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He is diagnosed of diabetes mellitus type 2. We choose this case because diabetes mellitus type 2, which can somehow be prevented, can lead to its worst complications if taken for granted. Over the past years, this non-infectious disease is becoming a worldwide epidemic – more and more people are becoming affected with it even at an early age. There is then a need for a massive health promotion that with good lifestyle, proper nutrition, and discipline, we can prevent the onset of this disease. Aside from that, once you have it, it will be a lifetime maintenance. Type 2 diabetes mellitus is previously known as adult-onset diabetes, maturity-onset diabetes, or non-insulin dependent diabetes mellitus (NIDDM) - is due to a combination of defective insulin secretion and defective responsiveness to insulin (often termed insulin resistance or reduced insulin sensitivity), almost certainly involving the insulin receptor in cell membranes. It is a group of disorders characterized by hyperglycemia and associated with microvascular (ie, retinal, renal, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and neuropathic (ie, autonomic, peripheral) complications. Unlike patients with type 1 diabetes mellitus, patients with type 2 are not absolutely dependent upon insulin for life, even though many of them are ultimately treated with insulin. There are numerous theories as to the exact cause and mechanism for insulin resistance, but central obesity (fat concentrated around the waist in relation to abdominal organs, not it seems, subcutaneous fat) is known to predispose for insulin resistance, possibly due to its secretion of adipokines (a group of hormones) that impair glucose tolerance. Abdominal fat is especially active hormonally. Obesity is found in approximately 90% of patients diagnosed with type 2 diabetes. Other factors may include aging and family history, although in the last decade it has increasingly begun to affect children and adolescents. In early stages, the predominant abnormality is reduced insulin sensitivity, characterized by elevated levels of insulin in the blood. Also in this stage, hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose 1
production by the liver; but as the disease progresses, the impairment of insulin secretion worsens and therapeutic replacement of insulin often becomes necessary. However, it may go unnoticed for years in a patient before diagnosis, since the symptoms are typically milder (e.g. lack of ketoacidotic episodes) and can be sporadic. Short term complications can happen quickly such as hypoglycemia, hyperglycemia, ketoacidosis, and hyper-osmolar syndrome. Patients need to be aware of their signs and symptoms and what to do to reverse them. Long term complications such as heart disease, kidney disease, neuropathy, diseases of the eyes, peripheral vascular disease and more can seriously compromise the diabetic patient. Moreover, due to poor circulation of blood in the periphery and loss of sensation due to neuropathy, patients with diabetes mellitus should avoid being wounded and infected at their limbs, especially their feet as this would lead to gangrene (death of tissues). If not treated promptly, the affected limb requires amputation as to prevent the infection from spreading. This disease is usually first treated by changes in physical activity (usually increase), diet (generally decrease carbohydrate intake, especially glucose generating carbohydrates), and through weight loss. These can restore insulin sensitivity. The next step, if necessary, is treatment with oral antidiabetic drugs. As insulin production is initially unimpaired, oral medication (often used in combination) can still be used that improves insulin production (eg, sulfonylureas) and regulate inappropriate release of glucose by the liver which substantially decreases insulin resistance (eg, thiazolidinediones). If these fail, insulin therapy will be necessary to maintain normal or near normal glucose levels. A disciplined regimen of blood glucose checks is recommended, in most cases, most particularly and necessarily when taking most of these medications.
II. OBJECTIVES OF THE STUDY With the case study presentation, we intend to: 1. Identify the anatomy and physiology of the endocrine system particularly the pancreas, the integumentary system and the cardiovascular system. 2. Discuss the causes of dysfunction of the aforementioned bodily systems. 3. Explain and connect the assessment of the client to the clinical manifestations of the condition and its pathophysiologic process. 4. Determine the medical and nursing management of the patient with the said disease and its complications. 5. Create a nursing process approach to serve as a background or blueprint of care for the client. 6. Identify the prognosis of a client affected with diabetes mellitus type 2. 7. Identify lifestyle revision for health maintenance in the discharge plan.
III. SCOPE AND LIMITATION OF THE STUDY This study deals with the general knowledge of diabetes mellitus including its ideal management and prevention. It also aspires to deal with the pathophysiological features of the disease and covers the anatomy and physiology of the affected systems. It consists of nursing care plans integrated to serve as a framework of care for the client with the support of the diagnostic evaluation and assessment findings. Furthermore, the study focuses on determining and assessing on how the said condition is acquired and to how to manage its complications. Our study is limited due to the fact that the scope focuses only on the possible management of diabetes mellitus in the given span of time. Since we only had a four (4) day exposure to the patient, we only had limited time to acquaint ourselves with the client regarding her needs and other factors related to her condition thus, we only render our nursing care plans with only short sighted management and interventions.
IV. PATIENT'S PROFILE Patient’s Name: Address: Age: Sex: Birth Date: Birth Place: Religion: Nationality: Spouse’s Name: Admission Date: Chief Complaint: Diagnosis: Physician: BP: T: PR: RR: Allergies: Mr. X Purok 1 San Martin, Villanueva, Misamis Oriental 62 years old Male June 5, 1958 Villanueva, Misamis Oriental Roman Catholic Filipino Mrs. X August 3, 2010 infected stump at left foot infected stump left below knee amputation secondary to diabetes mellitus type II Dr. Alburo 130/90 mmHg 36◦C 75 bpm 20 cpm No Known Food & Drug Allergies
Time of Admission: 1:15 PM
A person may experience midlife crisis between the ages of 35-45 years old. as a husband and as part of the community. 6 . Being non-productive led him to be stagnant after the occurrence and diagnosis of his disease which made him to be dependent with his family . the “deadline decade”. This occurs when the individual recognizes that he has reached the halfway mark of life.he can’t attend. the developmental task of the middle-aged adult is Generativity vs. Sociallyvalued work and disciplines are expressions of generativity.V. a 64-year old man belonging to a middle age group. This led him to be non-productive. As to our patient’s case. Stagnation. he is undergoing a developmental crisis because he cannot perform his daily activities as what he used to do due to the amputation of his left leg. function and be able to accomplish his responsibilities as a father. DEVELOPMENTAL STAGE Generativity vs Stagnation Maturity (35-65 yrs old) Generativity is the concern of establishing and guiding the next generation. and according to Erik Erikson.
