Chapter 1

INTRODUCTION

Diabetes mellitus (DM) is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria, polydipsia, and polyphagia. When the glucose concentration in the blood is raised beyond its renal threshold (about 10 mmol/L), reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine (glycosuria). This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water held in body cells and other body compartments, causing dehydration and increased thirst. Type 1DM results from the body's failure to produce insulin, and presently requires the person to inject insulin (Also referred to as insulin-dependent diabetes mellitus (IDDM) or "juvenile" diabetes). Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency (formerly referred to as noninsulindependent diabetes mellitus (NIDDM) or "adult-onset" diabetes). If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin (insulin insensitivity or resistance), or if the insulin itself is defective, then glucose will not have its usual effect, it will not be absorbed properly by those body cells that require it, nor will it be stored appropriately in the liver and muscles. The net effect is persistent high levels of blood glucose, poor protein synthesis, and other metabolic derangements, such as acidosis. Type 2 Diabetes is a chronic disease that affects an estimated 16 million or more Americans. Studies show that the number of people suffering from Type
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2 Diabetes is increasing in almost every country around the globe. Every year more than 3 million people worldwide die of Type 2 Diabetes. Globally, as of 2010, an estimated 285 million people have type 2 diabetes, making up about 90 percent of all diabetes cases. The glucose level in the body in Type 2 Diabetes patients is higher than in normal people who do not suffer from this condition. Generally after eating, the food reaches the stomach where it breaks down into a sugary substance known as glucose. This glucose is then carried through the blood stream to all the cells in the body. In Type 2 Diabetes patients the insulin, which is the substance that does the work of converting glucose into energy, is produced in insufficient quantities. Because of this, cells found in the body's fat, liver and muscles are unable to utilize the glucose that is present leading to a drastic increase in the glucose level of the blood while cells that need glucose to function properly are deprived of it. This has very severe consequences and after a period of time the blood vessels and nerves could get seriously affected and lead to other related illnesses including blindness, nerve problems, kidney disease, and heart attacks. In extreme cases, drastic action including amputation of limbs is called for. Diabetes mellitus and hypertension are common diseases that coexist at a greater frequency than chance alone would predict. Diabetic nephropathy is an important factor involved in the development of hypertension in diabetics. The hallmark of hypertension in type I and type II diabetics appears to be increased peripheral vascular resistance. Increased exchangeable sodium may also play a role in the pathogenesis of blood pressure in diabetics. There is increasing evidence that insulin resistance/ hyperinsulinemia may play a key role in the pathogenesis of hypertension in both subtle and overt abnormalities of carbohydrate metabolism. Population studies suggest that elevated insulin levels, which often occurs in type II diabetes mellitus, is an independent risk factor for cardiovascular disease. Other cardiovascular risk factors in diabetic individuals include abnormalities of lipid metabolism, platelet function, and clotting factors.

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Chapter 2

HEALTH HISTORY

A. Biographical Data Patient X is 59 years old, married and was born on December 31, 1952 at Tagbilaran Bohol. She is a Catholic. Her permanent residency is in Matalbis Masinloc, Zambales,with her husband and their six kids. She is unemployed. B. Present Health History Two days prior to admission, Patient X had facial edema. Prior to admission, Patient X complained of having facial edema and body weakness. She sought consultation at President Ramon Magsaysay Memorial Hospital and the doctor referred her immediately. She was admitted on June 20, 2012 at 10:35 pm. Her admitting diagnosis was Hypertension I and Diabetes Mellitus. C. Past Health History Patient X had no vaccinations during childhood. She has no known allergies to food or drugs. She has six children that were all normal deliveries. After the birth of her last child, shes been getting a recurrent hypertension In the past, the patient X has been admitted in the hospital two times. In 1989 she was admitted with the diagnosis of Pulmonary TB and on 2009 for the disarticulation of one of her right toe. D. Family Health History Patient X is the third child out of four. Her father died when she was 28 years old due to hypertension. He was an avid smoker and had a history of asthma and high blood. Her mother is still alive at the age of 78, and has a
Diabetes Mellitus with Hypertension (A Case Analysis) Page 3

