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TYPE 2 DIABETES MELLITUS

Presented by:

BSN II- BENEFICENCE

General Objectives:

At the end of 4 hours case presentation, the students will be able to acquire and enhance their

knowledge regarding patient¶s general health and condition, integrate the skills through several nursing

interventions and health management and to enhance the attitude of the students by promoting open-

mindedness all throughout the presentation.

Specific Objectives:

At the end of 4 hours case presentation, the students aim to achieve the following:

1. discuss client¶s specific assessments regarding its condition.

2. describe the signs and symptoms of the disease exhibited by the client.

3. define the disease process.

4. familiarize the systems affected by the disease of the client.

5. apply nursing process as framework for care of the patient.

6. formulate nursing care plans base on the complications manifested by the client.

7. practice the use of appropriate nursing intervention according to level of

competency.

8. establish interpersonal relationship while the case is going on. 9. value the essence of prevention and treatment towards diabetes mellitus



HEALTH ASSESSMENT

I. Biographical Data

Date of Interview: July 26, 2011Time of Interview: 11:00 am

Date of Admission: July 25, 2011Time of Admission: 6:20 pm

Name: C. A. Age: 86Sex: MMarital Status: MarriedReligion: Roman Catholic

Address: St. Francis Subdivision, Roxas ,CityBirth date: April 25, 1925Birthplace: Roxas, City

Race: BrownWho lives with the client: Wife, 3 Grand sonsSignificant others: Mrs. J. A.Educational Level: College UndergraduateOccupation: NoneNationality: FilipinoPhysician: Dr. B.

Provider of History Relationship to Patient: GrandsonPrimary: PatientSecondary: Mr. A., Patient¶s Chart

Vital Signs upon Admission:

T = 33.6 C P = 69 beats/min R = 20 breaths/min BP = 80/60 mmHg

II. Client¶s Health History A. Chief Complaint

Cold clammy skinB. Admitting Impression

Diabetes Mellitus Type II with neuropathyHypoglycemia possible secondary to OHA(Oral Hypoglycemic Agent)



C. History of Present Illness Night prior to admission the patient missed to take his dinner due to anxiety related to yellowish

discharge noted on his colostomy bag. 6:00AM in the morning he took Pritor Plus & vessel due F as hismaintenance and took small amounts of food for his breakfast (1 slice of bread and a cup of coffee) andlunch (half slice of fish and 1/3 cup of rice and ½ glass of softdrinks). Four (4) hours prior to admission,patient was noted to have cold clammy skin associated with blurred vision and weakness at home.Sugar diluted in a glass of water was given to him by his grandson to relieve his condition. Three (3)hours prior to admission, patient was somehow relieved from blurred vision but still felt weak and hascold clammy skin. One (1) hour prior to admission, the above chief complaint persisted so he decided tohave a consultation at Capiz Emmanuel hospital. Arrived 6:00 P.M brought via wheelchair at AS, seenand examined by Dr. B thus the admission at exactly 6:20 P.M. He was later transferred to PPWEST for continuous care.

D. Past Health History During his childhood years, patient had experienced minor illnesses like fever, colds, chicken

pox and mumps. He couldn¶t remember the type of immunization he had during his childhood. Hereported about his accident in the year 1963, when he was rushed at Saint Anthony College Hospitalbecause of three (3) gun shots at San Jose Street , Roxas City which affected his spleen, liver andstomach. In the year 2004, he had undergone colostomy at Iloilo Mission Hospital . Two years later, in2006, he had undergone appendectomy due to the rupture of his appendix. In the same year, he had

also undergone a left eye operation because of cataract with that same hospital. Patient was alsodiagnosed to have Diabetes Mellitus Type 2 at the age of 40 in the year 1985 upon his check-up at St.

Anthony College Hospital after experiencing hypertension, weakness and blurred vision. He has noallergies in any foods and drinks. As for his medical expenses, his children support him financially andhis grandsons assist him and his wife at home.

