at increased risk for being invaded by pathogenic organisms. Etiology: Client is at risk because of the presence of Diabetes Mellitus and Pulmonary Tuberculosis.

STG: At the end of 1 hour nursing intervention will be able to verbalize and demonstrate ways of preventing infection.

Demonstrated and verbalized understanding of the regimen; performed hand washing before and after meals; ate orange during lunch. “Kailangan kong pangalagaang mabuti ang kalusugan ko lalo na dahil may sakit ako, kailangan ko ng pag-iingat para maiwasan ang iba’t ibang mga inpeksyon.”

a. Presence of illnesses b. Presence of daily visitors c. Administration of medications (subcutaneous)

Independent 1) Provided clean environment by performing hygienic measures such as bedside care. ® This promotes cleanliness and lessens harboring of microorganism from the client’s environment.

2) Demonstrated proper hand washing technique. ® To see how proper way of hand washing is done. 3) Educated on the importance of regular hand washing procedure. ®Hand washing procedure is a first line defence to prevent transfer of microorganism. 4) Instructed to eat foods rich in Vit. C such as calamansi, bayabas, and citrus; protein-rich foods
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STG: met LTG: met

Background theory: According to Florence Nightingale “Nursing is the act of utilizing the environment of the patient to assist him in his recovery.”

Lung Center of the Philippines – Case Study about Diabetes Mellitus Type II/PTB

such as milk and other milk products, chicken meat, egg white, etc. ®Vit. C rich foods enhance strong immune system making the body résistance. Protein rich foods promote tissue and wound healing through collagen formation. Dependent 1.) Antibiotic and Anti-TB administered by NOD, as indicated. ® A prophylaxis against susceptible and possible pathogenic organism. ® To prevent the development of MDR-TB.

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DISCHARGE PLAN

Assessment Nursing Intervention See separate page for intervention. Statement of problem Readiness for enhanced Therapeutic Regimen Management R/T (to be developed) Definition: A pattern of regulating and integrating into daily living a program for treatment of illness and its sequelae that is sufficient for meeting health-related goals and can be strengthened. Background Theory: Imogene King’s Nursing as a helping profession that assist individual and groups to attain, maintain and restore health. LTG: At the end of 3 days will be able to demonstrate activities that will aid in health promotion. Planning STG: At the end of 1 hour will be able to verbalized understanding about treatment regimen. Expected Outcome To demonstrate activities that could promote health.

S: “Ano pa ba ang pwedeng makatulong sa akin paglabas ko rito?” as verbalized.

O: Frequent questioning regarding treatment modalities.

INTERVENTION

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Nursing Intervention Medication: Continue taking prescribed home medication if any. ® To ensure that the patient will achieve the desired effect of the medications. ® To stimulate endogenous insulin production and increase insulin production and insulin sensitivity.

Rationale

Exercise Perform breathing and other appropriate exercise.

®To promote oxygen supply thereby relaxes muscle and relieves anxiety. ® To increase insulin sensitivity, improve glucose tolerance, and promote weight loss. ® To meet nutritional needs, to control blood glucose levels, and to help the patient reach and maintain his ideal body weight.

Treatment Meal Plan for Diabetes Mellitus.

Health Teaching Practice proper Hand washing.

OPD

Advised to have follow-up check after discharge

® To prevent transfer of microorganisms and spread of infection. ® To further evaluate clients health status after discharge and to monitor progress. ® To provide positive nitrogen balance to aid in healing process and boosts resistance against infection. ®To regain strength. ® To maintain appropriate sugar level. ® To strengthen faith that will help in healing process.

Diet

Eat foods rich in vitamin C such as citrus fruits, proteins such as eggs and meat products Instruct the patient to follow special diet as ordered. Spiritual Encouraged to pray and always seek God’s help, always have faith that everything has a purpose and it happens according to God’s will

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CHAPTER VI PROGNOSIS
The patient has shown signs of improvement through the medications, interventions given. There is a good prognosis.

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SUMMARY AND CONCLUSION
This study focused intensively on the case of my patient, Mrs. Constellation received a good nursing care. She had been monitored especially in her glucose levels. She was given medications and maintenance medication for her Diabetes and PTB. Several risk factors were confirmed and evaluated which contributed to the said problem. In our patient’s case the predisposing and contributing factors were age (54 years old) and genetics (maternal and paternal), diet (increase carbohydrates and sugar intake). The problems identified were Hypothermia R/T decreased metabolic rate, unstable blood Glucose R/T Diabetes Mellitus, Disturbed Sensory Perception R/T Diabetes Mellitus, Imbalanced nutrition: less than body requirements R/T Insulin deficiency, Risk for infection R/T chronic disease (DM and PTB?). Specific interventions were given for each identified nursing problems and evaluated accordingly.

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BIBLIOGRAPHY
Doenges, Marilyn E.,Moorhouse,Mary Frances and Geissler-Murr, Alice C. Nurse’s Pocket Guide, Eleventh Edition Davis Company,2008. Nursing Drug Handbook, 28 Ed. Philippines: Lippincot Williams and Wilkins © 2008
th

Suzanne Smeltzer, et.al., Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, Vol. 1, 11 edition ( Lippincott Williams and Wilkins, reprinted in the Philippines, © 2008),

th

Mary Brambilla McFarland, RN, MSN, et.al. Nursing Implications of Laboratory Tests, 2 edition (Delmar Publishers Inc., New York, USA, © 1988) Elaine Marrieb et. al. Principles of Anatomy and Physiology 8 Edition © 2007
th

nd

Gould, B. E. (2007). Pathophysiology for the Health Professions. Singapore: Elsevier (Singapore) Pte Ltd. Wilkins, L. W. (2005). Pathophysiology made Incredibly Easy! Philadilphea et. al.: Lippincott Williams and Wilkins.

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