history of stroke and Diabetes Mellitus. She was also an avid smoker for 62 years. She doesnt know if any of her siblings have any health complications. E. Psychosocial Health History Patient X owns a house in Masinloc. Its a cemented house, with one room and one bathroom. Her third child resides with them and is financially dependent. F. Dietary Health History Patient X had body weakness on the day of her admission. She felt weak and had poor appetite. But on any other normal day she likes to eat 2 cups of rice, 2 pieces of tuyo, tinapa or daing, coffee, a glass of water and sweets for breakfast. She doesnt have snacks between breakfast and lunch. At lunch time, she likes to eat 2 cups of rice, tu, a glass of water and a soft drink. For her afternoon snack, she eats 2 pieces of bread, cup of soft drink and glass of water. For dinner, she likes to eat 2 cups of rice, tuyo and a glass of water. Patient X doesnt drink enough water daily. At the most, she drinks only five cups of water a day as opposed to 12 cups thats recommended daily. She tries to balance what she eats by eating a serving of vegetables and fruit at least once a day.

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Chapter 3

PHYSICAL ASSESSMENT

GENERAL APPEARANCE Inspection > Body built, height, weight in relation to clients age, lifestyle and health > Posture and gait, standing, sitting and walking > Over all hygiene and grooming > Body and breath odor

NORMAL FINDINGS > Proportionate varies with lifestyle

ACTUAL FINDINGS > slightly weak and fat

INTERPRETATION

> Generally appearance shows some abnormal result, due to her condition

> Relaxed, erect > Able to sit but posture; coordinated cannot walk and movement stand alone > Clean and neat > fair hygiene

> Signs of health and illness

> No body odor, or minor body odor related to work or exercise; no breath odor > Healthy appearance

> No body odor

> Generally uniform in color of skin, slightly weak > slightly cooperative > Appropriate to situation > Slow pace, soft

> Clients attitude > Cooperative, able to follow instruction > Clients mood > appropriate according to situation > understandable, moderate pace, clear tone and infection: exhibits thought association

> Quantity, quality, and organization of speech

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PROCEDURE BP PR RR Temp

NORMAL <120 / <80 60-100 16-20 36.5-37.5

VITAL SIGN 140/80 85 19 37.1

ASSESSMENT High Normal Normal Normal

BODY/ORGAN SKIN INSPECTION Skin Color

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

Skin Lesions

> Varies from light to deep brown; from ruddy pink to light pink; generally uniform except in areas exposed to the sun > Freckles, some birthmarks, some flat and raised nevi; no abrasion and other lesions > Moisture in skin folds in axilla > Within the normal range > When pinched, skin springs back to previous state (+) Edema

Light to deep brown

Skin is not normal due to edema

With scars and striae

PALPATION Skin Moisture

Dry

Skin Temperature Skin Turgor

Temp: 37.1 C

Skin springs back late

Presence of Edema

With facial/extremity edema

HEAD INSPECTION Skull

>Normocephalic

Normocephalic

Skull of the client is Page 6

Diabetes Mellitus with Hypertension (A Case Analysis)

>(-) Tenderness Scalp >Lighter in color >Moist/Oily >(-) Lice, nits and dandruff >(-) Lesions >(-) Tenderness nor masses > Black, brown or burgundy > Evenly distributed >Thick or thin > Brittle nor dry

(-) Tenderness Lighter in color Moist (-) Lice, nits and dandruff (-) Lesions (-) Tenderness nor masses Black with scanty amount of white hair Evenly distributed Thin Dry Rounded Symmetrical (-) involuntary muscle movement Evenly placed and in line Not protruding Equal palpebral tissue Symmetrical and in line Black and evenly distributed Black and evenly distributed It covers small

normal sized. Normal

Hair

White hair normally occurs during adulthood

FACE INSPECTION Eyes

> Shape may be oval or rounded > Face is symmetrical > (-) involuntary muscle movement > Evenly placed and in line > Not protruding > Equal palpebral tissue

Face is rounded because client is slightly fat

Eyebrows

> Symmetrical and in line > May be black or brown > Evenly distributed

Eyelashes

>Color depends on race > Evenly distributed > Upper eyelids

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cover small portion of the iris, cornea, and sclera when eyes are open Eyelids >(-) PTOSIS >Meets completely when the eyes are closed >Symmetrical >Pinkish or red > Moist > (-) Ulcers > (-) Foreign objects > (-) Irregularities in the surface > Looks smooth >Clear and/or transparent > (-) Visible materials >Color is black, blue, brown or green depending on the race >Equally round >Constrict briskly when light is directed to the eye >Dilates when looking at distant object >Constricts when looking at near objects > Sclera is white in

portion of the iris, cornea, and sclera when eyes are open (-) PTOSIS Meets completely when the eyes are closed Symmetrical Pale Moist (-) Ulcers (-) Foreign objects (-) Irregularities in the surface (-) Drooping of the eyes