This prompted him to consult at Northern Mindanao Medical Center (NMMC) and was diagnosed with infected left foot. 7 7 . he was advised by the doctor to go on amputation. he was amputated around last October 2009 and was discharged after 2 weeks. patient reported of itchiness around the amputated area on which he frequently scratched until it resulted to a wound. Thereafter. History of Present Illness Last August 3. this prompted the patient for consultation. 2010. he was diagnosed of suffering from diabetes mellitus type 2. the patient was diagnosed of infected stump left below knee amputation secondary to diabetes mellitus type 2. the patient was admitted at JR Borja Hospital. b. After further laboratory studies. he had an unhealed wound due to frequent scratching at his left leg which is worsening for about a month. Thereafter. One month prior to admission. He complained of painful and swollen condition around the amputated area with purulent discharges and foul odor. HISTORY OF PAST AND PRESENT ILLNESS a. about a year ago. Since the wound is at its worst condition.VI. Since the wound is getting worst and does not heal. Past History of Illness According to the patient.
5ₒC PR: Height( in ft and Diagnosis/ indication DM/ requested for amputation ALLERGIES Yes ___ No √ below) Food: _______________ Medication: _____________ _______________ BlOOD TRANSFUSSION HISTORY: Yes √ A Date of Transfussion Indication 8/4/10 To increase Hgb and Hct level No: ___ ( If Yes. ASSESSMENT STI COLLEGE Cagayan de Oro City COLLEGE OF NURSING ASSESSMENT FORM GENERAL INFORMATION Patient’s Name: Mr. Villanueva Educational Attainment: Elementary graduate trisikad driver Nationality: Filipino pesos/mo. HOSPITALIZATION HISTORY Date of admission Name of institution October 2009 NMMC Age: 62 y.o Status: Married Occupation: Income: 1000 Contact number: ---Time of T: 36.VII. X Date of admission(mm/dd/yy): 8/3/10 admission: 1:15 pm Base line vital sign: BP: 100/60 75bpm RR: 22 cpm Weight upon admission ( in Kg) : 51 kg in): 5’3” CHIEF COMPLAINTS Infected stump at left foot HISTORY OF PRESENT ILLNESS Patient was admitted august 3. X Address: Purok 1 San Martin. specify Others: Blood type: Reaction none 8 . Name of spouse/ guardian: Mrs. 2010 at 1:15 with chief complaints of painful and swollen amputated foot 1 week after prior to admission.
current. Indication for perioperative prophylaxis clindamycin 8/03/10 q8h Indicated for bacterial infection tramadol 8/03/10 q8h Relief of moderate to moderately severe pain LABORATORY EXAMS/IV FLUIDS Date Diagnostic/lab Date done Date ordered oratory ordered exams 8/03/10 Hgt 8/03/10 8/03/10 8/03/10 CBC 8/04/10 8/04/10 U/A 8/06/10 Have you been Taking your medication(s) as prescribed? Schedule PNSS Date discontinued 8/5/10 √Yes _ No _ No _ No _Obesity A.maintenance.MEDICATION HISTORY (previously taken.etc) DRUG NAME DATE TAKEN SCHEDULE INDICATION cefuroxime 8/03/10 q8h For risky people for bacterial infection. NUTRITION AND METABOLIC PATTERN Special Diet: √Yes (Specify) Full Diabetic Diet Supplements: √Yes (Specify) Milk Nutritional State: _Well Nourished √ Poorly Nourished _ Cachaxia Mouth: Lips Teeth Pinkish _ Complete_ Pallor √ _ Cyanosis _ Missing teeth √ Lesions_ Dentures_ Dryness/cracks_ Gums: Pinkish_ Terderness_ Pharynx: Mucosa Pinkish _ Pallor √ Cyanosis _ Tongue Midline √ Atropy _ Fasciculation_ Caries R/L deviation_ Pallor √ Bleeding_ 9 .
Laxatives. Specify Below) L_ Hematoma _ Non-Pitting_ Bi-Pedal_ Wounds/drains/dressing: wet and intact dressing at left leg Intravenous Fluids: PNSS B. at least once a day in minimal amount Date of last BM: 8/3/60 Are there any problem with hemorrhoids/continence? Yes _ No√ Use of anything to manage bowel( eg. anti –diarrhials) None 10 . enema.Uvula posterior pharynx Midline √ Inflammation_ R/l deviation _ Neck Trachea Others Midline √ Enlargement_ Lymphodenophaty _ Normal Rom √ Cervical Lymph Nodes _ Neck Rigity _ Skin General Color Moisture Pinkish _ Cyanotic_ Moist/Clammy_ Pallor√ Flushed_ Jaundiced_ Mottled_ Dusky_ Others Petechiae_ Lesions√ Edema: Pitting _ Pedal: R_ Grading_ mucosa Pinkish _ Pallor√ Reddish tonsil Not inflamed √ R/L deviation _ Thyroids R/L Deviation_ Tenderness_ Non-Palpable √ Enlarged_ Neck Texture _ Smooth _ Rough√ Others_ Temperature Warm √ Cool_ Others: _ Dry √ Oily_ Ecchymosis_ ( If Pitting. “ home remedies”. ELIMINATION Usual bowel pattern (describe character of stool. frequency. suppositories. discomforts) formed solid stool.
Abdomen General _ Palpation Superficial Veins_ Guarding_ Striae _ Tenderness_ Scars/Lesions_ Tenderness_ Bladder Distention_ Configuration Symmetrical √ Asymmetrical_ Flat_ Globular _ Protuberant_ Percussion Tympanitic √ Hypertympanitic_ Fluid Wave _ Shifting Dullness_ Dullness At: -----------------------Liver_ Mass Muscle Direct Rebound Organomegaly_ Scaphoid: _ Spleen_ es At:_______ Usual urinary pattern (describe frequency.regular Pericardial Rub____ Capillary refill 3 seconds Presence of pacemaker/A-V shunt/hemodynamic monitoring none Respiratory status: Breathing Pattern Shape Of Chest 11 . character. amount . ACTIVITY – EXERCISE PATTERN Cardiovascular status Chest Pain/Radiation_ Jugular Vein Distention_ Exertion_ Othopnea_ Palpitation_ nocturnal dyspnea_ Dyspnea On Paroxysmal Precordial Area Heart Sounds Peripheral Pulses Flat_ Distinct√ Symmetrical_ Bulging _ Regular √ Regular√ Tenderness_ Faint _ Faint√ Heave _ Irregular _ Strong_ Thrill_ Others_ Bounding_ Apical Rate And Rhythm: S3_____ S4_____ 80bpm . etc) Urine of clear yellow of at least 5-7 times a day in excessive amount Dysuria_ Retention_ Flank Pain_ Anuria_ : Hematuria_ Polyuria √ Nocturia_ Oliguria_ C. problem in control.