E. Family Health History

Heredofamilial Diseases Paternal MaternalHypertension ¥ ×Heart Disease × ¥

Diabetes Mellitus × ×

Patient¶s father died due to hypertension at the age of 86 and his mother died of heart attack at 85. Hisgrandparents died due to old age; grandmother (mother side) died at 110 years old and grandmother (father side) died at 130 years old.

F. Socio CulturalHistory Patient is a natural born Filipino presently living at St. Francis Subdivision, Roxas City together

with his second wife and 3 grandsons. He was married twice due to the death of his first wife after their ambush in the year 1963; a retired business man and a Roman Catholic who usually goes to churchwith his family every Sunday. The patient admits that he has a sedentary life pattern. He doesn¶t do anyhouse chores rather just watch television in the living room almost of his time. He enjoys bonding withhis grandchildren whenever they visit in their home. Oftentimes, he goes to the market after the masstogether with his grandson and wife to buy their foods. They also have a poultry farm in Pontevedra,

Capiz which he visits once a month. He usually becomes impulsive whenever there¶s a delay in givinghis demands and sometimes, he would throw things when he¶s mad. They also have a car as a meansof transportation usually driven by his grandson who is also with his wife living on that same house.Sometimes, his friends visited him and they tend to play cards as a form of relaxation. Whenever hefeels bored, he usually goes to the beach to unwind and to have fun. He finished his secondaryeducation and went to college with an associate arts degree at Colegio dela Purisima Concepcion butstopped after 2 years due to early marriage with his first wife. Patient¶s family maintains a close bondingrelationship with their neighbors and friends.



G. Environmental History Patient lives in a 2 storey concrete house that is more or less 800 square meters lot situated at

St. Francis subdivision with complete facilities and services like water and electricity from MRWD andCAPELCO respectively. They use mineral water for drinking. They have 3 air conditioned rooms and 2guest rooms. They have also 3 comfort rooms: one (1) for the master¶s bedroom, one (1) in the firstfloor and one (1) in the second floor all with flush type toilets. Patient with his wife and grandsons arecomfortable with their place because of its good camaraderie. There are few trees near their house likeCalachuchi, Pine tree and flowering plants found in front and back of their house. They throw their garbage in a trash can in front of their house which is collected by the damp truck every Monday. Theyalso use insect repellants (Baygon) for killing mosquitos and other insects. They have 2 maids whomaintain the cleanliness inside their house every day.

H. Medications and Substance Use Prior to admission, patient was given sugar diluted in water as a relief to his complaints. At

home, his medications used as maintenance are as follow: Pritor Plus 40 mg 1 tablet OD for hypertension and Vessel due F 40 mg 1 tablet OD for diabetes. Patient takes supplements like Centrum3x a week. He usually drinks 1 cup of coffee once a day and 3 bottles (8ounces) of soft drinks everyday.

III. PATTERNS OF FUNCTIONING

Home HospitalFluids and Nutrition Patient eats 1 slice of bread

and a cup of coffee during breakfast while half slice of fish and 1/3 cup of rice and½ glass of softdrinks as hislunch.

In full diabetic diet

IVF of D5 NSS 1L x60cc/hr

Consumes 75% from thetotal meals given.

Rest and Sleep Patient sleeps at longintervals. Sleeps around 8 in

the evening and wakesaround 6 in the morning.Takes short nap for 2-3hours.Uses 2-3 pillows andusually prays beforesleeping.Average time of sleep: 13hrs.

Sleep at short intervals dueto environmental changes.

Uses 2 pillows in sleeping.

Elimination Patient defecated into ayellowish watery stool as

seen in the colostomy bagUrinates for about 6 timesevery day6-7 times a day changing of colostomy bag.

Haven¶t defecated sinceadmission

Urinates for at least 500cc.

Activity and Exercise Walks at short distancearound their house and sitsif he feels tired.

Rests on bed, changes his position every now andthen, sits at times and while



eating.PersonalHygiene Patient takes full body bath

3-4 times a week with warmwater, soap and shampooUses hair color, cologne

and deodorant after bath.

Haven¶t taken a bath sinceadmission.

