Foundation University COLLEGE OF NURSING Dumaguete City
Submitted to: Ms. Michelle B. Dales, B.S.N. - R.N. Level III
Clinical Instructor Submitted by: Faelnar, Germaine, S.N. Real,
Julie Christy, S.N. Level III - B1 & B2 Date Submitted:
September 04, 2008
COURSE TITLE TOPIC PLACEMENT TIME ALLOTMENT TITLE
: NURSING CARE MANAGEMENT 101 : CARE OF THE CLIENT WITH DIABETES
MELLITUS : Level III Medicine Rotation 1st Semester 2008-2009
Negros Oriental Provincial Hospital : 1.5 hours : This topic
discusses on the care of the client with diabetes mellitus and its
common classifications. It also touches on the endocrine system
where the pancreas, which is responsible for insulin production, is
located. It talks about the signs and symptoms of diabetes
mellitus, the complications the clients experience, the drugs to be
administered, the therapy and management of diabetes mellitus.
GENERAL OBJECTIVE: At the end of one hour and thirty minutes
discussion using the various T-L Activities, the learners shall be
able to gain additional knowledge, enhance skills, and acquire
positive attitude and values towards caring for clients with
Diabetes Mellitus. SPECIFIC OBJECTIVES Throughout the One (1) hour
and thirty (30) minutes teaching with the use of various T-L
activities, the learners shall: 1. discuss overview of topic
briefly; CONTENT T.A. TL ACTIVITIES REFERENCES EVALUATION After One
(1) hour and thirty (30) minutes of teaching with the use of
various T-L activities, the learners were able to: 5 mins
Socialized discussion Shyrock, Harold. MD. (2002). Modern Medical
Guide, Revised Edition. Philippines: Phillippine Publishing House.
p.495. Porth, Carol Mattson. et. al. (2002).Pathophysiology
Concepts of Altered Health States, 6th Edition. USA (Philadelpia) :
Lippincott Williams and Wilkins. p.930. Kee, Joyce LeFever, RN MS.,
et. al. (1993) Pharmacology: a Nursing Process Approach, 2nd ed.
USA: WB Saunders 5 mins Socialized discussion
www.emedicinehealth.com Crossword Puzzle 2. define at least five
(5) related terms correctly 1. discussed the overview of the topic
the I. Introduction the The word diabetes is derived from the
Greek word meaning going through and Melilitus from the Latin word
for honey or sweet. Reports of the disorder dates back to the first
century AD wherein it characterizes the 3Ps. Polyuria, Polydipsia,
and Polyphagia. It was the discovery of insulin by Banting and Best
in 1922 that transformed the disease into a manageable chronic
health problem. Diabetes is a serious metabolic disorder ,
characterized by defects in the bodys use of carbohydrates. It also
includes the disorder aside from carbohydrates, of proteins and fat
metabolism resulting from an imbalance between insulin availability
and insulin need.
2. define at least II. Definition of terms five (5) out of 8
related terms in A. Glucose: The simple sugar (monosaccharide) that
serves their own words; as the chief source of energy in the body.
Glucose is the principal sugar the body makes. The body makes
CONTENT proteins, fats and, in largest part, carbohydrates.
Glucose is carried to each cell through the bloodstream. Cells,
however, cannot use glucose without the help of insulin. B.
Hormone: a specific messenger molecule synthesized and secreted by
a group of specialized cells called an endocrine gland. A chemical
substance produced in the body that controls and regulates the
activity of certain cells or organs. C. Glucagon: hormone produced
in alpha cells of pancreatic islets of langerhans. Causes breakdown
of glycogen into glucose, thus preventing blood sugar from falling
too low during fasting. D. Insulin: A natural hormone made by the
pancreas that controls the level of the sugar glucose in the blood.
Insulin permits cells to use glucose for energy. Cells cannot
utilize glucose without insulin. E. Metabolism the sum of physical
and chemical changes in the body by which nutrition is effected, It
encompasses the total collection of chemical reactions in the body
and reflects the ability of the body to capture and store energy
derived from foods and to make that energy available in the
appropriate form when needed. F. Hypoglycemia: abnormally low blood
glucose levels. G. Hyperglycemia: an excessive amount of glucose in
the circulating blood. H. Diabetes Mellitus: Diabetes mellitus (DM)
is a set of related diseases in which the body cannot regulate the
amount of sugar in the blood.