g ET. CHEST.Productive__ Sputum__ Color__ Amount __ Consistency__ O2 supplement/ventilatory assistance: none Respiratory tubes (e.Total independence 1. TRACH.Lung Expansion Regular √ Resonant√ Eupnea _ Dullness At: ______ Tachypnea_ Hyperresonant Dyspnea _ At:________ Exertion_ Use Of Accessory Muscles_ ICS Refractions/Bulging_ Pain on respiration_ Vocal/ Tactile Fremitus Symmetrical√ Decreased/Increased At: √ _____________ Rub_ Irregular _ Hyperpnea_ Bradypnea_ Rest _ Normal Apl Ratio√ Barrel Chest_ Funnel_ Pigeon_ Percussion Resonant√ Dullness At: _________ Hyperresonant Breath Sounds Rhonchi_ Bronchovesicular Rales /Crackles At_ Bronchial At_ Pleural Friction Wheezes At_ Cough Productive __ Non.Assist with device person 4.Assist with person 3.Assist with device 2.Total independence ADL Status Status Feeding 2 2 Bathing 2 Transfer 1 Dressing 2 1 Mobility Meal Preparation Cleaning Laundry 2 2 2 Bed Mobility Chair/Toilet Ambulation 12 .TUBE/describe secretions and/or drainage) N/A A Activities of daily living/motility status Use the activity level code below to assess ADL and motility status 0.
regularity): regular active .O. COGNITIVE.Grooming 2 2 Toileting 2 R.PERCEPTUAL PATTERN Level Of Consciousness Conscious√ Alert √ Drowsy__ Stuporous __ Comatose__ Orientation Oriented√ Restless__ Disoriented To: ___ Tingling Sensation__ Time/Person/Place __ Head: Normocephalic√ other:___ Facial movement scalp Symmetrical √ Assymetrical : __ Dandruff__ Lag at R__ L __ Wounds/Scars/Lesions__ 13 Close√ Sunken __ Fine__ Coarse √ Clean √ Lice_ Asseymetrical__ Fontanels Enlarge___ Hair Masses __ Muscle Tone and Equally Strong Symmetrical In Size__ R/L Upper Lower Extremities√ R/L Upper Lower Paresis__ R/L Upper/Lower Paralysis__ Gait Coordinated__ Smooth __ Staggering√ Shuffling Confused __ Others __ Emotional State Calm __ Worried/Anxious √ Dizziness __ Others:__ Numbness __ Bulging __ Dry √ Open: Specify__ Alopecia__ .M Reasons for ADL/mobility Limitation: Amputated leg Device used for assistance: crutches Exercise pattern( describe type.assistive R.M BACK AND EXTREMITIES Range of motion Strength Decreased ROM √ Joint Tenderness √ Varicose Veins__ Deformities√ Joint Swelling At:__ Spine Midline √ Lordosis__ __ Kyphosis __ Scoliosis__ Uncoordinated __ D.O.
Eyes: Licis and lens Symmetrical √ R/L edema/swelling __ R/L ptosis__ Periorbital region Conjunctiva Edema __ Sunken_√ Discoloration_ Pink_ Pale√ Lesions _ Discharges _ Cornea Opacity: R_ L_ Lesions_ Sclera Visual Aculty Peripheral vision Reaction to accomodation Anicteric __ Grossly normal __ Intact/full __ Uniform constriction/convergence√ Subicleric __ farsighted __ Decreased/Limited√ Unequal constriction/convergence_ Icteric __ Nearsighted√ Hemorrhrages __ Wears eyeglasses__ Ears: External Pinnae Grosshearing Normoset√ Normal_ Symmetrical√ Decreased√ Tenderness_ Symmetrical_ Lesion_ R/L Deafness_ Gross Abnormalities_ External Canal Discharge: Foul Smelling_ Serous√ Purulent_ Mucoid_ Cerumen: Impacted_ Not impacted√ Shallow nasolabial fold__ Mucosa Pinkish_ Pale √ Reddish __ Discharge Serous√ Mucoid __ Purulent__ Bloody __ Masses/lesion___ Gross smell Normal/Symmetrical √ Sinuses Tenderness__ 14 Both R L Tympanic Membrane Intact√ Not Intact_ Nose Alar flaring__ Septum Patency Midline √ patent√ Deviated__ obstruction__ Perforated__ obstruction__ .
SLEEP.SEXUALITY-REPRODUCTIVE PATTERN Are there any changes/problem with sexual relation?yes Male Prostate problems : Monthly problems : Penis Discharge __ Tenderness__ Scrotum Equal shape w/L lower than R __ enlargement__ R/L undescended testes __ Tenderness __ Nodules/growth/lesions__ Others: Hernia __ Hydrocele__ H. COPING-STRESS TOLERANCE PATTERN Have you experienced any recent stressful situations in addition to your illness/hospitalization? 15 Non-tender__ R/L ___ Yes ___ Yes √ No √ No Nodules/growths/lesions__ . Filipino Speech difficulties none Are there learning difficulties ____ Yes √ No Are there changes in memory lately ___ Yes √ No Pain No problem _____ Problem √ Location left foot Type aching pain Intensity Pain scale of 8/10 Onset___ Duration 15-20 seconds Methods of pain management: tramadol 50 mg IVTT q8h E. I can no longer perform my daily activities independently. Are there any ways the patient feel differently about his/her since has been ill/hospitalize? Yes.SELF-PERCEPTION AND SELF-CONCEPT PATTERN How do you describe yourself? I feel I’m useless.REST PATTERN Usual sleep/pattern 3 hours a day Adequate: ___ Yes √ No Factors affecting sleep/rest: pain Methods to promote sleep: taking pain medication __________________________________________________________________________________ F.R olfactory deficiency__ Maxillary__ L/ olfactory deficiency___ Frontal__ Cognition Primary language Cebuano. he blames himself all the time for being so careless. Description of nonverbal behavior: narrowed focus and frowning __________________________________________________________________________________ G.
What do you do for relaxation? Deep breathing exercise. friends. sleeping. family. foul odor __________________________ Aching Pain __________________________ 2nd amputation Sweling and 16 . neighbors ____________________________________________________________________________ __ INSTRUCTION: Place an X to the specific area of abnormality during your physical Assessment Infected stump At left leg BKA redness Purulent discharges. watching tv Support groups/counseling resources used: spouse. How do you usually manage stresses? Resting and listening to radio.Yes √ No__ If ‘yes “ please describe briefly: I got stress especially I felt pain.
upon which they act. and the gonads (testes for males and ovaries for female). however. tissue function. The major organs of this system include hypothalamus. These glands are ductless. and metabolism.beta cells. pineal gland. pancreas (islets of Langerhans – alpha cells . The aforementioned endocrine organs produces its own hormones to regulate and control the many and varied functions of the human body e. parathyroid gland. There are 17 . growth and development.g. is much slower and more prolonged than that of the nervous system. ANATOMY AND PHYSIOLOGY THE ENDOCRINE SYSTEM The endocrine system is a major controlling system in the body. A hormone is a specific messenger molecule synthesized and secreted by a group of specialized cells called an endocrine gland. the other major body system that acts to maintain homeostasis. thyroid gland.. pituitary gland (anterior and posterior pituitary gland). mood. thymus gland. adrenal gland (adrenal cortex and adrenal medulla). Its means of control.VIII. and delta cells). as well as sending messages and acting on them. which means that their secretions (hormones) are released directly into the bloodstream and travel to elsewhere in the body to target organs.
In standard histological sections of the pancreas. glucagon and somatostatin. • Beta cells (B cells) produce insulin and are the most abundant of the islet cells. allowing their secreted hormones ready access to the 18 .also other hormone-producing tissues and organs but we will focus here about the endocrine pancreas. Insulin is released when blood levels of glucose are high. islets. The endocrine pancreas refers to those cells within the pancreas that synthesize and secrete hormones. which is also produced by a number of other endocrine cells in the body. This portion takes the form of many small clusters of cells called islets of Langerhans or. Islets are richly vascularized. which severely disturbs body metabolism. Humans have roughly one million islets. Pancreatic islets house three major cell types. the different cell types within an islet are not randomly distributed . Cardinal signs are polyuria. Insulin and glucagon are critical participants in glucose homeostasis and serve as acute regulators of blood glucose concentration. stimulates the liver to release glucose to blood. Glucagon. plus a few other hormones. and polyphagia. which produce an alkaline fluid loaded with digestive enzymes which is delivered to the small intestine to facilitate digestion of foodstuffs. The bulk of its mass is exocrine tissue and associated ducts. The Endocrine Pancreas The pancreas is an elongated organ nestled next to the first part of the small intestines which houses two distinctly different tissues. released when blood levels of glucose are low. Scattered throughout the exocrine tissue are several hundred thousand clusters of endocrine cells which produce the hormones insulin and glucagon.beta cells occupy the central portion of the islet and are surrounded by a "rind" of alpha and delta cells. more simply. It increases the rate of glucose uptake and metabolism by body cells. Hyposecretion of insulin results in diabetes condition. polydipsia. a number of other "minor" hormones have been identified as products of pancreatic islets cells. each of which produces a different endocrine product: • Alpha cells (A cells) secrete the hormone glucagon. islets are seen as relatively pale-staining groups of cells embedded in a sea of darker-staining exocrine tissue. Aside from the insulin. • Delta cells (D cells) secrete the hormone somatostatin. Interestingly. thus increasing blood glucose levels.
protects and informs the animal with regard to its surroundings. from integere to cover. It is also very involved in maintaining the proper temperature for the body to function well. pressure. It distinguishes. The skin is an ever-changing organ that contains many specialized cells and structures. from in. Additionally. From bottom to top the layers are named: • • stratum basale stratum spinosum 19 . The skin functions as a protective barrier that interfaces with a sometimes-hostile environment.5 mm. The integumentary system has a variety of functions. and is the attachment site for sensory receptors to detect pain. In humans the integumentary system also provides vitamin D synthesis. feathers. Although islets comprise only 1-2% of the mass of the pancreas.circulation. Epidermis The epidermis is the outer layer of skin. dermis. and plays an active role in the immune system protecting us from disease. Small-bodied invertebrates of aquatic or continually moist habitats respire using the outer layer (integument). comprising the skin and its appendages (including hair.5-2m 2 of surface area. where gases simply diffuse into and out of the interstitial fluid. Understanding how the skin can function in these many ways starts with understanding the structure of the 3 layers of skin . The thickness of the epidermis varies in different types of skin. and nails). and subcutaneous tissue. The Integumentary System The integumentary system (Etymology . they are innervated by parasympathetic and sympathetic neurons. In humans.Latin integumentum. and nervous signals clearly modulate secretion of insulin and glucagon.05 mm and the thickest on the palms and soles at 1. is called integumentary exchange. it may serve to waterproof. The integumentary system is the largest organ system. this system accounts for about 16 percent of total body weight and covers 1. and protect the deeper tissues. they receive about 10 to 15% of the pancreatic blood flow. cushion. It gathers sensory information from the environment.the epidermis. It is the thinnest on the eyelids at . sensation.+ tegere to cover) is the organ system that protects the body from damage. separates. The epidermis contains 5 layers. and regulate temperature. excrete wastes. and temperature. scales. This gas exchange system.
0 mm on the back. It is . they flatten and eventually die. and temperature. • The hair follicles are situated here with the erector pili muscle that attaches to each follicle. has cells that are shaped like columns. elastic tissue.3 mm on the eyelid and 3. and reticular fibers. 20 • • • • . The nerves transmit sensations of pain. Specialized Dermal Cells The dermis contains many specialized cells and structures. but they are not associated with hair follicles.not in layers. Layers of the Dermis The two layers of the dermis are the papillary and reticular layers. Specialized Epidermal Cells There are three types of specialized cells in the epidermis. As the cells move into the higher layers. flat skin cells that shed about every 2 weeks. Blood vessels and nerves course through this layer. the stratum corneum. the stratum basale. The lower. reticular layer. The types of tissue are collagen. The top layer of the epidermis. The dermis is composed of three types of tissue that are present throughout . There are also specialized nerve cells called Meissner's and Vater-Pacini corpuscles that transmit the sensations of touch and pressure.• • • stratum granulosum stratum licidum stratum corneum The bottom layer. • • The upper. is thicker and made of thick collagen fibers that are arranged parallel to the surface of the skin. is made of dead. contains a thin arrangement of collagen fibers. In this layer the cells divide and push already formed cells into higher layers. Sebaceous (oil) glands and apocrine (scent) glands are associated with the follicle. papillary layer. itch. This layer also contains eccrine (sweat) glands. • • • The melanocyte produces pigment (melanin) The Langerhans' cell is the frontline defense of the immune system in the skin The Merkel's cell's function is not clearly known Dermis The dermis also varies in thickness depending on the location of the skin.
The size of this layer varies throughout the body and from person to person. the living blood cells that make up about 45% of whole blood includes (1) erythrocytes or RBCs – disk-shaped. (2) leukocyte or WBCs – ameboid cells involved in protection of the body. They are an important part of the immune system. provides the means by which the bodies cells receives vital nutrients and oxygen and dispose of their metabolic waste. Agranulocytes on the other hand includes lymphocytes and monocytes. Plasma makes up 55% of whole blood. so that vital activities can go on continuously. wastes. Normal adult blood is 5 to 6 liters. It is composed of a nonliving fluid matrix (plasma) and formed elements. This layer is important is the regulation of temperature of the skin itself and the body. White blood cells are only activated by chemical messengers in the body such as chemicals produced by the inflammatory process. White blood cells (WBCs) are important in fighting off infections in the body. gases. eosinophils and basophils. Formed elements. antibodies. Its propulsive force is the contracting heart. 21 . gases.Subcutaneous Tissue The subcutaneous tissue is a layer of fat and connective tissue that houses larger blood vessels and nerves. electrolytes. hormones. the vital fluid that courses through the body's blood vessels. proteins. the blood and the blood vessels. anucleate cells that transport oxygen bound to their hemoglobin molecules. and so on. the system carries nutrients. They are classified into major groups based on the presence of granules: granulocytes and agranulocytes. and many other substances to and from body cells. depending on the amount of oxygen carried. Granulocytes include neutrophils. Its color is from scarlet to dull red. but homeostatic mechanisms act to keep it relatively constant. exchanges continually occur between the blood and the tissue cells. The major function of the cardiovascular system is transportation. Plasma condition changes as body cells remove or add substances to it. The Cardiovascular System This system composes of the heart. waste. Dissolved in plasma (primarily water) are nutrients. salts. As blood flows past the tissue cells. THE BLOOD Blood. and (3) platelets – cells fragments that act in blood clotting. Using blood as the transport vehicle.
inactivity Destroyed beta cells Insulin production/ decrease secretion of insulin Feeling of hunger Stimulation of hunger mechanism via hypothalamus Cell starvation (INTRACELLULAR HYPOGLYCEMIA) Insulin resistance of body cells Absorption of glucose by the cell POLYPHAGIA Gluconeogenesis * humulin – 18 “u” @ 6 AM & 8 “u” @ 6 PM SQ Hgt: 221 mg % blood glucose level (EXTRACELLULAR HYPERGLYCEMIA) Breakdown of fats Degradation of proteins Systemic Blood Viscosity Hyperlipidemia plasma osmolality of glucose Weight Loss Thickening of blood vessel walls (Artheresclorosis) From 58 kg to 51 kg Hypertension Glusose spill to renal tubules Glucose attracts water BP: 130/100 mmHg 22 .o Precipitating factors: 1.IX. family history of DM 2. lifestyle 2. PATHOPHYSIOLOGY Predisposing factors: 1. Age: 62 y.
50 mg IVTT q8h *wound dressing *foul odor *discoloratio .Glucosuria Excessive Urination: 5-7x a day Polyuria Perfusion of blood to vital organs dehydration Feeling of excessive thirst: intake of water Polydipsia Nerve demyelinazation Impaired immune function Retinopathy Risk for Nephropathy Neuropathy Tingling and numbness Impaired sensation at the periphery ability to fight off infection & to repair tissue Blurred vision *clindamycin .Signs/Symptoms *Below Knee Amputatio n (BKA) Infection * purulent discharges *WBC count: 13.Disease Process Injury at the right foot Wound Delayed wound healing . 100 *Pain *tramadol .Treatment .750 mg IVTT q8h *ceftriaxone 1 gm q8h *tetanus toxoid 5mL IM *anti-tetanus serum 6000 IU IM Prone to infection LEGEND: .300 mg IVTT q8h *cefuroxime .The name of the disease or disorder Gangrene Diabetes Mellitus Type II *Above Knee Amputation (AKA) 23 .
18 70-110 mg% 40-165 mg/dL 130-250 mg/dL 31-85 mg/dL 60-175 mg/dL 0-40 mg/dL Below 4.0 mg% 109.7-5.2 g/dL 0.6-1.hyperglycemia Normal Normal Below normal Normal Normal Below normal – protein deficiency Normal 24 .80 1.X.40 79.53 129.85 2.33 94.0 mg%.0 0-38 IU/L 100-290 U/L 3. MEDICAL MANAGEMENT a.0 mg% 08/04/2010 Tests Fasting Blood Sugar Lipoprotein Profile: Triglycerides Total Cholesterol HDL LDL VLDL HDL RATIO (CHOL/HDL) ALAT (SGPT) ALB.52 19. 139.0 mg% 221.5 mg/dL Above normal .0 mg% 08-04-2010 221. Laboratory Results Test/Date HEMOGLUCOSE TOLERANCE 08-03-2010 123.34 15. PHOSPHATASE Albumin Creatinine RESULT REFERENCE REMARKS 121.
30 32.0 vol% 70.HEMATOLOGY REPORT 08/3/10 CBC Total WBC Total RBC Hemoglobin Hematocrit MCV MCH MCHC Platelet count RESULT 13.0-97.90 x 103/mm 12 .10-33.69 .5.0 – 47.0 150.6 26 221.0-390.0-35.infection Below normal .anemia normal ABO TYPING RESULT: Type A + Result BUN CREATININE 25 2 Range 10-20 0.5 8.anemia Below normal .0 x 103/mm REMARKS Above normal .16 gm/dL 37.1 5.2 Indication decreased renal function decreased renal function 25 .10 x 103/mm 3.0 26.0 REFERENCE 5 .anemia Below normal .6-1.
Doctor’s Order 26 .b.
o For legal medical action o To have a baseline data for comparison of data and to monitor patient’s condition o To control blood glucose level o To screen if hematologic components are within normal range o To screen renal function o To determine blood glucose level o To determine fat content in the blood o To determine cardioactivity.now FBS Lipid profile ECG 12 lead CXR PA RATIONALE o To render proper medical management and treatment of condition. 8/3/10 2 PM Refer for any unusualities IM NOTES: Patient seen and examined o History and PE done o hypertensive o 2009 – amputation 27 o To treat hyperglycemia o For active CO-management o For accurate monitoring of patient’s condition o To provide prompt action to potential problems .DATE 8/3/10 TIME 6 AM DOCTORS ORDER Please admit to surgical ward Secure consent for care TPR q4h Full diabetic diet LAB: • CBC • • • • • • • U/A Start Hgt . o To evaluate suspected cardiovascular disorders o To evaluate renal/liver function o To administer safe and effective infusions of medications intravenously Albumin phosphatase. albumin IVF: PNSS 1 L @ KVO Rate MED: o To boost protection against (1) TTO 5ml PO tetanus infection (2) ATS 6000 “u” ANST (3) Cefuroxime 750mg IVTT every shift o For anti-infection ANST (4) Clindamycin 300mg IVTT q8h ANST (5) Tramadol 50mg IVTT o For pain every shift PRN for pain Refer to IM department Monitor V/S q2h & record pls.
Drug Study STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine.o Civil Status: Married Attending Physician: Dr. Reuben San Martin. Villanueva Infected stump at left foot DRUG STUDY Age: 62 y. Alburo 29 .c.
.Have vit. K available in case of hypoprothombin emia occurs . anorexia.indicatio n for bacterial infection .Date Order ed Generic Name (Brand Name) Classificat ion Dosa ge Mechanism of Action Indicatio ns Conraindication Side Effects or Adverse effects . dizziness. . diarrhea.Hematolo gic: bone marrow depressio n Nursing Implication/ Responsibilities 8/04/1 CEFUROXI 0 ME (CEFTIN) ANTIBIOTIC (2nd generation cephalospo rin) 750 mg IVTT q8h Bactericidalinhibit synthesis of bacterial cell wall causing cell death . vomiting.paresthe sia. lactation and pregnancy .used cautiously with renal failure.GI: Nausea.contraindic ated with allergy to cephalospo rin or penicillin .Avoidance of alcohol while taking this drug and for 3 days 30 after because severe reactions often occur .Give oral drug with food to decrease GI upset .CNS: Headach e .Teach client to take the full course of the therapy even if they are feeling better .
Inhibit protein synthesi s in suscepti ble bacteria.Have vit. tartrazine. eosinophili a . lactation . 31 . Villanueva Infected stump at left foot Classifica tion Dosa ge Mechanis m of Action .o Civil Status: Married Attending Physician: Dr. hepatic or renal dysfunction . hypotensio n .GI: pseudome mbranous colitis.STI COLLEGE Name Of Patient: Address: Chief Complaint: Date Order ed Generic Name (Brand Name) DRUG STUDY Palamine. K available in case of hypoprothom binemia occurs .Teach client to take the full course of the therapy even if they are feeling better . vomiting .used cautiously history of asthma or other allergies.leucopen ia.used cautiously in newborns and infants due to benzyl alcohol content.Hematolog ic: neutropeni a.Local: thrombopl ebitis after IV use Nursing Implication/ Responsibiliti es .Avoidance of alcohol while taking this drug and for 3 days after because severe reactions often occur 8/04/1 CLINDAMY 0 CIN (CLEOCIN HCL) ANTIBIOTI C (lincosami de) 300 mg IVTT q8h . causing cell death Indications Age: 62 y.CNS: cardiac arrest (with rapid IV infusion). . nausea. Reuben San Martin.Treatment for septicemia and sepsis adjunct to surgical treatment of chronic bone and joint infections due to susceptible organisms. Alburo Contraindication Side Effects/Adv erse Effects .
STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine. Villanueva Infected stump at left foot DRUG STUDY Age: 62 y. Reuben San Martin. Alburo Date Orde red Generic Name (Brand Name) Classificati on Dosag e Mechani sm of Action Indicatio ns Contraindication Side Nursing Effects/Adv Implication erse Effects / Responsibi lities 32 .o Civil Status: Married Attending Physician: Dr.
Alburo 33 .Binds to mucopio id receptor s and inhibits the reuptak e of norepin ephire and serotoni n .Use of CNS depressant or MAOIS.GI: nausea vomiting.Limit used in patients with past or presents history of addiction to or dependen ce STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine. diarrhea. or psychoactive drugs . lactation. renal dysfunction.8/04/1 TRAMADOL 0 ANALGESIC 50 mg IVTT q8h . Villanueva Infected stump at left foot DRUG STUDY Age: 62 y.CV: hypotensio n . opioids.used cautiously in pregnancy. dizziness or vertigo. seizures .Contraindicat ed with allergy to tramadol or opioids or acute intoxication with alcohol. head ache. dry mouth . hepatic impairment .o Civil Status: Married Attending Physician: Dr. Reuben San Martin.Dermatolog ic: Sweating .Relief of moderat e to moderat ely severe pain .CNS: sedation. seizures. concomitants .
Most infectio ns caused by suscepti ble organis ms .Tell patient to report adverse reactions promptly .GI: nausea vomiting. usually bactericid al .Date Orde red Generic Name (Brand Name) Classificati on Dosag e Mechanis m of Action Indicatio ns Contraindication Side Nursing Effects/Adv Implication erse Effects / Responsibi lities .CNS: dizziness and head ache .skin: Pain. diarrhea . rashes .Instruct patient to report discomfort in IV insertion site .Teach family of the patient and the patient about drug administra tion 8/04/1 CEFTRIAXO 0 NE (ROCIPHEN) Antibiotics 1 mg q8h IVTT A third generatio n cephalosp orin inhibits cell wall synthesis promoting osmotic instability.Contraindicat ed with patient with hypersensitiv e to drug or other cephalosporin s 34 .
be given paralysis of the more recurrent frequently nerve. brachial occur. disorders. Guillain-Barré syndrome .Rule out with or without thrombocy tenderness as topenia well as mor other urticaria.indicate antigen d for response booster in the injection immunized only for patient persons causing 7 years the of age formation or older of against antibodies tetanus to tetanus toxins . Malaise.o Civil Status: Married Mechanis m of Action Indicatio ns Contraindication Side Effects/Advers e Effects Nursing Implication / Responsibi lities 08/04/ TETANUS 10 TOXOID (TETANUS TOXOID ADSORBED) Vaccine 5 mL IM . booster paralysis of the should not radial nerve.STI COLLEGE Name Of Patient: Date Orde red Generic Name (Brand Name) Palamine. and coagulatio rash.Induces an . Reuben Classifica tion Dosa ge DRUG STUDY Age: 62 y.Inflammation. plexus .A routine neuropathies.CNS: allergic cochlear reaction lesion.Instruct hypotension. than every 35 accommodatio ten years. . n paresis.should be given with great care in patients suffering from thrombocyto penia or other coagulation disorders . n transient fever. pain. . client to nausea and immediate arthralgia may ly if develop adverse .
Address: Chief Complaint: San Martin. Alburo 36 . Villanueva Infected stump at left foot Attending Physician: Dr.
.o Civil Status: Married Attending Physician: Dr.Redness or hard lumps at place of en . Villanueva Infected stump at left foot DRUG STUDY Age: 62 y. Reuben San Martin.STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine. Alburo Date Orde red Generic Name (Brand Name) Classificati on Dosag e Mechani sm of Action Indicatio ns Contraindication Side Nursing Effects/Adv Implication erse Effects / Responsibi lities .Prophyla xis and treatme nt of tetanus . blocking the action on the body’s system.It binds to the tetanus toxins in your blood.Contraindicat ed in patient sensitive to serum 37 .Limit used in patients with past or presents history of addiction to or dependen ce 8/04/1 ANTIImmune 0 TETANUS sera TOXOID (TEFABULIN) 6000 IU IM .
ts hypoglycem .Metabolic: vity to drug hypokalemi and its a.Other: edema.Promotes glucose transport . sodium componene retention.promotes phosphor Indicatio ns Contraindication Side Effects/Adv erse Effects Nursing Implication/ Responsibili ties -Be aware that insulin is a high alert drug whether given subcutaneou -sly or I. rash. Villanueva Infected stump at left foot DRUG STUDY Age: 62 y. -Monitor glucose level frequently to assess drug efficacy and appropriaten ess of dosage -Monitor for signs and symptoms of hypoglycemi 38 8/05/1 HUMULIN 0 (INSULIN ISOPHANE) Insulin 18 “u” SQ 8”u” SQ . pruritus .V. lipodystroph y.decreas e high blood glucose levels . rebound ia hyperglyce mia (Somogyi effect) . lipohypertro .STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine.Skin: urticaria. Alburo Date Orde red Generic Name (Brand Name) Classificati on Dosag e Mechanis m of Action . Reuben San Martin.o Civil Status: Married Attending Physician: Dr.hypersensiti .hypoglycem ia. stimulate s carbohyd rate metaboli sm in skeletal and cardiac muscle and adipose tissue .
erythema. or warmth at injection site. where it is converte d to glycogen phy. allergic reactions including anaphylaxis a -Keep glucose source at hand in case hypoglycemi a occurs 39 .ylation of glucose in liver. stinging.
leucopenia. tachycardia. dizziness. bradycardia .Inhibits the action of histamin e at the H2 receptors at the parietal cells of the stomach. impaired real or hepatic function. constipation . inhibiting basal gastric acid secretion Indicatio ns Contraindication Side Effects/Adv erse Effects .DRUG STUDY Name Of Patient: Address: Chief Complaint: Palamine. rash.Contraindic ated to patients that are allergic to the drug . -Take drug as prescribed. malaise. thrombocyt openia. pancytopeni a. abdominal pain.headache.o Civil Status: Married Attending Physician: Dr. Alburo Date Orde red Generic Name (Brand Name) Classificati on Dosag e Mechanis m of Action . nausea and vomiting. granulocyto penia. Nursing Implication/ Responsibili ties -Assess history of allergy to ranitidine. Villanueva Infected stump at left foot Age: 62 y.To prevent gastric irritation . Reuben San Martin. 8/08/1 RANITIDINE 0 Histamine (H2) antagonist 50 mg IVTT prior OR Transp ort . -Inform the patient about the side effects of the drug.Use cautiously to patients with impaired renal function 40 . diarrhea.
itching at IV site 41 .
Alburo 42 .o Civil Status: Married Attending Physician: Dr.XI. NURSING MANAGEMENT Actual Nursing Care Plan STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine. Villanueva Infected stump at left foot NURSING CARE PLAN Age: 62 y. Reuben San Martin.
>To promote circulation and prevent pressure ulcer >To increase gravitational blood flow > To improve peripheral circulation. Villanueva Nursing Diagnosi s >Ineffecti ve peripheral tissue perfusion related to high glucose level in the blood and low hemoglobi n count NURSING CARE PLAN Age: 62 y. >Elevated head of the bed > Encourage for early ambulation >Increase fluid intake COLLABORATIVE: >START BLOOD TRANSFUSION OF FWB .cge ug ngotngot’’.STI COLLEGE Name Of Patient: Address: CUES Subjectiv e ‘’Dili gakaau akong samad . the patient will be able to show signs of increased perfusion by: > skin is less pallor > less swelling and pain at the operative site >Review laboratory result especially hemoglobin. Enhance venous return. >Encourage patient to perform active or assistive range of motion. Alburo Interventions Rationale Evaluation Goals & Objectives At the end of 8hrs nursing care. the problem was completely met since patient was less pallor and there is less swelling and pain at the operative site.as verbalize by the patient Objectiv e >decrea sed hemogl obin count Hgb -8. Reuben San Martin. 43 . >For adequate hydration >To increase Hgb concentration in the blood >To treat bacterial infection and thus promoting healing process At the end of 8 hours duty.o Civil Status: Married Attending Physician: Dr. > Administer cefuroxine 750 mg IVTT 98 and ceftriaxone 1gm 98’ >To monitor closely the hemoglobin count and to document properly.6 mg/dl >HgT: 221 mg % > pale as noted >slightl y weak in appeara nce as noted >swellin g & pain at the operativ e site Palamine. 450 cc.
Objectiv e >Weakn ess >With amputat ed left residual limb >Limited range of motion >Fatigue >Functio nal level: 1 (requires use of crutches) Nursing Diagnosi s Impaired physical mobility related to musculoskeletal impairmen t Goals & Objectives At the end of my 8-hr duty. Interventions Rationale Evaluation >Encourage and assist patient to facilitate early ambulation >Teach/demonstrate patient on how to use appropriate assistive device (crutches) >Putting a pillow on each side of the patient to serve as side rails >Assist patient in turning to side every two hours >Carefully plan Patient’s daily activities -To promote blood circulation With good nursing intervention -Helps the patient done.” As verbaliz ed by the patient. adequate rest in between physical activities to prevent fatigue. 44 . patient will demonstrate a better range of motion and ambulate according to patient’s mobility and tolerance.Chief Complaint: Infected stump at left foot CUES Subjecti ve “Kapoy kayo magliho k-lihok kung isa ra atong tiil kay dili ko kataron g og balance sa akong lawas. my goal is ulcer completely -As to provide met. my client to increase the was able to level of mobility demonstrate a -This promotes safe better range of environment and motion and prevent patient ambulate from possible adequately accident enough -This promotes according to his blood circulation to level of mobility all body tissues and and tolerance. prevent decubitus thus.
Villanueva Infected stump at left foot NURSING CARE PLAN Age: 62 y. Reuben San Martin.o Civil Status: Married Attending Physician: Dr.STI COLLEGE Name Of Patient: Address: Chief Complaint: Palamine. Alburo 46 .
Elevation of the residual limb reduces swelling and promotes venous return -For caution and prevention of putting pressure and weight bearing under the residual limb -Exposing the residual limb to microorganism increases the risk of infection and to minimize foul odor -To aid tissue repair -To minimized the infection and clean the wound. 47 . patient’ s affected limb’s swelling and redness would be reduced . since there was a noticeable decrease in redness and swelling in the affected site. .” As verbal ized by the patien t. DISCHARGE PLAN CUES Subje ctive “ Dili kaayo ko kaliho klihok kay sige og ngutngot ang sama d.XI. Objec tive >Red ness in ampu tated site >Swe lling in the ampu tated site >Puru lent disch arges as noted Nursi ng Diagn osis Impai red skin integri ty relate d to surgic al incisio n Goals & Objecti ves At the end of my 8-hr duty. Interventions Rationale Evaluatio n >Elevate the residual limb >Put soft material/pillow under the residual limb >Protect the residual limb from contamination by wrapping it properly >Encourage to eat protein –rich food when on DAT COLLABORATIVE: >Do wound dressing BID as prescribed. >After 8h of with good nursing interventio n the goal was partially met.
.PROGNOSIS Medications medication o 6am Teach client about strict compliance to humulin (Insulin Isophane) – 18 “u” SQ at 8 “u” SQ at 6PM Exercise Take the full course of the therapy and do not skip taking medication. Emphasize to patient the importance of regular exercise that it improves blood circulation Teach client how to do proper exercise Encourage frequent ambulation.adequate fluid intake Outpatient Check-up . Refer to physician if condition worsens Emphasize the compliance of full diabetic thinking and hope for the better.avoid eating foods with refined sugars such as soda & cake. health according to their religion and culture. Treatment of wound care happens.regular exercise . Instruct on proper wound care Educate about maintain aseptic technique Notify physician if any unusualities Impart health teachings with emphasis even if with cranes. Diet diet .strict compliance to medication .proper wound care Inform client about the scheduled followup visit as ordered by the physician.XII. opt for more complex carbohydrates like crackers. on: Health Teaching . Spiritual Maintain adequate fluid intake Advise client to always have positive Encourage client and to pray for good 48 Pray. Instruct client not to sleep most of the time.
and successful implementation of controlled measures and of the disease.X.The prognosis of the patient with diabetes mellitus type 2 depends on the access of medical care. compliance of medications and proper hygiene. financial resources. We therefore conclude that the patient’s prognosis is poor. In the case of Mr. In addition to that. preventing injury. Since the patient is financially incapable for the necessary treatments and medication to treat the worsening condition. the patient does not comply well to the instructions given especially on the modifications he had to take to prevent complications of diabetes such as proper diet. regular exercise. 49 . two problems arises that will result to good prognosis – financial resources and the patient’s attitude. it is expected that prognosis will likely be poor.
aacnjournals.org/wiki/Blood o http://en.Lippincotts Nursing Drug Guide(4th edition) Elaine N.com o http://www.XIII. Mary Frances Moorhoose.net/mmpe/sec06/ch067/ch067c. Erb (2008).virtualmedicalcentre.wikipedia. Fundamentals of Nursing(8th edition) Amy M. Kozeir. Snyder.medscape.com o http://www. Essentials of Human Anatomy & Physiology(8th edition) Marilynn E. Marieb(2006).scribd.ask. Karch(2008). Mary Frances Moorhoose. Doenges.html o http://www.com/article/890740-overview o http://www. Nursing Care Plan(7th edition) Marilynn E.com/anatomy. Doenges. Alice C. Murr (2006). Murr (2002).Maternal & Child Health Nursing Amy M. Alice C.google. Nurse's Pocket Guide(8th edition) Lippincott Manual of Nursing Practice (8th edition) Volume 1 • • E-BOOKS Brunner and Suddarth's Textbook of Medical-Surgical Nursing David’s Comprehensive Handbook of Laboratory and Diagnostic Tests with ABC of Diabetes (6th Edition) by Tim Holt and Sudhesh Kumar Nursing Implication (2nd Edition) INTERNET o http://ccn. Focus on Nursing Pharmacology(4th edition) Adele Pititteri(2003).com 50 .org/wiki/endocrine_system o httpmerckandcoinc.REFERENCES BOOKS • • • • • • Berman.wikipedia.org/cgi/content/full/28/1/42#SEC6 o http://emedicine.asp?sid=16#C8 o http://en. Karch(2010).
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