IV. PH YSICAL ASSESSMENT

A. General Survey Patient awake lying on bed with IVF infusing well at the right hand vein. Can turn to side

independently and alert. He can stand erect with help of his cane and have limited movements. He isoften assisted by folks most of the time. He is approachable, cooperative, well oriented with time andplace and conversant to the people around him. Vital signs upon assessment are as follows: temperatureof 36.2 C, respiration rate of 20 breaths/min, pulse rate of 66 beats/min and blood pressure of 110/80mmHg. Wt. 55 kgs , height of 5 ft. and 8 inch.

B. Physical Examination

Cephalocaudal Inspection Palpation Percussion AuscultationSkin -Brown complexion

-presence of brownand white patches

-no lesions- age spots noted

- slightly warm- dry skin-wrinkle and tent

when pinched- poor skinturgor

N/A N/A

Hair -Thin, gray and black in color -absence of infestations/infections-graying of scalp-unevenly distributedhair

-body hair in lower extremities

- dry-slightly roughscalp

N/A N/A

Nails -Long concave nails-slightly pink -presence of whitemarks

-capillary refillless than 3 sec.

N/A N/A

Head normocephalic-limited flexes

-temporal pulsesare palpated



-presence of moles atthe parietal part N/A N/A

Face -presence of moles,mustache andwrinkles

-slightly assymetricalfacial features

-no edema or lesions

N/A N/A

Eyes -outer canthus alignswith the tips of pinna-skin around the eyesare thin and wrinkled-arcus senilis areevident-blurring of vision of the right eye-pupils are black

-eyebrows aresymmetrical andunevenly distributed-eyelashes turnslightly outward

-no drainage-no edema andtenderness

N/A N/A

Ears -ears aligned witheyes-earlobes are hangingdownward-inability to hear lowfrequency sounds

during conversation

-soft, no nodulesor lesions

N/A N/A

Mouth -Lips are symmetricaland slightly pink -gums and mucosa are pink and moist-uses 2 teeth denturesat the upper part of teeth-teeth are slightlyyellowish

-Lips are softand slightly dry-no lesions, nodrainage

N/A N/A

Nose andSinuses

-midline in face-septum is straight-nose more prominentin face-patent nares-slightly flaring-no discharges &inflammations

-no deformities-no edema N/A N/A



Thorax &Lungs

-Smooth andsymmetric-presence of molesand brown patches

-no masses-skin intact-unevenvibration duringtactile fremitus

test.

-dull soundsheard in the posterior thorax

-wheezingsounds areheard uponauscultation

Breasts -Breasts even with thechest wall-presence of molesand patches-nipples are dark brown in color

-no masses or lesions noted

N/A N/A

Heart -Apical pulsesare palpated-cardiac rateof 68 beats/min

N/A

-Extra heartsounds or systolicmurmurs are

heardAbdomen -no discharge of

umbilicus-presence of whitemarks and moles-healed withappendectomy scar -scars from past accidents-surgery scars due tocolostomy with

colostomy bagattached.

-soft withoutmasses or tenderness

N/A

-clear bowelsounds

Upper Extremities andLower Extremities

-performs limitedrange of motionexercises-noted swelling at theright hand-muscle atrophy-dark scars noted-able to flexextremities

-radial pulse of 66 beats/min-numbness of

lower extremities-skin intact anddry-dead skin isvisible

N/A N/A



V. Diagnostic Exams A. Laboratory Exams

1. Exam Desired: CBC Date: 7/25/2011

Result Normal Values Indication

Hemoglobin MassConcentration 122 120-150 gms/L With in normal

range Erythrocyte VolumeFraction 0.36 0.37-0.45 Below ± there is

increase CO2content in the blood,O2 shortage andthere is ischemia.

Erythrocyte Number Concentration 3.8 4.0-5.0 x10 /L Below ± there isincrease CO2

content in the blood,O2 shortage andthere is ischemia.