REFERENCES Price, Sylvia A. et al. (2003). Pathophysiology
Clinical Concepts of Disease Processes, 6th Edition. p.950.
www.wikepedia.com Blackwell's Nursing Dictionary, 2nd ed.(2005).
Blackwell Publishing Ltd. p.179,286,289, 304, 358,253
EVALUATION A. Glucose: The simple sugar (monosaccharide) that
serves as the chief source of energy in the body. B. Glucagon:
hormone produced in alpha cells of pancreatic islets of langerhans.
C. Insulin: A natural hormone made by the pancreas that controls
the level of the sugar glucose in the blood. D. Hypoglycemia:
abnormally low blood glucose levels. E. Hyperglycemia: an excessive
amount of glucose in the circulating blood.
SPECIFIC CONTENT OBJECTIVES 3. pinpoint the III. Anatomy and
Physiology of the Endocrine System gland responsible for diabetes
A. Endocrine System mellitus correctly; The Endocrine System and
Nervous System have similar regulatory functions. The nervous
system sends electrical messages to control and coordinate the body
while the endocrine system has a similar job, but uses chemicals to
communicate. These chemicals are known as hormones. The glands in
the endocrine system are ductless, which means that their
secretions (hormones) are released directly into the bloodstream
and travel to elsewhere in the body to target organs, upon which
they act. 1. Glands of the Endocrine System
T.A. 5 mins
TL ACTIVITIES Socialized discussion Pin Me! Game
Seeley, Rod R. et al. (2005). Essentials of Anatomy and
Physiology, 5th ed. New York: Mc-GrawHill Companies, Inc. pp. 272
296. http://en.wikipedia.org/wiki/ Endocrine_system
2. Functions of the Endocrine System The main regulatory
functions of the endocrine system include: a. Water balance The
endocrine system regulates water balance by controlling the solute
concentration of the
SPECIFIC OBJECTIVES blood.
b. Uterine contractions and milk release - .regulates uterine
contractions during delivery of the newborn and stimulates milk
release from breasts in lactating females. c. Growth, metabolism
and tissue maturation regulates the growth of many tissues, such as
bone and muscle, and the rate of metabolism f many tissues which
helps maintain a normal body temperature and normal mental
functions. d. Ion regulation it regulates sodium, potassium and
calcium concentrations in the blood. e. Heart rate and Blood
pressure regulation the endocrine systems helps regulate the heart
rate and blood pressure and helps prepare the body or physical
activity. f. Immune system regulation reproduction and function of
immune cells. helps control the
g. Reproductive functions control controls the development and
the functions of the reproductive system in males and females. h.
Blood glucose control regulates blood glucose levels and other
nutrients levels in the blood. 4. differentiate the IV.
Classification of Diabetes Mellitus two types of Diabetes Mellitus
A. Type 1 Diabetes: also known as IDDM or Insulinaccurately in
their dependent diabetes mellitus, occurs mainly in children and
own words; young adults and the onset is usually sudden. The
deficiency 10 mins Socialized Discussion Waugh, Anne. et.al. (2002)
Ross and Wilson. Anatomy and Physiology in Health and Illness, 9th
Edition. Elsevier Science Ltd. pp. 234- 236. 4. differentiate the
two types of Diabetes Mellitus accurately in their own words;
CONTENT or absence of insulin is due to the destruction or
dysfunction of beta cells by the cells of the immune system. The
causes are unknown but there is a familial tendency, suggesting
genetic involvement. In many cases an autoimmune reaction has
occurred in which antibodies to beta cells are present. As of
today, this type is not curable. B. Type 2 Diabetes: this is the
non-insulin dependent type or NIDDM that occurs later in life, the
body has an adequate supply of insulin , but a defect has developed
in the mechanism by which insulin enables cells to make use of
glucose. The pancreas secretes insulin, but the body is partially
or completely unable to use the insulin. This is sometimes referred
to as insulin resistance. The body tries to overcome this
resistance by secreting more and more insulin. People with insulin
resistance develop type 2 diabetes when they do not continue to
secrete enough insulin to cope with the higher demands.
REFERENCES Shyrock, Harold. MD.p.497.
EVALUATION Type I Diabetes is also known as Insulin-dependent
diabetes mellitus. Type II is the non insulin-dependent diabetic
Porth, Carol Mattson. et. al. p. 936.
