RLE 35

A CASE PRESENTATION ON

DIABETES MELLITUS TYPE II

By: RLE-35
Fritzie Hana Azurin Reinhard Columna Iverson Cruz Jaymar Cunanan Maureen Guzman Mark Jerome Justo Neriza Angela lagas Aida uyun Jonalyn !agun "in Rui #Mi$helle%

INTRODUCTION
Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, which result from defects in insulin secretion, or action, or both. Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. Carbohydrates are broken down in the small intestine and the glucose in digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the cells in the body where it is utilized. owever, glucose cannot enter the cells alone and needs insulin to aid in its transport into the cells. !ithout insulin, the cells become starved of glucose energy despite the presence of abundant glucose in the bloodstream. Diabetes is due to one of two mechanisms" (#) $nade%uate production of insulin (which is made by the pancreas and lowers blood glucose) or (&) $nade%uate sensitivity of cells to the action of insulin. $nsulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. ('he pancreas is a deep(seated organ in the abdomen located behind the stomach.) $n addition to helping glucose enter the cells, insulin is also important in tightly regulating the level of glucose in the blood. )fter a meal, the blood glucose level rises. $n response to the increased glucose level, the pancreas normally releases more insulin into the bloodstream to help glucose enter the cells and lower blood glucose levels after a meal. !hen the blood glucose levels are lowered, the insulin release from the pancreas is turned down. $nsufficient production of insulin (either absolutely or relative to the body*s needs), production of defective insulin (which is uncommon), or the inability of cells to use insulin properly and efficiently leads to hyperglycemia and diabetes. 'his latter condition affects mostly the cells of muscle and fat tissues, and results in a condition known as +insulin resistance.+ 'his is the primary problem in type & diabetes. 'here are two ma,or types of diabetes, called type # and type &. Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or ,uvenile onset diabetes mellitus. $n type # diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. 'ype # Diabetes tends to occur in young, lean individuals, usually before -. years of age, however, older patients do present with this form of diabetes on occasion Diabetes mellitus type 2 also referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus ()/D0).) is the type of diabetes in which the beta cells of the pancreas produce insulin but the body is unable to use it effectively because the cells of the body are resistant to the action of insulin. 1ymptoms of Diabetes type & includes" Classical 'riad"

23cessive thirst (polydipsia)" 23cessive urination (polyuria)" 23cessive eating (polyphagia)"

/ther symptoms include"

4atigue" 5ne3plained weight loss" 6oor wound healing" $nfections" )ltered mental status" 7lurry vision"

8isk factors for developing type & diabetes include the following" )ge 9: or older 4amily history of diabetes /verweight $nactive lifestyle (e3ercise less than - times a week) )frican()merican, ispanic;<atin )merican, )merican $ndian and )laska =ative, )sian()merican, or 6acific $slander ethnicity igh blood pressure (#9.;>. mm; g or higher) D< (good) cholesterol less than -: mg;d< or triglyceride level &:. mg;d< or higher ave had diabetes during pregnancy (gestational diabetes) or have given birth to a baby that weighed more than > pounds istory of disease of blood vessels to the heart, brain, or legs ) number of lab tests are available to confirm the diagnosis of diabetes this includes" 4ingerstick blood glucose 4asting plasma glucose /ral glucose tolerance test Glycosylated hemoglobin" 'his test is a measurement of how high your blood sugar level has been over about the last #&. days?the lifespan of a red blood cell.

Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following

fasting plasma glucose level at or above #&@ mg;d< (A.. mmol;l). plasma glucose at or above &.. mg;d< (##.# mmol;l) two hours after a A: g oral glucose load as in a glucose tolerance test. random plasma glucose at or above &.. mg;d< (##.# mmol;l).

2pidemiology of Diabetes

4ilipino()mericans had a higher risk for type & D0 than non( ispanic white )mericans. 'hey reported a prevalence of #@.# percent (>:(percent C$) among 4il()ms, higher than the &..: 51 prevalence rate of seven percent reported by the 51 =ational $nstitute of Diabetes and Digestive and Bidney Diseases (=$DDB) through the =ational Diabetes $nformation Clearinghouse (=D$C). 'he situation hardly differs in the 6hilippines where the prevalence of D0 has risen from four percent in #>>C to 9.@ percent based on the &..- =ational =utrition and ealth 1urvey. $t is estimated that there are about - million 4ilipinos who are diabetic, :.D are undiagnosed. )nother - million 4ilipinos have impaired glucose tolerance which is a risk factor for future diabetes and cardiovascular disease. Possible ompli ations in ludes

)therosclerosis (hardening of the arteries) can lead to poor circulation in the legs, stroke and heart attack. Diabetic kidney disease. Diabetic retinopathy (diabetes(related eye disease). Diabetic neuropathy (degeneration of the nerves). 5lcers and infections of the feet. 1usceptibility to infections, eg urinary tract infections.

Diabetes mellitus type & is currently a chronic disease, without a cure, and medical emphasis must necessarily be on managing;avoiding possible short(term as well as long(term diabetes( related problems. 'here is an e3ceptionally important role for patient education, dietetic support, sensible e3ercise, self glucose monitoring, with the goal of keeping both short(term blood glucose levels, and long term levels as well, within acceptable bounds. Careful control is needed to reduce the risk of long term complications. 'his is theoretically achievable with combinations of diet, e3ercise and weight loss various oral diabetic drugs.