Leukocyte Number Concentration 6.5 5.0-10.0 x10 /L With in normal

range Segmenters 0.84 .60-.70 L Segmenters

indicates presence of infection

Lymphocytes 0.16 18-30 Decreaselymphocytesoften timesindicates a signof infection

2. Exam Desired: Urinalysis Date: 7/26/2011

Result Normal Values Clinical IndicationColor Pale straw Amber/straw Excessive consumption

of vitamin capsules,leading to a potentialrisk of hyper vitaminosis



Transparency Slightly hazy Clear Inability of the kidneys

to produce normal urine, presence of protein inurine

Urinary tract infection,like inflammation of theurethra (urethritis), bladder infection,kidneystones etc.

Reaction pH 5.0 Slightly acidic 4.6-8 With in normal rangeSpecific gravity 1.010 1.010-1.025 With in normal range

Protein Negative Negative Absence of protein inurine

Sugar Negative Negative Absence of glucose in

urineRBC Negative Negative Absence of RBC in urine

Pus Cells Negative Negative Absence of pus cells inurine

Amorphous Urates Occasional Few No clinical manifestationof uric acid crystals

Bacteria Occasional Few No Clinicalmanifestation of urinarytract infection

Date: 07/25/11Results Normal Values Clinical Indication

Creatinine 115 mg/dL Male:55-113umol/L Increase Creatinineindicates a kidneydisease, muscledegradation, renalinsufficiency, chronic renal disease

SGPT 47 iul/L 10-40 iul/L Elevated SGPT levelindicates may mean aliver disease or other

injury from diseases .Sodium 134mmol/L 135-148mmol/L Normal range of sodiumcontent in urine

Potassium 5.0mmol/L 3.5-5.3mmol/L Normal range of potassium content in

urine



3. Exam Desired: CBG Monitoring

Date and time Results Normal Values Clinical IndicationJuly 25, 2011 (7:30

pm)

77mg/dL 82-110mg/dL Hypoglycemia

July 26, 2011 (2pm) 179mg/dL 82-110mg/dL Hyperglycemia

4. Exam Desired: Chest PA: Date: 7/26/2011

As compared with previous exam dated 7/13/2011 shows interval regression of the bibasalpneumonic infiltrates. The pulmonary congestion is unchanged. Rest of the findings are fine.





6. SEDENTARY LIFESTYLE

Being inactive ± exercising fewer than 3 times a week makes you more likely to developdiabetes.

7. AGE ± increasing age puts you at higher risk of developing type 11 diabetes mellitus.

MANAGEMENT OF DIABETES

y TYPE I Diabetes Mellitus ± Insulin

y TYPE II Diabetes Mellitus ± Diet, Exercise, OHA (Oral Hypoglycemic Agent)

y Gestational Diabetes Mellitus ± Insulin, Diet, Exercise

DIET

y DIABETIC DIET

PURPOSE

Maintain blood glucose as near as normal as possible, delay or prevent onset of diabeticcomplications.

FOODS ALLOWED:

y Choose foods with low glucose index compose of:a. 45-55% carbohydratesb.30-35% fatsc.10-25% protein

y Coffee, tea, spices and flavorings can be used as desired

y Exchange groups include milk, vegetables, fruits, bread/starch, meat (divided in lean,medium fat, and high fat), and fat exchanges.

y The number of exchanges allowed from each group is dependent on the total number of calories allowed

y Non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics.

FOODS TO BE AVOIDED:

y Concentrated sweets or regular soft drinks

EXERCISE:

y PURPOSE

- Helps burn fats which in excess may lead to obesity that can cause serious

complications.- Not allowed during period of stress (illness or surgery).

INSULIN Insulin increases glucose transport into cells and promotes conversion of glucose toglycogen, decreasing serum glucose levels. Primarily acts in the liver, muscle, adipose tissue byattaching to receptors on cellular membranes and facilitating transport of glucose, potassium and magnesium. Hormone secreted by the alpha cells of the isletsof langerhans in the pancreas. Increase blood glucose by stimulating glycogenolysis in the liver.



CLINICAL MANIFESTATIONS: EARLY SYMPTOMS INCLUDE:

y Thirst or a very dry mouth

y Frequent urinationy High blood glucose levels

y High levels of ketones in the urine (type 1)

y Polyphagia

y Constantly feeling tired

y Dry or flushed skin

y Nausea, vomiting or abdominal pain

y Short, deep breaths

y Fruity odor or breath (type 1)

y Confusion

y OTHER SYMPTOMS APPEAR

Manifested by client: Signs and Symptoms (from the book)y Polyuriay Tingling or numbness in feety Polydipsiay Blurring of visiony Dry skiny Dark scars on lower extremities

y polyuriay polydipsiay polyphagiay fatiguey weaknessy sudden vision changesy tingling or numbness in hands or

feety weight loss

y sores that heal slowlyy dry skin

H YPOGLYCEMIA Clinical Manifestations:

y Shakiness

y Dizziness

y Sweating

y Hunger

y Pale skin color

y Clumsy or jerky movements

y Confusion



NEUROPATH Y

Clinical Manifestations:

y Numbness and tingling of extremities

y Decreased or loss of sensation to a body part

y Muscle weakness

y Difficulty swallowing

y Speech impairment

y Vision changes

y Urinary incontinence

Cerebrovascular disease

y Hypertension

y Myocardial infarction (MI) or acute myocardial infarction (AMI),

y Ischemia (restriction in blood supply)PERIPHERAL VASCULAR DISEASE

In peripheral vascular disease, a diabetic client can develop arterial occlusion and thrombosis that canlead to gangrene but this can be developed years after you have been diagnosed of diabetes mellitus andnot properly treating it. Both the types of diabetes mellitus have a risk to develop this type of disease.

Clinical Manifestations:

y Tingling sensation of affected area

y Numbness / loss of sensation

y Pale skin color

PREVENTION Maintain body weight and prevent obesity through proper nutrition and physical activity/exercise.

Encourage proper nutrition ± eat more dietary fiber, reduce salt and fat intake,avoid simple sugars like cakes and pastries; avoid junk foods.Promote regular physical activity and exercise to prevent obesity, hypercholesterolemia, and enhanceinsulin action in the body.Advise smoking cessation for active smokers and prevent exposure to second hand smoke. Smokeamong diabetes increases risk for heart attack and stroke

PATHOPH YSIOLOGY





REVIEW OF SYSTEMS

THE DIGESTIVE SYSTEM

The human digestive system is a complex series of organs and glands that processes food. In

order to use the food we eat our body has to break the food down into smaller molecules, and it also hasto excrete waste. Most of the digestive organs (like the stomach and the intestines) are tube-like and

contain the food as it makes its way through the body. The digestive system is essentially a long, twisting

tube that runs from the mouth to the anus, plus few other organs (like the liver and pancreas) that

produce or store digestive enzymes.



THE DIGESTIVE PROCESS

The digestive process begins in the mouth. Food is partly broken down by the process of chewingand by chemical action of salivary enzymes (these enzymes are produced by the salivary glands andbreak down starches into smaller molecules).

After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube

that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements.Then, food enters the stomach which is a large, sac-like organ that churns the food and bathes it

in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomachacids is called chyme.

After being in the stomach, food enters the jejunum, the duodenum and then the ileum of the smallintestine. In the small intestine, bile (produced in the liver and stored in the bladder),pancreatic enzymesand other digestive enzymes produced by the inner wall of the small intestine help in the break down of food.

After passing through the small intestine, food passes into the large intestines. Here, some of thewater and electrolytes are removed from the food. Many microbes (like Bacteroides, Lactobacillusacidophilus, Escherichia coli and Klebsiella) in the large intestines help in the digestion process. The firstpart of the large intestine is called cecum in which the appendix is connected, food then travels upward inthe ascending colon, then travels across the abdomen in the transverse colon to the descending colon

then to the sigmoid colon.

Solid waste is then stored in the rectum until excreted via the anus.

The illustration above shows two cycles occurring separately to maintain homeostasis in the

body. When glucose levels are too high the pancreas secretes insulin to convert excessglucose to glycogen for storage. When glucose levels are too low the pancreas

produces glucagon to convert stored glycogen to glucose, resulting in an increase in glucose

levels.