5. enumerate 6 out V. Common Signs and Symptoms of Diabetes
Mellitus of the 10 signs and symptoms of A. Polyuria: excessive
urination. Another way the body tries Diabetes Mellitus to get rid
of the extra sugar in the blood is to excrete it in the urine.
correctly ; This can also lead to dehydration because excreting the
sugar carriesa large amount of water out of the body along with
Lecture discussion Match Me! Game
Porth, Carol Mattson. et. al. 5. Give 6 out 10 p.936. signs and
symptoms of diabetes mellitus. A. Polyuria B. Polydipsia C.
Polyphagia D. Weight loss E. Blurred Vision F. Fatigue
B. Polydipsia: excessive thirst. The body encourages more water
consumption to dilute the high blood sugar back to normal levels
and to compensate for the water lost by excessive urination. C.
Polyphagia: excessive hunger. One of the functions of insulin is to
stimulate hunger. Therefore, higher insulin levels lead to
increased hunger and eating. Despite increased caloric intake, the
person may gain very little weight and may even lose weight.
CONTENT D. Unexplained Weight loss: People with diabetes are
unable to process many of the calories in the foods they eat. Thus,
they may lose weight even though they eat an apparently appropriate
or even excessive amount of food. Losing sugar and water in the
urine and the accompanying dehydration also contributes to weight
loss. E. Blurred Vision: Blurred vision develops as the lens and
retina are exposed to hyperosmolar fluids or very high blood
glucose levels. F. Fatigue: In diabetes, the body is inefficient
and sometimes unable to use glucose for fuel. The body switches
over to metabolizing fat, partially or completely, as a fuel
source. This process requires the body to use more energy. The end
result is feeling fatigued or constantly tired. G. Paresthesias: is
a sensation of tingling, pricking, or numbness of a person's skin
with no apparent long-term physical effect. It is more generally
known as the feeling of "pins and needles" or of a limb being
"asleep." H. Infections: Certain infection syndromes, such as
frequent yeast infections of the genitals, skin infections, and
frequent urinary tract infections, may result from suppression of
the immune system by diabetes and by the presence of glucose in the
tissues, which allows bacteria to grow well. They can also be an
indicator of poor blood sugar control in a person known to have
diabetes. I. Poor wound healing: High blood sugar levels prevent
white blood cells, which are important in defending the body
against bacteria and also in cleaning up dead tissue and cells,
from functioning normally.
SPECIFIC CONTENT OBJECTIVES 6. classify the VI. Complications of
Diabetes Mellitus different complications of A. Acute Diabetes
Mellitus appropriately; 1. Diabetic Ketoacidosis: diabetic
ketoacidosis occurs when ketone production by the liver exceeds
cellular use and renal excretion. The most serious complication of
type 1 diabetes. This develops due to increased insulin requirement
or increased resistance to insulin due to some added stress such as
pregnancy, microbial infection, infarction, cerebrovascular
accident. Severe hyperglycemia is developed. a. Management: This
can be treated by restoring water and electrolyte balance. IV
therapy by means of unmodified insulin to allow glucose utilization
and antibiotics to overcome infections. 2. Hyperglycemic
Hypersmolar Nonketotic Syndrome: occurs most often in older
individuals with type 2 diabetes. Because of relative but not
absolute insulin deficiency, hyperglycemia develops without
ketosis. It is caused by severe dehydration due to the continuous
removal of sugar in urine known as hyperglycaemic diuresis. The
patient may become unconscious and may die if the condition is not
quickly reversed. The major difference between HHNK and DKA is the
lack of ketosis with HHNK. a. Management: The treatment of HHNK
consists of rehydration, electrolyte replacement, IV of large
amount of bicarbonates and half a dose of regular insulin. 3.
Hypoglycemia: also known as insulin reaction or insulin shock which
is mainly a complication of insulin therapy. Insulin-dependent
diabetic patients may occasionally receive insulin in amounts
larger than that needed to maintain normal glucose levels with
T.A. 10 mins
TL ACTIVITIES Socialized discussion
EVALUATION 6. Give at least one two (2) complications of
diabetes mellitus and classify; A. Hypoglycemia: acute B. Diabetic
www.wikepedia.com Waugh, Anne. et.al. p.235.
CONTENT Management: Administering quickly absorbed glucose
source such as softdrinks, orange juice, pinch of cake frosting,
foods rich in vitamins C, E and B complex and glucose containing
tablets. IM of glucagon. B. Chronic 1. Diabetic nephropathy- kidney
damage from diabetes. The diseased small blood vessels in the
kidney. As the disease progress, the kidney stops filtering and
cleaning the blood leading to accumulation of toxic waste products
in blood. a. Management: Controlling high blood pressure ,dialysis.