P!TI"NT#$ PRO%I&"
=)02" )G2" G2=D28" D)'2 /4 7$8' " 6<)C2 /4 7$8' " C$E$< 1')'51" 82<$G$/=" =)'$/=)<$'F" )DD8211" /CC56)'$/=" D$)<2C'" )''2=D$=G 6 F1$C$)=" C $24 C/06<)$='" D)'2 )D0$''2D" '$02 )D0$'2D" /16$')<" C<$=$C)< $068211$/=" 4$=)< D$)G=/1$1" !2$G '" D$2'" $=$'$)< E$')< 1$G=1" 76" #..;@. mmhg 'emperature" -C.-IC 88" #A cpm 68" >C bpm 0r. Cupid 9A years old 0ale =ovember &:, #>@. 0anila 0arried 8oman Catholic 4ilipino <una 1t., 5gac =orte, 'uguegarao City 7usinessman $loco G Fbanag Dr. Carmela Combate Chills and fever Hanuary #A, &..C >":. )0 16 D0 $$, 5'$, G =ephrolithiasis D0 $$, 5'$, G =ephrolithiasis #9: lbs. Diabetic diet with #@.. kcal;day C /= @.D, C / &.D and fats &.D

2D5C)'$/=)< )'')$=02='" 5ndergraduate (&nd Fear College)

NUR$IN' (I$TOR)
P!$T (I$TOR) 'he patient received complete immunization. 'wo years ago, the patient was e3periencing blurredness of the eye, fre%uency of urination (polyuria) and prickly sensation on his feet. J=ilalanggam din ang ihi koK he added. 'hese symptoms caused him to suspect that he has Diabetes 0ellitus. 0oreover, last )ugust &..A he had cough for - weeks and this prompted him to submit himself to a check(up at 1t. 6aul ospital and also to ask about the first symptoms mentioned earlier. e was then diagnosed of (L) pneumonia and (L) Diabetes 0ellitus, 'ype $$. <ast 1eptember, he went to 0anila with his wife to have a general check(up at the eart Center. e was confined there for - days while he was undergoing different laboratory and diagnostic tests such as 5ltrasound of B57, M(ray, and clinical chemistry. $t was then found out that he has also =ephrolithiasis. %!MI&) (I$TOR) 'he patientNs mother died because of a D0 complication (heart disease) while his father who is also deceased now had a hypertension. )side from these, there are no other diseases present in his family as mentioned by the patient. (I$TOR) O% PR"$"NT I&&N"$$ ) day prior to admission, the patient had fever and chills. e then took # tablet of biogesic to manage these but his fever and chills persist and he was also having diaphoresis and muscle weakness. 'his prompted his wife to bring him to 1t. 6aul ospital. e was then admitted to a private room at the hospital. 4inal Diagnosis was D0 ('ype $$), 5'$ and =ephrolithiasis.

'ORDON#$ 11 %UNCTION!& ("!&T( P!TT"RN

("!&T( P"RC"PTION !ND ("&T( M!N!'"M"NT *e+o,e (ospitali-ation. 'he patient views health as having good condition of oneNs body and mind. e views health as a gift from God and a gift that should not be deprived of the ne3t generation. )ccording to him he perceived himself as unhealthy person because of his illness (diabetes mellitus). e said so because of the many precautions that must be followed (eg. eating). e believed that discipline and faith can get you through any problem even those that concern health. e also said that when he got sick he takes /'C drugs such as paracetamol, ala3an and loperamide. e also had maintenance drug for his Diabetes 0ellitus which are the Glucotrol and glumet and for his kidney stone he takes uriflow and 3atral. Du,in/ (ospitali-ation. 0r. Cupid told us that his perception on health did not change. e still see his self as unhealthy person. e said also that he follows all the doctorsN advice and said that he takes the same drugs (Glumet, 5riflow) when he was confined. e said that he does his best in managing his health and he ,ust let God do the rest. NUTRITION!&-M"T!*O&IC P!TT"RN *e+o,e (ospitali-ation. 0r. Cupid eats - times a day. e preferred eating vegetable (ampalaya, malunggay and pechay) and fish (tilapia and bangus) and a cup of rice. e takes in between snack like biscuits and fruits like orange and apple, he also said that he was fond of eating sweets like cakes and chocolates. e drinks appro3imately C to #. glasses of water everyday. e was fond of drinking soft drinks and does not drink coffee. e also said that before he used to be a heavy drinker but he stop it when his wife asked him to. $t was now A years since he stop drinking alcohol. )ccording to him he has no food allergies. Du,in/ (ospitali-ation. 0r. CupidNs diet on the hospital was diabetic diet with #@.. kcal;day C /= @.D, C / &.D and fats &.D. )ccording to him, his appetite was decreased. e drinks #.(#@ glasses of water a day. e has an $E4 of #< 6=11 3 &.gtts;min. $&""P-R"$T P!TT"RN *e+o,e (ospitali-ation.