Pancreas (pronounced: pan-kree-us)

-is a part of the body's hormone-secreting system. The pancreas produces (in addition to

others) two important hormones, insulin (pronounced: in-suh-lin)

and glucagon (pronounced: gloo-kuh-gawn). They work together to maintain a steady level of

glucose, or sugar, in the blood and to keep the body supplied with fuel to produce and maintain

stores of energy.

FUNCTION

The pancreas is a dual-function gland, having features of both endocrine and exocrine (digestive system)

glands.



The part of the pancreas with endocrine function is made up of approximately a million cell clusters

called islets of Langerhans. Four main cell types exist in the islets. They are relatively difficult to

distinguish using standard staining techniques, but they can be classified by their secretion: cells

secrete glucagon (increase glucose in blood), cells secrete insulin (decrease glucose in blood), cells

secrete somatostatin (regulates/stops and cells), and PP cells secrete pancreatic polypeptide.

The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed

by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in

direct contact with vessels, and most endocrine cells are in direct contact with blood vessels. The islets

are "busily manufacturing their hormone and generally disregarding the pancreatic cells all around them,

as though they were located in some completely different part of the body." The islet of Langerhans plays

an imperative role in glucose metabolism and regulation of blood glucose concentration.

The pancreas as an exocrine gland helps out the digestive system. It secretes pancreatic juice that

contains digestive enzymes that pass to the small intestine. These enzymes help to further break down

the carbohydrates, proteins, and lipids (fats) in the chyme.

OHAs: Oral Hypoglycemic Agents Alpha-glucosidase inhibitors are oral anti-diabetic drugs used for diabetes mellitus type 2 that work bypreventing the digestion of carbohydrates (such as starch and table sugar).

Includes :- ACARBOSE, MIGLITOL, Mogliboze Very important group of drugs and very popular nowadays. The most important point that those drugsmainly reduce the absorption of carbohydrates from the intestine , so the amount of sugar absorbed into bloodstreamis reduced and the requirement for insulin will be reduced.

Those drugs play important role particularly inpostprandial rise of glucose ( the rise of glucose in the blood after eating ).

Why those drugs causes hypoglycemia attack? ¸ You know that diabetic patients when they eat,immediately ( or after .5 hour , 1 hour or two hours )

the blood sugar will rise sharply , and this sharp rise means that there is astressful condition for pancreas particularly in NIDDM , so

pancreas will start producing insulin and if the patient taking OHA which stimulates insulin releasingfrom the pancreas( such as Sulfonylureas class) , the pancreas will work greatly. But the requirement for insulin is high because of the high level of sugar in the blood after eating and the pancreas can¶t produceenough amount of insulin to

lower the blood sugar . So there is asharp rise in blood sugar level, followed by sustained highlevel and then gradual decrease in the blood sugar . Sometimes this gradual decrease will reach alevel below the normal level that the brain used to be in and the patient goes into hypoglycemia (hypoglycemic attack).

CARDIOVASCULAR SYSTEM



RELATIONSHIP OF PANCREAS TO CIRCULATOY SYSTEM:

The islets of Langerhans cells within the pancreas are a compact collection of endocrine cellsarranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells arein direct contact with blood vessels.HCVD- Hypertensive cardiovascular disease refers to heart conditions that develop as a result of uncontrolled high blood pressure (hypertension). Ten percent of individuals with chronic hypertensiondevelop enlarged left ventricles (left ventricular hypertrophy, or LVH). Enlargement of the left ventricleputs the individual at greater risk of illness and death (morbidity and mortality) due to congestive heartfailure, heart rhythm irregularities (ventricular arrhythmias,atrial fibrillation), and heart attack (myocardialinfarction).

The left ventricle is one of four chambers (two atria and two ventricles) in the human heart. Itreceives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via

the aortic valve.

FUNCTION:

For excellence of health, the left ventricular muscle must:

(a) relax very rapidly after each contraction so as to fill rapidly with oxygenated blood flowing from

the lung veins, i.e. diastolicrelaxation and filling.