2. Diabetic retinopathy: diabetic retinopathy is the leading cause
of blindness and is cause by an underlying microangiopathy a.
Management: Controlling high blood pressure , blood sugar level,
eating raw natural foods, rich in vitamin A foods and exercise of
the eyes. 3. Diabetic neuropathy: A family of nerve disorders
caused by diabetes. It involves temporary or permanent damage to
nerve tissues. Diabetic neuropathies cause numbness and sometimes
pain and weakness in the hands, arms, feet, and legs. Neurologic
problems in diabetes may occur in every organ system, including the
digestive tract, heart, and genitalia. People with diabetes can
develop nerve problems at any time, but the longer a person has
diabetes, the greater is the risk. a. Management: Controlling,
blood sugar level, analgesics, regular foot examination, oral and
SPECIFIC CONTENT OBJECTIVES 7. name at least VII. Medical
Management for Diabetes Mellitus one (1) drug and one (1)
laboratory A. Drugs test in the medical management of 1. Insulin:
Regular and NPH insulin; can be classified as diabetes mellitus
intermediate and long acting insulin. concisely; a. Action:
Increases glucose transport across muscle and fat cell membrane to
reduce glucose level. Helps convert glucose to glycogen; b.
Indication and dosage: This is for type 1 diabetes mellitus Many
people with type 2 diabetes eventually require insulin
therapy.varies according to the clients blood sugar. c. Side
effects: hunger, tremors, weakness, headache, lethargy, fatigue,
redness, irritation or swelling at insulin injection site,
flushing, confusion, agitation. d. Adverse effects: urticaria,
tachycardia, palpitations, hypoglycaemic reaction, rebound
hyperglycemia (somogi effect), lipodystrophy, life threatening
adverse reactions are shock and anaphylaxis. 2. Sulfonylureas:
T.A. 20 mins
TL ACTIVITIES Socializeddiscussion
REFERENCES Kee, Joyce LeFever, RN MS., et. al. p. 635-637.
EVALUATION 7. Name at least one (1) drug and one (1) laboratory
test in the medical management of diabetes mellitus;
(2008) Nursing 2008 Drug Handbook, 28th Edition. New York:
Lippincott A. Sulfonylureas Williams & Wilkins. p. 795
(Dymelor) 828. B. Benedicts Test
a. Action: These drugs stimulate the pancreas to make more
insulin. This increases the insulin cell receptors, thus increasing
the cells ability to bind insulin for glucose metabolism. b.
Indication and dosage The sulfonylureas are used in the treatment
of type 2 diabetes or NIDDM. metabolism. P.O.: 250 to 1,000mg
CONTENT in 1 or 2 divided doses. Maximum dosage is 1.5 grams
daily and maintenance is 1000 mg daily. c. Side effects: Nausea,
vomiting, diarrhea, rash, pruritis, headache and photosensitivity.
d. Adverse effects: Hypoglycemic reaction, life threatening adverse
effects are aplastic anemia, leukopenia, thrombocytopenia. 3.
Nonsulfonylureas: expanding knowledge of glucose metabolism has
revealed new mechanisms for the management of NIDDM or type 2
diabetes. These new drugs, metformin and acarbose, use different
methods to control serum glucose levels following a meal. Unlike
the sulfonylureas, which enhance insulin release. Metformin
(Glucophage) a. Indication and dosage: for NIDDM when no response
to Sulfonylureas. Take with meals. May be combined with
sulfonylurea (dose reduction of metformin would be needed). PO:
Initial:500. mg, daily b.i.d.; increase dose gradually; max:2500
mg/daily. b. Adverse effects : diarrhea, nausea, vomiting,
abdominal bloating, flatulence, anorexia, taste perversion, anemia,
lactic acidosis, hypoglycaemia. 4. Hypoglycemic a. Action: Raises
glucose level by promoting catalytic depolymerization of hepatic
glycogen to glucose. Relaxes the smooth muscle of the stomach,
duodenum, small bowel and colon.
CONTENT b. Indication and dosage: Adults and children who weigh
more than 20 kg or 44 lbs.: 1 mg IV , IM, or subcutaneously.
Children who weigh 20 kg or less: .5 mg or 20 to 30 mcg/kg. IV, IM,
or subcutaneously: maximum dose 1 mg. May repeat in 15 minutes, if
needed. IV glucose must be given if patient fails to respond. b.