Conjunctiva

Conjunctiva is pale due to insufficient blood supply

Cornea

Iris

Looks smooth Clear

Pupils

(-) Visible materials Black

Equally round Constrict briskly when light is directed to the eye Dilates when looking at distant object Constricts when looking at near objects White in color

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Sclera

EARS INSPECTION

color >(-) yellowish discoloration > Some capillaries maybe visible > Earlobes are bean shaped, parallel, and symmetrical > Earlobe is parallel to the outer canthus of the eye >Skin is the same color as in the complexion > (-) Lesions > Auricles has a firm cartilage > Ear canal has normally some cerumen >(-) Discharge or lesions

(-) yellowish discoloration (-) capillaries visible Bean shaped, parallel, and symmetrical Parallel to the outer canthus of the eye Skin is the same color in the complexion (-) Lesions Auricles has a firm cartilage Cerumen serves as protection of the ears against dirt Ear is normally placed and in size

With some cerumen >(-) Discharge or lesions (- ) pain or tenderness when palpated

PALPATION

> (-) pain or tenderness when palpated

NOSE INSPECTION

>Nose in the midline > (-) discharges > Both nares are patent > (-) Tenderness > Nasal mucosa is pinkish to red >With visible margin > Symmetrical in appearance and

In midline (-) discharges Both nares are patent (-) Tenderness Nasal mucosa is pinkish With visible margin Symmetrical in

Nose is normally placed with no discharge

MOUTH INSPECTION

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movement > Pinkish in color >(-) Edema Gums > Pinkish in color > (-) Gum bleeding >(-) Receding gums >32 teeth for adults > White to yellowish in color

appearance and movement Pinkish (-) Edema Pinkish (-) Gum bleeding (-) receding gums 26 teeth White to yellowish in color (-) Halitosis Pinkish with white taste buds (-) Lesions (+) Gag Reflex Able to move freely and with strength Surface of tongue is rough Dental loss, dental fillings and/or dental carries normally seen during adult because calcium level decreases

Teeth

> (-) Halitosis Tongue > Pinkish with white taste buds > (-) Lesions > (+) Gag Reflex > Able to move freely and with strength > Surface of tongue is rough Uvula >Positioned in the midline > Pinkish to red in color > (-) swelling or lesions > Straight and in mid line > Symmetrical > Trachea is palpated > (-) Mass or Lymph nodes

Positioned in the midline Pinkish (-) swelling or lesions

NECK INSPECTION

PALPATION

Straight and in mid line Symmetrical Trachea is palpated (-) Mass or Lymph nodes

Lymph nodes may be a sign of infection in head area

BREAST INSPECTION

> When overlying

Breast is even

Breast is normal Page 10

Diabetes Mellitus with Hypertension (A Case Analysis)

the breast should be even > Not completely symmetrical at rest > Areola is round or oval with same color (pink to dark brown) >Nipples are rounded, averted, same size and equal in color >(-) Discharge from the nipples PALPATION >(-) palpable masses or lumps > (-) Tenderness upon palpation

when overlying Not completely symmetrical at rest Round and dark brown in color

Rounded, averted, same size, and equal in color (-) Discharge from the nipples (-) palpable masses or lumps (-) Tenderness upon palpation

ABDOMEN INSPECTION

> Skin color is uniform > Some clients have striae or scar > Contour may be flat, rounded, or scaphoid > Visible peristalsis

Not uniform With striae and scar Rounded Not visible

Presence of striae and/or scars are normal Peristalsis is only seen on thin clients

EXTREMITIES INSPECTION

PALPATION

> Both extremities are equal in size > Has equal contraction and even > (-) Involuntary movement >(-) Edema >Color is even > Temperature is warm and even

Equal in size Not equal in contraction (-) Involuntary movement (+) Edema Color is not even Temperature is warm and even

Extremities are not normal

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LUNGS &THORAX INSPECTION Skin Integrity > Chest must be symmetric; skin is uniform in temperature; full and symmetric expansion Chest is symmetric; skin is uniform in temperature; full and symmetric Lungs are not normal

AUSCULTATION Breathing and Breath sounds > Quiet, effortless respiration Breathing is not equal and irregular, presence of wheezing sounds

CARDIOVASCULAR INSPECTION Skin Color Veins PALPATION Intercostal space

> Uniform in color >Chest veins are evenly distributed > Intercostal space and clavicles are visible > No masses

Masses

Uniform in color Chest veins are evenly distributed >Intercostal space and clavicles are visible No masses

Cardiovascular is normal

AUSCULTATION Cardiac sound MUSCOSKELETAL INSPECTION Muscle size

> Murmurs are absent

Murmurs are absent

Muscle strength

Equal in size on the both side of the body Equal strength on each body

>Equal in size on the both side of the body >Equal strength on each body side

Muscoskeletal is not normal

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Deformities

side No deformities, no bone contracture

>No deformities, no bone contracture

PALPATION Muscle tonicity Normally firm Slightly firm

Crania l Nerves I II III

Name

Type

Function

Assessment

Olfactory Optic Oculomotor

Sensory Sensory Motor

Smell Vision & Visual fields Extra ocular eye movement(EOM ); movement of sphincter of pupil; movement of ciliary muscles of lens EOM; specifically moves eyeball downward and laterally Sensation of cornea, skin of face, and nasal mucosa

Client is able to identify different aromas Clients can identify different objects Client can move her eyes in different directions

IV

Trochlear

Motor

Client can move her eyes downward and laterally

Trigeminal Opthalmic branch

Sensory

Clients eye normally reacts and client can also identify light and deep palpation

Sensory Maxillary branch Motor and Sensory Sensation of skin of face and anterior oral cavity (tongue Page 13

Diabetes Mellitus with Hypertension (A Case Analysis)

Mandibular branch

and teeth) Muscles of mastication; sensation of skin of face EOM; moves eyeball laterally Facial expression; taste (anterior twobirds of tongue) Equilibrium Hearing

VI VII

Abducens Facial

Motor Motor and Sensory

VIII

IX

Auditory Vestibular branch Cochlear branch Glossopharyng eal

Sensory Sensory

Client can move eyeball laterally Client can do different facial expressions and able to raise her eyebrows and close eyes tightly Client can hear and identify different sounds

Motor and Sensory

Swallowing ability, tongue movement, test(posterior tongue) Sensation of pharynx and larynx; swallowing; vocal cord movement Head movement; shrugging of shoulders Protrusion of tongue; moves tongue up and down and side to side

Client can move her tongue horizontally and laterally

Vagus

Motor and Sensory

Client can talk clearly

XI

Accessory

Motor

Able to move her shoulder against resistance of the eye Client can move her tongue side to side

XII

Hypoglossal

Motor

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NEUROLOGIC MENTAL STATUS 1. Orientation

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

>Should be able to orient to date, time place and reason for being hospitalized (Q: Alam nyo po ba kung ano ang dahilan kung bakit kayo nandito? At alam nyo rin po ba kung ilang araw na kayo dito at kung anong araw at oras ngayon?)

> Not able to remember the date of admission (Dahil dito sa sakit kong diabetes kaya ako nalipat dito galing San Marcelino, pero diko na alam kung ilang araw na ako dito, at di ko rin kasi alam kung anong oras na ngayon.)

Result shows not normal findings

2. Memory Immediate recall >Able to answer questions being asked (Q:Ano ang pangalan pong pangalan nyo?) >Able to recall recent memories (Q: Uminom ka na po ba ng gamot nyo?) > Able to answer questions that happened a long time ago (Q: ilang taon po kayo ng nabuntis kayo) >Score should be 15, inactive of the persons alertness, responsive and being oriented >Able to answer questions being asked (A: Monina) Result shows normal findings

Recent memory

>Able to recall recent memories (A: Hindi pa eh)

Result shows normal findings

Remote memory

> Able to answer questions that happened a long time ago (A: 25)

Result shows normal findings

3. Level of Consciousness

> Best eye opening response:4 (opens spontaneously), best verbal response:5 (oriented),best motor response: 6 (obeys verbal command) GCS=15

Result shows normal findings

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BASIS: 0 +1 +2 +3 +4 REFLEXES A. Biceps Reflex B. Triceps Reflex C. Patellar Reflex L +2 R +1 D. Achilles Reflex E. Plantar Reflex L +2 R +0 L +2 No reflex respond Minimal activity (hypoactive) Normal responses More active than normal Maximal activity (hyperactive) ASSESSMENT +2 +2 R +1 FINDINGS Normal Response Normal Response Minimal Activity (Hypoactive) Normal Response Minimal Activity (Hypoactive) Normal Response No reflex respond Normal Response

ASSESSMENT Finger to nose test Alternating supination and pronation of hands on knees Finger to nose and to the Nurse finger Finger to finger Finger to thumb Pain sensation Temperature Sensation Position or kinaesthetic sensation Stereognosis (ability to identify objects by touching them)

NORMAL FINDINGS (+) repeatedly and rhythmically touches the nose (+) Can alternately supinate and pronate hands in rapid pace (+)Performs with coordination and rapidity (+)Performs with coordination and rapidity Rapidly touches each finger to thumb with each hand (+) Able to identify sharp and dull sensation (+) Able to indentify hot and cold sensation (+) Can readily determine the position of fingers and toes (+) Recognize common objects

DEVIATIONS FROM NORMAL Gives slow response

Performs with slow irregular timing of movements Moves slowly and often misses the hand Moves slowly and not able to touch finger continuously Slow movement of hand and uncoordinated Some areas have reduced sensation Some areas have a reduced sensation Slowly identifies the position of fingers and toes Unable to identify common objects

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Chapter 4

LABORATORY FINDINGS

A. HEMATOLOGY Date: June 20, 2012 Time: 10: 25 am TEST RESULT 8.85x 109/L NORMAL VALUES WBC 5-10,000 cells cubic cm NEUTROPHILS LYMPHOCYTES 0.695 0.233 0.45-0.73 20-40 Normal Decreased. May indicate aplastic anemia. MONOCYTES 0.015 2-5 Decreased. May be due to use of medication (corticosteroid) EOSINOPHILS 0.052 1-4 Decreased. May indicate viral infection, bone marrow suppression. RBC HGB 5.14x1012/L 93g/L 4.0-4.9 12-16 Normal. Increased. May be due to transfusion reaction and intravascular
Diabetes Mellitus with Hypertension (A Case Analysis) Page 17

ANALYSIS & INTERPRETATION Normal

hemolysis. HCT 24.3% 33-47 Decreased. May indicate massive anemia. PLATELET 282 150,000-450,000 DECREASED: May indicate decreased platelet production, increased platelet destruction

B. URINALYSIS Date: June 20, 2012 Time: 10: 25 am TEST RESULT NORMAL FINDINGS COLOR yellow Amber yellow/ pale yellow TRANSPARENCY Turbid Clear to slightly hazy Ph Specific gravity 5.0 1.030 3.35-7.45 1.015-1.025 ANALYSIS &INTERPRETATION Concentrated urine due to dehydration. May be due to pus in the urine. Normal Hypersthenuria.increased concentration of solutes in the urine Rbc Plenty Negative or rare Pus cells Plenty 0-8 May indicate pyuria May indicate hematuria.

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C. HEMATOLOGY Date: June 20, 2012 Time: 10:25 am TEST RESULT NORMAL VALUES RBS 204 mg/dl 200 mg/dl ANALYSIS & INTERPRETATION Slightly elevated. May indicate diabetes mellitus due to damage of the blood vessels.

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Chapter 5

ANATOMY AND PATHOPHYSIOLOGY

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The endocrine system is the system of glands, each of which secretes a type of hormone directly into the bloodstream to regulate the body. The endocrine system is in contrast to the exocrine system, which secretes its chemicals using ducts. It derives from the Greek words "endo" meaning inside, within, and "crinis" for secrete. The endocrine system is an information signal system like the nervous system, yet its effects and mechanism are classifiably different. The endocrine system's effects are slow to initiate, and prolonged in their response, lasting from a few hours up to weeks. The nervous system sends information very quickly, and responses are generally short lived. Hormones are substances (chemical mediators) released from endocrine tissue into the bloodstream where they travel to target tissue and generate a response. Hormones regulate various human functions, including metabolism, growth and development,tissue function, and mood. The field of study dealing with the endocrine system and its disorders is endocrinology, a branch of internal medicine. Features of endocrine glands are, in general, their ductless nature, their vascularity, and usually the presence of intracellular vacuoles or granules storing their hormones. In contrast, exocrine glands, such as salivary glands, sweat glands, and glands within the gastrointestinal tract, tend to be much less vascular and have ducts or a hollow lumen. In addition to the specialized endocrine organs mentioned above, many other organs that are part of have other body systems, endocrine such as the For as

kidney, liver, heart and gonads, example the kidney

secondary endocrine

functions. such

secretes

hormones

erythropoietin and renin. The endocrine system is made of a series of glands that produce chemicals called hormones. A number of glands that signal each other in sequence are usually referred to as an axis, for example, the hypothalamicpituitary-adrenal axis.

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Pancreas The pancreas is an elongated organ located toward the back of the abdomen behind the stomach. The pancreas has digestive and hormonal functions. One part of the pancreas, the exocrine pancreas, secretes digestive enzymes. The other part of the pancreas, the endocrine pancreas, secretes hormones called insulin and glucagon. These hormones regulate the level of glucose (sugar) in the blood. The pancreas houses two distinctly different tissues. The bulk of its mass is exocrine tissue and associated ducts, which produce an alkaline fluid loaded with digestive enzymes which is delivered to the small intestine to facilitate digestion of foodstuffs. Scattered throughout the exocrine tissue are several hundred thousand clusters of endocrine cells which produce the hormones insulin and glucagon, plus a few other hormones. Insulin and glucagon are critical participants in glucose homeostasis and serve as acute regulators of blood glucose concentration. From a medical perspective, insulin in particular is enormously important - a deficiency in insulin or deficits in insulin responsiveness lead to the disease diabetes mellitus.

SECRETED HORMONE

FROM CELLS Islet cells

EFFECT Intake of glucose, glycogenesis and glycolysis in liver and musclefrom blood intake of lipids and synthesis of triglycerides in adipocytes. Other anabolic effects. Glycogenolysis and gluconeogenesis in liver increases blood glucose level. Inhibits release of insulin, inhibits release of glucagon and suppresses the exocrine secretory action of pancreas.

Insulin (Primarily)

Glucagon (also primarily) Somatostatin

Islet cells Islet cells

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Chapter 6

PATHOPHYSIOLOGY

Modifiable Factor Love to eat sweets

Non-modifiable Factor Obese With history of DM

Insulin Resistance Hyperglycemia

Decrease Blood Osmolality Fluid shifting from intracellular to extracellular Intracellular DHN

Blood sugar exceeds renal threshold Glycosuria Osmotic Diuresis Increase Urine Output Polyuria

Glucose cannot enter cell Cellular Starvation Sensation of hunger Polyphagia

Gluconeogenesis activation Lipolysis Fatty Acids Hypertension

Thirst Sensation Increase Blood viscosity Decrease Blood Flow Decrease Tissue Perfusion Decrease Wound Healing Diabetes Mellitus with Hypertension (A Case Analysis) Page 23

Polydipsia

Favors bacterial growth

Edema

Chapter 7

DRUG STUDY

DRUGS

ACTION

INDICATION

Generic name: Combizar Brand name: Hyzaar Date and Time ordered: 6/20/12 @ 10:50 am Dosage and Frequency: 100 mg/25mg 1 tab OD

Angiotensin II receptor antagonist/ diuretic/ antihypertensiv e.

Treatment of hypertension; for patients in whom combination therapy is appropriate.

SIDE EFFECT/ ADVERSE REACTION None

NURSING CONSIDERATION

->Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right patient, right dosage, right time and frequency, right route.

Generic name: Furosemide Brand name: Lasix Date and Time ordered: 6/20/12 @ 10:05 am Dosage and Frequency: 40mg IV q8

A loop diuretic, inhibits water reabsorption in the nephron by blocking the sodiumpotassiumchloride cotransporter (NKCC2) in the thick ascending limb of the loop of Henle.

For the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. Also for the treatment of hypertension alone or in combination with other antihypertensive agents.

None

>Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right patient, right dosage, right time and frequency, right route. >Give the medicine through IV slowly.

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>Clean the port with the antiseptic or alcohol swab.

Generic name: Glibenclamide Brand name: Daosin Date and Time ordered: 6/20/12 @ 10:05 am Dosage and Frequency: 5mg 1tab BID 30 mins before meals Generic name: Celecoxib Brand name: Celebrex Date and Time ordered: 6/21/12 @ 8:00 am Dosage and Frequency:200 mg/ 1 cap OD

Works by inhibiting ATPsensitive potassium channels in pancreatic beta cells.

Used in the treatment of type 2 diabetes.

None

>Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right patient, right dosage, right time and frequency, right route.

Inhibition of prostaglandin synthesis

For relief and management of osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis, acute pain, primary dysmenorrhea and oral adjunct to usual care for patients with familial adenomatous polyposis. For use as an adjunct to diet and exercise in adult patients (18 years and older) with NIDDM. May also be used for the management of metabolic and

-None

>Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right patient, right dosage, right time and frequency, right route.

Generic name: Metformin

Decreases blood glucose levels by Brand name: decreasing Glucophage hepatic glucose production, Date and Time decreasing ordered: intestinal 6/21/12 @ 8:00 absorption of am glucose, and

None

>Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right Page 25

Diabetes Mellitus with Hypertension (A Case Analysis)

Dosage and Frequency: 500mg 1 tab

improving insulin sensitivity by increasing peripheral glucose uptake and utilization. Inhibiting the mucopeptide synthesis in the bacterial cell wall

reproductive abnormalities associated with polycystic ovary syndrome (PCOS).

patient, right dosage, right time and frequency, right route.

Generic name: Ceftriaxone Brand name: Aciphin Date and Time ordered: 6/21/12 @ 8:00 am Dosage and Frequency: 20 mg OD

For the treatment of the infections (respiratory, skin, soft tissue, UTI, ENT) caused by S. pneumoniae, H. influenzae, staphylococci, S. pyogenes (group A beta-hemolytic streptococci), E. coli, P. mirabilis, Klebsiella sp, coagulasenegative staph

None

>Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right patient, right dosage, right time and frequency, right route.

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Chapter 8

NURSING CARE PLAN

ASSESSMENT Subjective: Nagmamanas yung mukha at paa ko:, as verbalized by the patient. Objective: 1. Edema 2. Blood pressure changes 3. Decreased hematocrit 4.Restlessness BP: 140/80 PR: 85 RR: 19 T: 37.1

DIAGNOSIS Excess fluid volume related to excess sodium intake as evidenced by edema on face and lower extremeties.

PLANNING After 8 hours of nursing intervention, patient will verbalize understanding of individual dietary and fluid restrictions.

INTERVENTION Independent: 1. Compare current weight with admission or previously stated weight. Rationale: To evaluate degree of excess. 2. Note patterns and amount of urination. Rationale: To evaluate degree of excess. 3. Evaluate edematous extremities or change positions frequently. Rationale: To facilitate movement of diaphragm, thus improving respiratory effort and prevent stasis. Dependent: 1. Administer medications, as prescribed by physician. Rationale: To eliminate excess fluid. Collaborative: 1. Restrict sodium and fluid intake, as indicated. Rationale: To eliminate excess fluid.

EVALUATION Goals met. After 8 hours of nursing intervention patient reported that pain is controlled from 5/10 to 3/10. The patient also demonstrated use of relaxation skills and diversional activities, as indicated.

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2. Set an appropriate rate of fluid intake or infusion throughout 24 hour period. Rationale: To prevent peaks and valleys in fluid level and thirst. 3. Review dietary restrictions and safe substitutes for salt (e.g. lemon juice or spices like oregano). Rationale: To promote wellness.

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ASSESSMENT Subjective: Nanghihina po ang katawan ko, as verbalized by the patient. Objective: 1. Lethargic 2. Listless 3. Lack of energy 4. Eye bags BP: 140/80 PR: 85 RR: 19 T: 37.1

DIAGNOSIS Fatigue may be related to decreased metabolic energy production, as evidenced by overwhelming lack of energy, and listlessness.

PLANNING After 4 hours of nursing intervention, patient will report improved sense of energy.

INTERVENTION Independent: 1. Assess vital signs. Rationale: To evaluate fluid status and cardiopulmonary response to activity. 2. Review medication regimen/use. Rationale: Certain medications are known to cause or exacerbate fatigue. 3. Note daily energy patterns. Rationale: Helpful in determining pattern/timing of activity. 4. Instruct in methods to conserve energy (e.g. to sit instead of standing during daily care and other activities; take frequent short breaks during activities; asking for and accepting assistance). Rationale: To conserve energy. 5. Discuss routines that promote sleep. Rationale: To improve stamina and strength. 6. Assist client to identify appropriate coping behaviors. Rationale: Promotes sense of control and improves selfesteem. 7. Establish realistic activity goals with client and encourage forward movement. Rationale: Enhances commitment to

EVALUATION Goals met. After 4 hours of nursing interventions, patient reported improved sense of energy by identifying basis of fatigue and individual areas of control.

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promoting optimal outcomes. Dependent: 1. Discuss therapy regimen relating to individual causative factors. Rationale: Helps client understand relationship of fatigue to illness. Collaborative: 1. Encourage nutritionally dense, easy to prepare foods and avoidance of caffeine and highsugar foods and beverages. Rationale: To promote energy. 2. Schedule activities for periods when client has the most energy. Rationale: To maximize participation. 3. Encourage client to do whatever possible (e.g. selfcare, sit up in chair, interact with family). Rationale: To increase activity level, as tolerated. 4. Provide diversional activities. Rationale: Participating in pleasurable activities can refocus energy and diminish feelings of unhappiness and worthlessness that can accompany fatigue.

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ASSESSMENT Subjective: Nagmananas ang mukha ko. Ang pangit kung tignan, as verbalized by patient. Objective: 1. Monitoring ones body 2. Actual change in structure 3.Intentional hiding of face 4. Change in social involvement BP: 140/80 PR: 85 RR: 19 T: 37.1

DIAGNOSIS Disturbed body image related to illness as evidenced by facial edema.

PLANNING After 4 hours of nursing intervention, patient will verbalize acceptance of self in situation.

INTERVENTION Independent: 1. Establish therapeutic nurseclient relationship. Rationale: To convey an attitude of caring and developing sense of trust. 2. Evaluate level of clients anxiety related to situation. Rationale: May indicate acceptance or non-acceptance of situation. 3. Observe interaction of client with significant others. Rationale: Distortions in body image may be unconsciously reinforced by family members. 4. Listen to clients comments and responses to the situation. Rationale: Different situations are upsetting to different people, depending on individual coping skills and past experiences. 5. Provide assistance with selfcare needs. Rationale: To promote individual abilities and independence. 6. Work with clients self-concept, avoiding moral judgment regarding clients efforts or progress.

EVALUATION Goals met. After 4 hours of nursing intervention, patient verbalized relief of anxiety and adaption to altered image.

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Rationale: Positive reinforcement encourages client to continue efforts and strive for improvement. Collaborative: 1. Note signs of grieving or indicators of severe or prolonged depression. Rationale: To evaluate need for counseling and medications. 2. Visit client frequently and acknowledge the individual as someone who is worthwhile. Rationale: Provides opportunities for listening to concerns and questions. 3. Alert staff to monitor own facial expressions and other non-verbal behaviors. Rationale: They need to convey acceptance and not revulsion when the clients appearance is affected.

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REFERENCES

1. Medical-Surgical Nursing 12th Edition; Brunner and Suddarth 2. Nurses Pocket Guide; Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Murr 3. Principles of Internal Medicine 4. Fundamentals of Nursing 8th Edition; Kozier & Erb 5. Essentials of Human Anatomy & Physiology; Elaine N. Marieb, R.N., Ph.D 6. The Merck Manual of Medical Information 2nd Edition 7. Mosbys PDQ for RN; Jean Foret Giddens, Rae W. Langford 8. Oxford Minidictionary for Nurses 6th Edition 9. Burtons Microbiology for the Health Sciences 8th Edition; Paul G. Engelkirk, Gwendolyn R. W. Burton 10. Pharmacology for Nursing Care 7th Edition; Richard A. Lehne 11. Internet:www.Nursingcrib.com 12. Internet: www.Medplus.com 13. Internet: www.youtube.com 14. Internet: www.Wikipedia.com 15. Internet: www.Nursing Department.com 16. Internet: www.Nursingfornurses.com

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