(b) contract rapidly and forcibly to force the majority of this blood into the aorta, overcoming the

much higher aortic pressure and the extra pressure required to stretch the aorta and other major

arteries enough to expand and make room for the sudden increase in blood volume,

i.e. systolic contraction and ejection.

(c) be able to rapidly increase or decrease its pumping capacity under nervous system control.

What is the connection between diabetes, heart disease, and stroke?

If you have diabetes, you are at least twice as likely as someone who does not have diabetes to have

heart disease or a stroke. People with diabetes also tend to develop heart disease or have strokes at an

earlier age than other people. If you are middle-aged and have type 2 diabetes, some studies suggest

that your chance of having a heart attack is as high as someone without diabetes who has already had

one heart attack.People with diabetes who have already had one heart attack run an even greater risk of having a second

one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death.

High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the

blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and

hardening of blood vessels (atherosclerosis).



Ischaemic or ischemic heart disease (IHD), or myocardial

ischaemia, is a disease characterized by ischaemia (reduced

blood supply) of the heart muscle, usually due to coronary

artery disease(atherosclerosis of the coronary arteries). Its risk

increases with

age,smoking, hypercholesterolaemia (high cholesterol levels),

diabetes, and hypertension (high blood pressure).

IMMUNE SYSTEM

COMMUNITY ACQUIRED PNEUMONIA (CAP) Is a term used to describe one of several diseases in which individuals who have not recentlybeen hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and canaffect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains,and a cough.CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAPinclude bacteria, viruses,fungi, and parasites.

What is the connection between diabetes and CAP? Obese and persons who suffer from the type 2 diabetes have an altered immune system. If the diabetesgoes untreated, the cells become sugar concentrated making them paradise for all microorganisms. It canbe better explained like this: The person¶s immune system is dysregulated (impairment of physiological

function), because of the presence of high concentration of sugars.



High sugar implies abundant food reserves making conducive for yeast, bacteria and other parasites tomultiply. A person acquires infections very soon as the immune system becomes dwarfed and cannoteliminate them totally.It is for the same reason the diabetics have issues with multiple yeast and bacterial and also fungalinfections. These infections also presumably take time longer time to heal when compared to healing in anon-diabetic person.So in order to keep these infections and parasites at bay and to keep immune system function well, youneed to take steps to manage type 2 diabetes.Furthermore, physicians and diabetologists believe that the hemoglobin A1C or HbA1C is correlated toimmune system; and blood sugars and HbA1C are directly proportional and it gives a picture of bloodglucose concentration over 2 months time period. Higher the HbA1C figures reflect higher blood glucoseand likelihood for weaker immune system.Therefore, weight loss or addressing the obesity becomes the immediate goal in those type 2 diabeticswho are prone to infections and it is from an immunological perspective. This could be achieved with a

combination of planned nutritious diet and exercise.

MEDICAL INTERVENTION

Nam

e of

Drug

with

Dosa

ge

Drug Classi fication

Mechanism of

Action Indication/

Use Special

Consideration Side Effects/

Adverse

Reaction

Pritor Plus40

mg,1

tabletOD

Angiotensin IIAntagonists / Diuretics

PritorPlus is acombination of an angiotensin

II receptor antagonist,telmisartan,

and a thiazidediuretic,

hydrochlorothiazide. The

combination of

theseingredients hasan additive

antihypertensive effect,

reducing blood pressure to agreater degree

Treatment of essentialhypertension

H

epaticimpairment.Renovascular HTN, renal

impairment &kidney

transplant,intravascular vol depletion,

other conditions w/

stimulation of the renin-angiotensin-aldosterone

system, primary

aldosteronism,aortic & mitral

EyeDisorders:Abnormalvision,transient blurredvision.Respiratory,Thoracic andMediastinalDisorders:

Respiratorydistress(including pneumonitisand pulmonaryedema),



than either component

alone.PritorPlus oncedaily produces

effective andsmoothreductions in

blood pressureacross thetherapeuticdose range.

valve stenosis,obstructive

hypertrophiccadiomyopathy, may impair

glucosetolerance &hyperuricemiaor frank goutmay occur,electrolyteimbalance.

dyspnea.GastrointestinalDisorders:Diarrhea,

dry mouth,flatulence,abdominal pain,constipation,dyspepsia,vomiting,gastritis.Hepatobiliar y Disorders:

Abnormalhepaticfunction/liver disorder EndocrineDisorders:Loss of diabeticcontrol.PsychiatricDisorders:Restlessness. NervousSystemDisorders:Lightheadedness.

Vessel

dueF, 1

tabletOD

B01AB11 -Sulodexide ;

Belongs to theclass of heparingroup. Used inthe treatment of

thrombosis.

Vessel Due-Fcontains

sulodexide, aglycosaminoglycan featuring

a markedantithromboticaction either on

arterial or venous

Vascular pathologies w/thrombotic risk,

transientischemic attacks

&cerebrovascular

disease, peripheral

vascular

In all caseswhereanticoagulanttreatment isunder way,hemocoagulative parametersshould bemonitored periodically.

Occasionaloccurrenceof thefollowingside effectshave beenreported:Capsule:Disorders inthe



systems.Sulodexide is

also capable of normalizing

altered

viscosimetry parametersgenerally

present in patients with

vascular pathologies

withthrombotic

risk, this actionmainly relies

on reducedfibrinogenvalues.

insufficiency,diabetic

retinopathy, MI,retinal vasalthrombosis.

Use in pregnancy: Due to precautionaryreasons, the

administrationof VesselDue-F to pregnantwomen is notrecommended.

gastroentericsystem withnausea,vomitingand

epigastralgia.Ampule:Pain, burnandhematoma atthe site of injection.Rarely, therecan besensitization

withcutaneousreaction or reaction inother sites.

Isoket 40mg,1 tabOD

C01DA08 -Isosorbidedinitrate ;

Belongs to theclass of organic

nitratevasodilators.Used in thetreatment of

cardiac disease.

Isosorbidedinitrate causesa relaxation of vascular smooth muscle

therebyinducingvasodilatation.Both peripheralarteries andveins arerelaxed byisosorbidedinitrate. Thelatter effect promotesvenous poolingof blood anddecreasesvenous returnto the heart,therebyreducingventricular

Oral Use: Long-term treatment

of coronaryartery disease;severechronic

heart failure incombinationwith cardiacglycosides,

diuretics,ACE inhibitors or

arterialvasodilators; pul

monaryhypertension;treatment & prevention

of angina pectoris (even

after treatedmyocardialinfarction).

Isoket Retardshould be used

only with particular caution and

under medicalsupervision in:Low filling

pressure eg, inacute

myocardialinfarction,

impaired leftventricular

function (leftventricular

failure); aorticand/or mitral

stenosis;disease

associatedwith an

increasedintracranial

Duringadministration of Isoket,thefollowing

undesirableeffects may be observed:CardiacDisorders:Common:Tachycardia.Uncommon:Enhancedangina pectorissymptoms.GastrointestinalDisorders:Uncommon: Nausea,vomiting.Very Rare:



end-diastolic pressure andvolume(preload).

pressureorthostaticsyndrome.

Heartburn.GeneralDisordersandAdministrati

on SiteConditions:Common:Feeling of weakness. NervousSystemDisorders:VeryCommon:Headache.

Common:Lightheadedness,dizziness,drowsiness.Skin andSubcutaneous TissueDisorders:Uncommon:Allergicskin

D50 W ½VialnowIV

pushD5050

½vial,

q4hrs.

References: Doenges, Marilyn E. et. Al, Nursing Care Plan. 7th Edition, 2006. Medical-Surgical Nursing, 10th Edition by:Joyce Young Johnson



Clinical Anatomy and Pathophysiology for the Health Professionalby:Joseph Stewart,M.D

Nursing Care of the Patient with Medical Surgical Disorder by: Lippincott &Sudharta

Nursing Pocket Guide, 10th Edition by: Doenges, Marilyn E. et. Al Fundamentals in Nursing Practice by: Udan ,RN,MAN

Mims.com.ph

www.nlm.nih.gov

www.Free-yd.Net En.Wikipedia.com

www.google.com

www.yahoo.com

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