Adverse effects : nausea, vomiting, bronchospasm, respiratory
distress, hypersensitivity reactions. d. Nursing considerations:
Use drug only in emergency situations. Monitor glucose level
before, during, and after administration. Alert: arouse patient
from coma as quickly as possible, and give additional carbohydrates
orally to prevent hypoglycaemic reactions. B. Laboratory and
Diagnostic Tests 1. Blood Tests: Blood glucose measurements are
used in both diagnosis and management of diabetes. a. Fasting Blood
Glucose Test- the fasting blood glucose has been suggested as the
preferred diagnostic test because of ease of administration,
convenience, patient acceptability, and cost. Glucose levels are
measured after food has been withheld for 8-12 hours. If the
fasting plasma glucose level is higher than 126 mg/dl, on two
occasions diabetes is diagnosed. A fasting plasma glucose level
below 110 mg/dl, is normal. A level between 110 mg/dl to 126 mg/dl,
is significant and is defined as impaired fasting glucose. b.
Random Blood Glucose Test: a random blood glucose is one that is
done without regard to meals or time of day random blood glucose
concentration that is unequivalent elevated (>200 mg/dl,) in the
presence of classic symptoms of
CONTENT diabetes such as polydipsia, polyphagia, polyuria, and
blurred vision is diagnostic of diabetes mellitus of any age c.
Glucose Tolerance Test: the oral glucose tolerance test ensures the
bodys ability to store glucose by removing from the blood. In men
and women, the test measures the plasma glucose response to 75 g of
concentrated glucosylution at selected intervals, usually 1 hour to
2 hours. Persons with diabetes lacks the ability to respond to an
increase in blood glucose by releasing adequate insulin to
facilitate storage, blood glucose levels rise above the served in
normal people and remain elevated for long periods. d. Capillary
Blood Tests and Self-Monitoring of Capillary: These methods use a
drop of capillary blood obtained by pricking the finger or forearm
with a special needle or lancet. Small trigger devices make use of
the lancet usually painless. The drop of capillary blood is placed
on absorbed by a reagent strip, and glucose levels are defined
electronically using a glucose meter e. Glycosylated Hemoglobin
Test: is a blood test that reflects average blood glucose levels
over a period of approximately 2 to 3 months. 2. Urine Tests a.
Benedicts test :determines the presence of sugar in the body. b.
Urine test for ketones: a urine test to determine if your blood
glucose is dangerously high and if you are producing substances
called ketones. Ketones are the by-product of the fat burning
process that occurs in the absence of insulin. When a person with
diabetes has a high blood glucose, if there is not enough insulin
around (type 1 diabetes) or if their body is unable to utilize the
insulin properly (type 2 diabetes) and break
CONTENT down glucose, the body turns to fat stores to create
energy for the cells. While ketones can be a source of energy for
many cells, they can be toxic in large amounts and cause a
lifethreatening emergency condition called ketoacidosis.
8. itemize the VIII. Nursing Care Management for Patients with
Diabetes Nursing Care Mellitus Management for Diabetic patients A.
Assessment thoroughly; 1. Vital Signs 2. Clients level of knowledge
3. Lab results 4. Blood Sugar 5. Skin 6. Blood Pressure 7. Eyesight
8. Urine Output 9. Activity 10. Diet 11. Weight 12. Fluid Intake B.
Diagnoses 1. Self-care Deficit: potential self-care deficit related
to physical impairments or social factors 2. High Risk for Injury
3.Altered Nutrition: imbalanced nutrition related to imbalance of
insulin, food, and physical activity 4. Risk for Infection 5. Risk
for Impaired Tissue Integrity 6. Knowledge Deficit: deficient
knowledge about diabetes self-care skills/information 7. Risk for
Impaired Adjustment 8. Risk for Disturbed Sensory Perception
8. Give at least 3 the Nursing Care Management for Diabetic
CONTENT 9.Compromised Family Coping 10. Anxiety- related to loss
of control, fear of inability to manage diabetes, misinformation
related to diabetes, fear of diabetes complications 11.Risk for
Fluid Volume Deficit- related to polyuria and dehydration C.
Interventions 1. Dependent a. Insulin Therapy: insulin regimens
vary from 1 or more injections per day. Usually there is a
combination of a short-acting insulin and a longer-acting insulin.