0r. Cupid has difficulty with his sleep pattern. e usually sleeps about @(A hours from #. pm to :"-. am. e said that J mababaw lang ang tulog ko, ung para bang nahahalata ko lahat ng galaw ko.K e does not take naps in the afternoon because it will be difficult for him to fall asleep at night. Du,in/ 0ospitali-ation. is favorite position when sleeping is side lying( left), and he prefers &(- pillows when sleeping. 0r. Cupid also told us that before he sleep at night he watches 'E. "&IMIN!TION P!TT"RN *e+o,e (ospitali-ation. 0r. CupidNs elimination pattern depends on how much he eats and drinks. e urinates at least #&(#: times a day with difficulty because of his kidney stone (this was diagnosed by his urologist on 1eptember &..A at 0anila). is urine was transparent to yellow amber in appearance, appro3imately &..(&:. ml per urination. )ccording to him he has difficulty in defecating but does not e3perience pain. e said that he defecate after the other day. is stool was semi(formed, brown in color and sometimes black. Du,in/ (ospitali-ation. During his hospitalization he says that he urinate #.(#& times a day still with difficulty. is urine was yellow in color and appro3imately &..ml per urination. e still have difficulty in defecating. !CTI1IT)- "2"RCI$" P!TT"RN *e+o,e (ospitali-ation. 0r. Cupid performs some e3ercise like stretching and walking. e also helps in some household chores. )ccording to him, his work was the form of his e3ercise sometimes. Du,in/ (ospitali-ation. !hen asked of what he does during his hospitalization he said that he does nothing because he was advised to have a bed rest. 0r. Cupid also said Jkung napapagod na akong nakahiga umuupo ako dito sa may kama ko.K e also said that he cannot do anything because of his $E4 that restricts his movement. CO'NITI1"-P"RC"PTU!& P!TT"RN *e+o,e (ospitali-ation.

0r. Cupid was an undergraduate at 51' ()rchitecture). e has problem with his vision and according to him he uses eyeglasses with a grade of #.: when reading. e has also problem with his hearing. e also added that he has a memory gap. )ccording to him their dialects in their house are $locano, Fbanag and 'agalog. Du,in/ (ospitali-ation. 0r. Cupid said that there were no changes in his cognitive(perceptual pattern, it was still the same. )nd also in his hearing. $"&% P"RC"PTION P!TT"RN *e+o,e (ospitali-ation. !hen asked about what 0r. Cupid sees of himself he said that he was a ,olly, kind, helpful, loving, responsible and a big hearted person. 0r. Cupid has a high self esteem, he believes on his capabilities to handle any situation. e also told us that sometimes he was impatient, especially when he was sick. e still sees himself as the head of the family. Du,in/ (ospitali-ation. 0r. Cupid told us that he sees himself as unhealthy. )ccording to him there was no changes on how he perceived himself, he added that he became more optimistic in order to cope with his situations. e said that J$Nm physically not feeling well but eventually $Nm spiritually strong.K RO&"-R"&!TION$(IP P!TT"RN *e+o,e (ospitali-ation. 0r. Cupid is with his wife. )ccording to him, he and his wife love each other and sweet to one another. e is a good person not only to her family but also to other people. e is so industrious. e said that he was the head of the family. e stated that he was the one working for his family. e is a very responsible husband and father because he sees to it that his family is in good condition. )ccording to him his love to his family is constant. Du,in/ (ospitali-ation. 0r. Cupid views himself as helpless when he was admitted. e is very thankful that his family is always there for him. During hospitalization he proved how strong and important his role as a husband and father and how important the relationships he made based on trust and love. $"2U!&-R"PRODUCTI1" P!TT"RN *e+o,e (ospitali-ation.

0r. Cupid told us that he was not circumcised. e got married when he was 9& years old. e then had his first coitus with his wife. )ccording to him he has only # son. J)ctive pa rin naman ang se3ual life ko ngayonK, he verbalized. Du,in/ (ospitali-ation. 0r. Cupid told us that there were no changes on his se3ual(reproductive pattern. COPIN'-$TR"$$ P!TT"RN *e+o,e (ospitali-ation. !hen faced with problems 0r. Cupid shares his feelings with his wife. e verbalized J pag sinasabi ko kasi ang aking problema gumagaan ang aking loob.K e told us that he was the one doing actions to solve his problem, but before doing it he confers it to his wife and also asks for suggestion. e also added that his best weapon in facing his problem is through praying. Du,in/ (ospitali-ation. 0r. Cupid told us that he seeks advice from his wife. =othing was changed on how he copes with his problem. 1!&U"-*"&I"% P!TT"RN *e+o,e (ospitali-ation. 0r. Cupid is a 8oman Catholic. e attends mass every 1unday and sees to it that he prays the rosary with his family everyday. e said that he has a strong faith in God and believes that e is the source of everything. e does not believe in any superstitions. Du,in/ (ospitali-ation. 0r. Cupid said that his faith ,ust grew stronger. e said, J$ am grateful with my situation now because God knows that $ can overcome this situationK. e believes that a continuous, steadfast, and strong faith can get you out of everything.

&!*OR!TOR) R"$U&T$
13 ("M!TO&O') R"PORT Date 8e%uested" Hanuary #A, &..C 8e%uesting 6hysician" Dr. Carmela Combate 6athologist" Dr. 2duardo 7adua $$$. 0D, 4616 0edical 'echnologist" Bate Ouintos

P!R!M"T"R$ !7C gb

NORM!& R"$U&T :(#.3#.Pg;< #-..(#C.. g;d<

!CTU!& R"$U&T &&.C3#.Pg;< #&.& g;d<

!N!&)$I$ $ncreased" Due to infection DecreasedQ due to inade%uate o3ygen supply to cells as a result of blood vessel constriction DecreasedQ due to fluid volume deficit $ncreasedQ due to inflammatory response DecreasedQ due to presence of infection

ct Differential Count" 1egmenters <ymphocytes

->..(:9..D

-AD

..@.(..A. ..&.(..-.

..>...A

23 *&OOD C("MI$TR) R"PORT Date 8e%uested" Hanuary #A, &..C 8e%uesting 6hysician" Dr. Carmela Combate 6athologist" Dr. 2duardo 7adua $$$. 0D, 4616 0edical 'echnologist" Bate Ouintos NORM!& R"$U&T @:(#&. mmol;< #-:(#:: mmol;< -.@(:.:. mmol;< !CTU!& R"$U&T C>.@> #&:.. -.#C !N!&)$I$ =ormal Decreased" Due to polyuria Decreased" Due to polyuria

Creatinine 1odium 6otassium

43 URIN!&)$I$ Date 8e%uested" Hanuary #A, &..C 8e%uesting 6hysician" Dr. 0a. Carmela Comabate 2M)0$=)'$/= 8215<'1"

P!R!M"T"R$ Colo, T,anspa,en y Rea tion $pe i+i ',a6ity $u/a, P,otein

R"$U&T$ Fellow Clear @.. #..#: 'race =egative

!N!&)$I$ =ormal =ormal =ormal =ormal Due to increased glucose in the blood. =ormal

0$C8/1C/6$C 2M)0$=)'$/=" P!R!M"T"R$ Pus Cells R*C R"$U&T$ #(& .(# !N!&)$I$ Due to infection as a result of increase accumulation of sugar in the urine =ormal 53 C("$T 2R!) Date 8e%uested" Hanuary #A, &..C 8e%uesting 6hysician" Dr. 0. Combate C 21' M8)F(6) E$2! 'he lungs are clear. 'he trachea is slightly shifted to the right. 'he heart is not enlarged transversely. 'he aortic knob is calcified. 'he hemidiaphragms are smooth. 'he costophrenic sulci are intact. 'he rest of the visualized soft and osseous structures are unremarkable. $0682111$/=" )therosclerotic aorta.

!N!TOM) !ND P()$IO&O')

Pan ,eas, insulin, and diabetes 'he endocrine part of the pancreas consists of pancreatic islets dispersed among the e3ocrine portion of the pancreas. 'he islets secrete two hormones(insulin and glucagons which function to help regulate blood nutrient levels, especially blood glucose. )lpha cells of the pancreatic islets secrete glucagons, and beta cells of the pancreatic islets secrete insulin. $t is very important to maintain blood glucose levels within a normal range of values. ) decline in the blood glucose level below its normal range causes the nervous system to malfunction because glucose is the nervous systemNs main source of energy. !hen blood glucose decreases, fats and proteins are broken down rapidly by other tissues to provide an alternative energy source. )s fats are broken down, some of the fatty acids are converted by the liver to acidic ketones, which are released into the circulatory system. !hen blood glucose levels are very low, the breakdown of fats can cause the release of enough fatty acids and ketones to cause the p proteins are broken down and used to synthesize glucose by the liver. $f blood glucose levels are too high, the kidneys produce large volume of urine containing substantial amounts of glucose. 7ecause of the rapid loss of water in the form of urine, dehydration can result. $nsulin is released from beta cells primarily in response to the elevated blood glucose levels and increased parasympathetic stimulation that is associated with digestion of a meal. $ncreased blood levels of certain amino acids also stimulate insulin secretion. Decreased insulin secretion results from decreasing blood glucose levels and from stimulation by the sympathetic divisio.n of the nervous system. 1ympathetic stimulation of the pancreas occurs during physical activity. Decreased insulin levels allow blood glucose to be conserved to provide the brain with ade%uate glucose and to allow other tissues to metabolize fatty acids and glycogen stored in the cells. of the body fluids to decrease below normal, a condition called acidosis. 'he amino acids of

 'he ma,or target tissues for insulin are the liver, adipose tissue, muscles, and the area of the hypothalamus that controls appetite, called the satiety center. $nsulin binds to membrane(bound receptors and, either directly, increases the rate of glucose and amino acids uptake in these tissues. Glucose in converted to glycogen or fat, and the amino acids are used to synthesized protein. Diabetes mellitus can result from any of the following" type # diabetes mellitus is caused by the secretion of too little insulin from the pancreas and type & diabetes mellitus is caused by insufficient numbers of insulin receptors on target cells, or defective receptors that do not respond normally to insulin. $n people who have type # diabetes mellitus, tissues cannot take up glucose effectively, causing blood glucose levels to become very high, a condition called hyperglycemia. 7ecause glucose cannot enter cells of the satiety center of the brain without insulin, the satiety center responds as if there were very little blood glucose, resulting in an e3aggerated appetite. 'he e3cess glucose in the blood is e3creted in the urine, causing the urine volume to be much greater than normal. 7ecause of e3cessive urine production, the person has a tendency to become dehydrated and thirsty. 2ven though blood glucose levels are high, fats and proteins are broken down to provide an energy source for metabolism, resulting in the wasting away of body tissues, acidosis, and ketosis. 6eople with this condition also e3hibits a lack of energy. Glucagons is released from the alpha cells when blood glucose levels are low. Glucagons binds to membrane(bound receptors primarily in the liver and cause the conversion of glycogen stored in the liver to glucose. 'he glucose is then released into the blood to increase blood glucose levels. )fter a meal, when blood glucose levels are elevated, glucagons secretion is reduced. $nsulin and glucagons function together to regulate blood glucose levels. !hen blood glucose level increase, insulin secretion increases, and glucagons secretion decreases. !hen blood glucose levels decrease, the rate of insulin secretion declines, and the rate of glucagons secretion increases. /ther hormones, such as epinephrine, cortisol, and growth hormone, also function to maintain blood levels of nutrients. !hen blood glucose levels decrease, these hormones are secreted at a greater rate. 2pinephrine

and cortisol cause the breakdown of protein and fat and the synthesis of glucose to help increase blood levels of nutrients. Growth hormone slows protein breakdown and favors fat breakdown.

DRU' $TUD)
2!TR!& Classi+i ation. Drugs action Genito(5rinary 'ract *,and Name. )lfuzasin C< Indi ation. t3 of certain functional symptoms of benign prostatic hypertrophy Dosa/e. 2lderly initially # tab bid, may be increase to a ma3imum of 9 tabR Day. Cont,a Indi ation. /rthostatic hypotension, hepatic insufficiency, severe renal insufficiency, intestinal occlusion. $3P. 2lderly with coronary insufficiency, discontinue if angina reappears or worsens. !3R. 0ore fre%uently" G$ disturbance , lipothymic events and headache. <ess fre%uently" Dry mouth, tachycardia, chest pain, asthenia, drowsiness, rash, pruritus and flushes. 6alpitation, orthostatic hypotension and edema. D3I3. )void combination with other alpha, (blockers or Ca antagonists. Nu,sin/ Responsibilities. #. )ssess for any hypersensitivity to the drug. &. $nstruct patient to swallow the medication whole and do not chew; crush. P!R!C"T!MO& Classi+i ation. )nalgesics and antipyretics *,and Name. 7iogesic ! tion. Decreases fever by a hypothalamic effect leading to sweating and vasodilation. )lso inhibits the effect of pyrogens on the hypothalamic heat( regulating centers. 0ay cause analgesia by inhibiting C=1 prostaglandin synthesis, however due to minimal effects on peripheral prostaglandin synthesis. Does not cause any anticoagulant effect or ulceration of the G$ tract. Indi ation. 0ild to moderate pain ( eadache, toothache) and fever. )s alternative to aspirin, in patients with viral infection, peptic ulcer disease, bronchial asthma and bleeding disorders. Dosa/e. :..mg; tab 68= $3P. 6atients with alcoholic liver disease. $mpaired liver or kidney function. !R. ypersensitivity reactions ( 1kin rashes, drug fever, acute overdosage produce a dosage dependent potentially fatal hepatocellular damage DI. )lcohol, oral anticoagulants, chlorampenicol, aspirins, phnobarb, liver enzyme inducers, hepatoto3ic agents. CI. ephropathy, renal insufficiency, anemia. Clients with cardiac or pulmonary disease are more susceptible to acetaminophen to3icity. Nu,sin/ Responsibilities. #. 'aken with or with out meals &. Check for any hypersensitivity to the drug. -. )ssess for any to3icity to the drug.

7!&IUM DURU&" Classi+i ation. 2lectrolytes and minerals *,and Name. BCl Indi ation. ypokalemia. )s prophyla3is during treatment with diuretics Dosa/e. # tab 7$D Cont,a Indi ation. 8enal insufficiency, hyperkalemia, untreated )ddisonNs disease, stricture of the esophagus and or destructive changes in the alimentary tract. $P. /bstructive changes in the alignmentary tract, stricture of the esophagus. eart; Bidney disease. 6regnancy and lactation DI. B salts and B( sparing diuretics , e.g spironolacture , amiloride , triamferene, tacrolimus. )C2 inhibitors. Nu,sin/ Responsibilities. #. 'aken with meals. &. $nstruct pt. to swallow the drug whole with S glass of li%uid, do not chew;crush. -. Do not administer to a pt. in a supine position. URI%&O8 (P,es ,ibed) Classi+i ation. Drugs acting on Genito(5rinary 'ract *,and Name. 7ethanechol Cl Indi ation. )cute post(op and postpartum non obstructive urinary retention, neurogenic atony of the urinary bladder with retention. Dosa/e. 5sual #.(:. mg '$D(O$D Cont,a Indi ation. yperthyroidism, peptic ulcer, latent or active bronchial asthma, pronounced bradycardia or hypotension, vasomotor instability, coronary artery disease, epilepsy and parkinsonism, recent urinary bladder surgery, G$ resection and anastomosis, 7aldder and G$ obstruction or acute inflammatory lesions of the G$', 1pastic G$ disturbances, peritonitis, marked vagotonia. $P. 8eflu3 infection due to bacteriuria , nausea or vomiting. Dizziness, lightheadedness, or fainting may occur. 6regnancy, <actation. !R. 0alaise, abdominal cramp or discomfort, nausea and belching, diarrhea, salivation, urinary urgency, headache, fall in 76 with refle3 tachycardia, vasomotor response, flushing, sweating, bronchial constriction, asthmatic attacks, lacrimation, miosis. DI. Ganglion( blocking compound Nu,sin/ Responsibility. #. 'aken on empty stomach. #(& after meals. '&UM"T (Maintenan e d,u/)

Classi+i ation. )nti Diabetic *,and Name. 0etformin Cl Indi ation. 'ype $$ D0 ! tion. Decrease hepatic glucose production, Decrease intestinal absorption of glucose and increases peripheral uptake and utilization of glucose. Dosa/e. $nitially :..mg bid. Dose may be increase by :..mg;wk to ma3imum &...mg daily. Daily doses T&...mg should be divided tid. Cont,a Indi ation. 8enal dysfunction, C 4, acute or chronic metabolic acidosis, diabetic ketoacidosis, with or without coma. ypersensitivity. $P. epatic and renal impairment, malnourished or debilitated conditions, adrenal or pituitary insufficiency. !R. Diarrhea, anore3ia, abdominal discomfort, nausea and metallic taste. DI. 'hiazide diuretics, morphine, )C2 inhibitors , corticosteroids, impair absorption of Eit. 7#& and folic acid, 4urosemide. Nu,sin/ Responsibilities. #. Check for any hypersensitivity to the drug. &. 'ake with food to decrease G$ upset. -. 'each pt. that there will be a metallic taste of the drug. 9. )dvise not to chew or crush the e3tended release tablets. :. )void alcohol and any situation that may precipitate dehydration. 'lu ot,ol ((OM" M"D$) Classi+i ation. )nti diabetic *,and Name. Glipizide Indi ation. control of yperglycemia in clients with non insulin dependent diabetis ! tion. )lso has mild diuretic effects. 0etabolized in liver to in activate metabolites, which are e3creted to the kidneys. DI. climetidine may increase glipizide effect 8$' !R. drowsiness, headache, anore3ia, constipation or diarrhea vomiting, stomachache. Nu,sin/ ,esponsibilities #. )ssess lifestyle to ensure that ma3imal changes in the areas of dier and e3ercise had been taken prior increasing dosage. &. 0onitor vital signs -. 'ake -. minutes before or with meals do not chew or crush the e3tended form 9. 8eport any skin reaction. 1i/o id (Pipe,a illin $odium 9 Ta-oba tam $odium) ! tion. 7actericidal in action by inhibiting septum formulation and cell wall synthesis of susceptible bacteria Use. used as antibiotic

Cont,aindi ations. 6atients with a history of allergic reactions to any of the penicillins, cephalosporins, beta(lactamase inhibitors !d6e,se "++e ts. nausea nad vomiting, diarrhea, constipation, rash, red skin, allergic reaction (hives), difficulty in sleeping, headache, diaphoresis, eczema Route and Dosa/e. &.&: g ; $E every C hours )=1' ( ( ) Nu,sin/ Responsibilities. T Document indications for therapy, symptom onset and weight history. T )ssess for other medical conditions that re%uire careful monitoring. T 'ake drug within ordered intervals to prevent further aggravation T Do not engage in activities that re%uire mental alertness.

NUR$IN' C!R" P&!N !$$"$$M"NT Ob:e ti6e Data. (warm to touch (flushed skin ( 'U -CIC ( 88U && cpm DI!'NO$I$ )ltered body temperature" yperthermia r;t increased production of pyrogens in the body ('he patient will be able to obtain body temperature within normal range (-@.AIC(-A.:IC.) and 88 of #@(&. cpm Tprovided the patient continues '17 T'o promote surface cooling and heat loss by evaporation and conduction. ;6ositioned the patient in a comfortable and safe position3 T 6romote client safety G to maintain patent airway. P&!NNIN' )t the end of one hour" INT"R1"NTION R!TION!&" T0onitor vital signs T'o determine basal G recorded particularly temperature body temperature, to have baseline data G to have a basis for evaluating the effectiveness of interventions. "1!&U!TION Goal met. 'he patient was able to obtain core body temperature within normal range -A.-IC. and 88 of #C cpm.

T6rovided a cool

T'o promote surface

environment

cooling G heat loss by convection.

T)dvised the patientNs 1/ to change the patientNs clothing to loose G light colored clothes.

T<oose clothing G light colored clothing promotes body surface cooling. <ight colored clothes are more absorbent to address diaphoresis.

T)dvised the patient to increase glasses;day.

T'o replace fluids G electrolyte to support tissue perfusion and to promote hydration.

fluid intake to #.(#@ circulatory volume G

T$nstructed the client to maintain bed rest.

T'o reduce metabolic demands G o3ygen consumption.

T)dministered antipyretics G due medications intravenously as ordered.

T'o restore normal body temperature G to treat underlying conditions.

!$$"$$M"NT $ub:e ti6e. 23 tremity weakness Ob:e ti6e. Capillary 8efill 'ime of 9 sec. 6ale con,unctiva, buccal mucosa,

DI!'NO$I$ )ltered peripheral tissue perfusion r;t decreased arterial blood flow.

P&!NNIN' INT"R1"NTION R!TION!&" )t the end of the Checked color, =eurovascular monitoring shift the patient temperature, pulses, may %uickly detect situations will be able to capillary refill, pain, and in which a limb salvaging show improvement appearance of skin. procedure is warranted. of arterial blood flow as manifested by Capillary 8efill 'ime of #( 0aintained patient on bed Gravity increases blood flow seconds and rest with head of bed to affected e3tremity. 7ed absence of elevated, foot in reversed. rest minimizes the o3ygen e3tremity demand. Bnee fle3ion further weakness. impedes arterial blood flow to a poorly compromised vascular e3tremity. 2ncouraged patient to 0ovement maintain muscle move about in bed at least tone and promote circulation every hour. $nstructed patient to 23ercise help maintenance perform active range of muscle tone and decrease motion for arms and legs negative effects of prolonged bed rest. $nstructed patient 6atient understanding of plan regarding rationale for bed of care increase compliance rest and e3ercise. with it. $nstructed patient to avoid 6revent formation of massaging calves of legs, embolizing thrombi due to crossing legs at the knee prolonged bed rest. 'hese and avoid constrictive e3ercises increase collateral clothing. circulation to the lower e3tremities.

"1!&U!TION Goal met. 'he patient was able to show improvement of arterial blood flow as manifested by C8' of - seconds and absence of e3tremity weakness

!$$"$$M"NT DI!'NO$I$ P&!NNIN' INT"R1"NTION$ R!TION!&" "1!&U!TION $ub:e ti6e. 8isk for )t the end of the Goal met. 2ncouraged use of 6rovides clearer vision so J=anlalabo!$$"$$M"NT ang in,ury shift, the patientP&!NNIN' 'he patient did eyeglasses as to prevent in,ury "1!&U!TION DI!'NO$I$ INT"R1"NTION$ R!TION!&" paningin $ub:e ko, kung will e3perience no not e3perience ti6e. 8isk for fluid )t the end of the !atched out 'o asses early TGoal met. 'he minsan hindi na in,ury duringshift, the patient in,ury of any /riented to room set(up minimize possibility of was J$hi ko ako ng ihi at volume deficit able to kind for signs of 'o signs of patient nga nakikita ang hospitalization. accidents (e.g. bumping) lagi akong will maintain fluid maintain fluid dehydration dehydration dinaraanan ko ehK nauuhaw,K as volume at a (eg. Dry and to prevent volume balance as as stated by the by the )ssisted in performing possibility of falls stated functional level as manifested by mucous self( 6revent its occurence patient patient. care evidence normal normal urine output embranes, 6revent possibility of urinary output of falls delayed 6rovided a capilliary well(lighted Ob:e ti6e. environment $ncreased urine refill, poor output of skin turgor) 'o provide immediate care )nticipated and provided $ 'o &..ml;voiding 0onitored assure patientNs need and / Decreased balance in $ and serum sodium / and to to #&: mmol;< prevent volume deficit Decreased serum 8egulated $E4 'o maintain potassium as ordered ade%uate fluid volume and to prevent dehydration $ncreased fluid intake to 'o prevent the &...(-... ml occurrence of per day dehydration

P()$IC!& !$$"$$M"NT
D!T". <anua,y 1=, 2>>?

'"N"R!& !PP"!R!NC". M,3 Cupid is lyin/ supine in bed @it0 on/oin/ I1% o+ A1 PN$$ 1& B 2>/ttsCmin at ?>> @ell at t0e le+t a,m3 T0e patient is @ell-/,oomed and neat3 1IT!& $I'N$. *P. 1>>CD> mm(/ RR. 22 pm PR. ?> bpm Temp3. 4? C le6el, patent and in+usin/

!R"! !$$"$$"D $7IN Color 'emperature 'urgor 0oisture 'e3ture N!I&$ =ail plate shape =ail bed color 'e3ture Capillary refill ("!D 1calp 'e3ture Circumference %!C" 4ace symmetry 4acial movements ")"$" 2M'28=)< 1'5C'5821 air distribution 1kin %uality

M"T(OD U$"D $nspection 6alpation 6alpation 6alpation 6alpation $nspection $nspection

NORM!& %INDIN'$ <ight to deep brown !arm to touch 1naps back immediately 0oist 1mooth, elastic Conve3 6ink

!CTU!& %INDIN'$ 4lushed skin !armer to touch 1naps back immediately Dry 1mooth Conve3 6ale 1mooth 9 seconds

!N!&)$I$ Due to hyperthermia Due to hyperthermia =ormal Due to hyperthermia =ormal =ormal Due to decreased peripheral tissue perfusion =ormal Due to decrease peripheral tissue perfusion

6alpation 1mooth 6alpation; 7lanch test 8eturns to normal immediately (&( seconds) $nspection 6alpation 6alpation $nspection $nspection $nspection 6alpation 1ymmetrical 1mooth 6roportional circumference to the body 1ymmetrical 2%ual facial movements 2venly distributed $ntact, smooth

1ymmetrical =ormal 1mooth =ormal 6roportional =ormal circumference to the body 1ymmetrical 2%ual facial movements 2venly distributed $ntact, smooth =ormal =ormal =ormal =ormal

2F2<$D1 )bility to blink 1C<28) Color C/=H5=C'$E) Color "!R$" 'e3ture )58$C<21 1ymmetry and position

$nspection

7links #:( &. times per minute involuntarily and bilaterally !hite <ight pink

7links #A times per minute involuntarily and bilaterally !hite 6ale

=ormal =ormal =ormal Due to decreased tissue perfusion =ormal =ormal

$nspection $nspection

$nspection 6alpation

1mooth without lesion )uricles are at level with each other

1mooth without lesion )uricles are at level with each other

NO$" 1ymmetry Cilia distribution =asal septum =ares

$nspection $nspection $nspection $nspection

1ymmetrical 2venly distributed 0idline 1ymmetrical size of opening

1ymmetrical 2venly distributed 0idline 1ymmetrical size of opening

=ormal =ormal =ormal =ormal

MOUT( 1ymmetry Color 05C/51 02078)=2 Color 0oisture <$61 Color 'e3ture 0oisture '/=1$<1 1ize N"C7 1ymmetry 8ange of motion 6osition <ymph nodes

$nspection $nspection $nspection $nspection $nspection 6alpation $nspection $nspection

1ymmetrical 6ink 6ink to 8ed 0oist 6ink to 8ed 1mooth 0oist 'onsils behind the tonsillar pillars 1ymmetrical 0oves freely Centrally located at the shoulder =ot palpable

1ymmetrical pink 6ale Dry 6ale 1mooth Dry 'onsils behind the tonsillar pillars 1ymmetrical 0oves freely Centrally located at the shoulder =ot 6alpable

=ormal =ormal Due to decreased tissue perfusion Due to decreased tissue perfusion Due to decreased tissue perfusion =ormal Due to decreased tissue perfusion =ormal

$nspection $nspection 6alpation 6alpation

=ormal =ormal =ormal =ormal

T(OR!2" 6osterior 1hape 1ymmetry 1pinal alignment Diaphragmatic e3cursion 8espiratory 8ate 8espiratory e3cursion 'rachea Chest

$nspection $nspection $nspection 6ercussion

8ounded, cylindrical Chest symmetric 1pine vertically aligned, no tenderness, no bulges 23cursion is -( : cm

8ounded, cylindrical Chest 1ymmetric 1pine vertically aligned no tenderness, no bulges 23cursion is -(: cm

=ormal =ormal =ormal =ormal

/bservation 6alpation )uscultation )uscultation

#@(&. cpm 4ull symmetric e3cursion 7ronchial and tubular breath sounds 7ronchovesicular and vesicular breath sounds

&& cpm 4ull symmetric e3cursion 7ronchial and tubular breath sounds 7ronchovesicular and vesicular breath sounds

Due to increased o3ygen demand =ormal =ormal =ormal

)7D/02= Color )bdominal Contour 7owel sounds

$nspection $nspection )uscultation

5niform with the rest of the body 6ot(bellied appearance 6resent and active

4lushed 6ot(bellied appearance 6resent" C times;min

Due to hyperthermia =ormal =ormal

56628

2M'820$'$21 1ymmetry Color 'e3ture 6resence of $E4 </!28 2M'820$'$21 1ymmetry Color 'e3ture =258/</G$C 1F1'20 <evel of Consciousness 0ental 1tatus $nspection $nspection 6alpation $nspection 1ymmetrical 5niform with skin color 1mooth =one 1ymmetrical 4lushed 1mooth # < 6=11 3 &. gtts;min =ormal Due to hyperthermia =ormal 'o correct fluid volume deficit

$nspection $nspection 6alpation

1ymmetrical 5niform with skin color 1mooth

1ymmetrical 4lushed 1mooth

=ormal Due to hyperthermia =ormal

$nterview $nterview

Conscious /riented to person

Conscious /riented to person

=ormal =ormal

P!T(OP()$IO&O') O% DI!*"T"$
Predisposing Lifestyle Race Genetics Stress Diet Environmental Factors Obesity Precipitating Age

Elevated serum lipid levels in Blood Development of Amyloid deposits in the islet Fat infiltration in live and pancreas Development of Amyloid deposit in the islets ancreatic ! hepatic atrophy due to ischemia ancreatic " hepatic fibrosis Deterioration of pancreas Function of pancreas

Function of Beta cells

Function of Alpha cells Glucagon roduction

#nsulin production

#nsulin Sensitivity

Lipolysis

Glucose concentration in E$F

Fatty acids 'etosis

%eight Loss $ellular Starvation

&yperglycemia

Send Signal FA(#G)E to the &ypothalamus *etabolic Acidosis OL+ &AG#A $ARBO " $ALOR#$ #-(A'E

Go to 'idneys E,creted to )rine 'E(O-)R#A

$-S 'ussmaul depression Respi

Blood Glucose Level Reach Renal (reshold

Blood .iscosity

olyuria

Glycosuria Rate of bacterial gro/th in )( Genital ruritis %EA'-ESS )(# #-FE$(#OFE.ER

Sluggish $irculation .ascular Resistance &ypertension

olyclipsia

&ypovolemic Shoc0

#schema in cells " &ypo,ia

Fluid and Electrolyte Loss #n blood volume &ypotension Diabetic Diabetic -europathy Diabetic Retinopathy -ephrophathy

(achycardia

7
*acrovascular disease

Autonomic erspiration

Sensory

*otor

ainless trauma

*uscle Atrophy Bone $hanges

Drys0in crac0s (hrombosis /ith large vessel acclusion E,tensive Gangrene -e/ ressure points Amputation *oderate areas of gangrene Fissures )lceration $hange in Gait #-FE$(#O-