The goal of all but the simplest, one injection insulin regimens is
to mimic this normal pattern of insulin secretion in response to
food intake and activity patterns. In people without diabetes,
insulin secretion compensates for varying amounts of food intake
and exercise. In contrast, individuals with diabetes are unable to
secrete sufficient quantity of insulin to maintain their blood
glucose level. As a consequence, blood glucose rise to high levels
in response to meals, and levels are high in the fasting state.
Patients with severe insulin insufficiency require injections of
insulin in addition to a meal plan. b. Medications the use of
antidiabetics help patients blood glucose level return to its
normal balanced state. 2. Independent a. Exercise and Limitations
in Activity: exercise appears to facilitate the transport of
glucose into cells and to increase sensitivity to insulin. However,
patients with diabetes complications should limit their activity
and is advised to consult the doctor before taking up an exercise
regimen or doing any activity.
Smeltzer, S., Bare, B. (2004). Medical Surgical Nursing, Vol. 2,
10th ed. New York: Lippincott Williams & Wilkins. pp. 1163.
CONTENT b. Diabetes education: patients with diabetes mellitus
can lead to a relatively normal life if they are well informed
about their disease and its management. Patients can learn to
administer their own insulin, monitor their blood glucose level,
and use this information to regulate their insulin dosage and plan
their diet and exercise to minimize hyperglycemia and hypoglycemia.
3. Collaborative a. Meal Planning - the meal planning of diabetic
patients is aimed at controlling the number of calories and the
amount of carbohydrates ingested daily. The recommended number of
calories varies, depending on the need for maintaining, reducing,
or increasing body weight. The meal plan should be developed in
consultation with a registered dietitian and based on a patients
diet history, food preferences, lifestyle, cultural background, and
physical activity. b. Glucose Monitoring various self-monitoring of
blood glucose (SMBG) methods are available. Most involved obtaining
a drop of blood from fingertip, applying the blood to a special
reagent strip, and allowing the blood to stay on the strip for the
amount of time specified by the manufacturer. The meter gives a
digital readout of the blood glucose value. c. Planning of Care -
must be done with the patient to fit his lifestyle. Self-care at
home should include diet, exercise, alcohol use, smoking, self
Price, Sylvia A. p. 946.
9. evaluate the IX. Open Forum presentation objectively
Question and Answer portion
9. Do you have any questions, clarifications and comments?
SPECIFIC OBJECTIVES X. Quiz
T.A. 5 mins
TL ACTIVITIES Pen and paper quiz
EVALUATION 10. get a seventy-five percent (75%) out of one
hundred percent (100%) level of competency. 1. It is a serious
metabolic disorder , characterized by defects in the bodys use of
carbohydrates. (Diabetes Mellitus) 2. Give the 3 Ps of diabetes
mellitus (Polyuria, polydipsia, Polyphagia) 3-6. Give and
Differentiate the two common types of diabetes mellitus. (Type I
insulin dependent and Type 2 noninsulin dependent).
EVALUATION 7. Is also known as insulin reaction or insulin shock
which is mainly a complication of insulin therapy. (Hypoglycemia)
8. What is the gland in the endocrine system that is responsible
for insulin production? (pancreas) 9 -10. What are the two hormones
produced by this gland? (insulin and glucagons)
BIBLIOGRAPHY: BOOKS: (2005). Blackwell's Nursing Dictionary, 2nd
ed. Blackwell Publishing Ltd. (2008) Nursing 2008 Drug Handbook,
28th Edition. New York: Lippincott Williams & Wilkins. p. 795
828. Seeley, Rod R. et al. (2005). Essentials of Anatomy and
Physiology, 5th ed. New York: Mc-Graw-Hill Companies, Inc. Kee,
Joyce LeFever, RN MS., et. al. (1993). Pharmacology: a Nursing
Process Approach, 2nd ed. USA: WB Saunders Company. Price, Sylvia
A. et al. (2003). Pathophysiology Clinical Concepts of Disease
Processes, 6th Edition. Porth, Carol Mattson. et. al. (2002).
Pathophysiology Concepts of Altered Health States, 6th Edition. USA
(Philadelpia) : Lippincott Williams and Wilkins. Shyrock, Harold.
MD. (2002). Modern Medical Guide, Revised Edition. Philippines:
Phillippine Publishing House. Smeltzer, S., Bare, B. (2004).
Medical Surgical Nursing, Vol. 2, 10th ed. New York: Lippincott
Williams & Wilkins. pp. 1163. Waugh, Anne. et.al. (2002) Ross
and Wilson. Anatomy and Physiology in Health and Illness, 9th
Edition. Elsevier Science Ltd. INTERNET SOURCES: