Angeles University Foundation College of Nursing Angeles City

In Partial Fulfillment of Requirements of RLE

Post-Debridement, Non-Healing Burn Wound of the Right Foot 2 Diabetes Mellitus Type 2A CASE STUDY

BSN 4-3 Group 11 Corpuz Mary Joyce Gomez, Bernard Langit, Cassandra Mallo, Josephtti

Submitted to: Kenneth Bisda, RN, MN

I.

INTRODUCTION To eat is a necessity, but to eat intelligently is an art.

-Franois de La Rochefoucauld

Eating is necessary in order to live, but to eat with knowledge is a talent in itself. Unhealthy eating is one of the contributing factors which leads to many deadly illnesses and is spreading throughout the nation. Eating healthy will help an individual to live longer and give the confidence needed in knowing that body is at its best. Making small changes in daily eating habits will enable people to move forward towards a healthier body and lifestyle. Having a chronic disease could be a source of torment to an individual. A person can do whatever he wants, but never do something that may alter bodily function because it is hard to cope with a condition that causes a person to lose the stability of his life. The term diabetes is derived from the Greek word siphon which means something which goes through thus the term diabetes is applied to diseases which are characterized by polyuria (overproduction of urine). The term mellitus is taken from the Latin word mel which means honey thereby describing the honeyed or sweet taste of urine. The urine is sweet in diabetes mellitus because, in the absence of sufficient insulin, sugar accumulates in the blood and eventually spills in the urine. Diabetes Mellitus Type 2 (DM type 2) is a chronic condition and the major organ involved is the pancreas. It secretes hormones that affect the level of sugar in the blood. The pancreas contains Islets of Langerhans, which are tiny groups of specialized cells that are scattered throughout the organ and these cells secrete glucagon that raises the level of glucose (sugar) in the blood; insulin that stimulates cells to use glucose; somatostatin which regulate the secretion of glucagons and insulin. When the pancreas cannot produce enough insulin or the body cannot utilize it properly to allow sugar (glucose) to enter the cells, where it is used for energy, Diabetes Mellitus develops. (Manaloto et. al, 2011)

Diabetes is a chronic disease where your body can't use glucose, or sugar, the way it should. It can cause a number of complications, including some that make it harder for wounds to heal. These include: 1) Nerve damage (neuropathy). When you have neuropathy, you may not feel the pain of a cut or blister until it has grown worse or become infected. 2) Weakened immune system. When the body's natural defenses are down, even a minor wound may become infected. 3) Narrow arteries. People with clogged arteries in their legs are more likely to develop wounds, have severe wound infections, and have problems healing. Narrowed arteries make it harder for blood to get to the wound. Blood flow promotes healing, so anything that blocks it can make wounds more likely to become infected. (WebMD, 2005)

a. NEW TRENDS ABOUT THE DISEASE CONDITION Beta Carotene Might Reduce Diabetes Risk Can this prevent Diabetes? PreventionNews by Katie Drummond In a groundbreaking new report, published in the journal Human Genetics, researchers at the Stanford University School of Medicine have concluded that people with a common genetic predisposition to type 2 diabetes are less likely to develop the illness if they have elevated blood levels of beta carotene. More specifically, those consuming around 6.5mg of the nutrient every day (that's equivalent to half a cup of cooked carrots) appeared best off, though the link also depends on how their body metabolizes beta carotene. Where type 2 diabetes is concerned, the genetic variant evaluated by investigatorsSLC30A4, which is found in the genomes of 50-60% of Americanshas already been linked to an increased risk of diabetes. But in parsing CDC data, researchers concluded that beta carotene levels seem inversely linked to whether or not at-risk individuals suffered from diabetes. This same study also concluded that gamma tocopherol, a common variety of vitamin E found in margarine as well as soybean and corn oils, seems associated with an increased risk of diabetes among these same genetically vulnerable people. Ironically,

vitamin E also appears to benefit diabeticsthe nutrient improves blood glucose metabolism, for instanceso researchers speculate that this latest finding might merely indicate a diet rich in processed foods (which often contain large quantities of gamma tocopherol). (http://www.prevention.com/diabetes-center/beta-carotene-might-reduce-

diabetes-risk#ixzz2L45FGoGP) b. STATISTICS Filipinos are not an exemption to this incidence as more and more Filipinos are affected by the disease. In fact, the last 2008 survey was alarming enough to conclude that one out of every five Filipinos have diabetes. That means that around 20% of the population have diabetes and this has significantly increase from only 4% in 1998. Another cause for alarm is that Filipinos diagnosed with diabetes are getting younger. Children, as young as 5-years old, have been diagnosed with type 2 diabetes. With this trend, the Philippines is expected to belong on the top 10 countries with the most people with diabetes 15 years from now. (http://www.allaboutdiabetes.net/philippine-diabetesstatistics/) According to the American Diabetes Association, there are 25.8 million children and adults in the United States, 8.3% of the population, have diabetes. c. REASONS FOR CHOOSING THE STUDY Diseases are prescribed in the clinical setting; nurses would specifically get in touch with patients and would also provide their specific studies. Mostly would result to curiosity, which means seeking out for answers to every question that linger their minds, especially to that of the student nurses who get to encounter and experience patients with certain disease. An interesting case study like Diabetes Mellitus is one of the most controversial and common diseases among older people that caught the group members attention to study about. It was also assigned by our clinical instructor in doing this case study.

d. OBJECTIVES Nurse Centered: SHORT TERM: During the course of this study, the student shall have: Built a good therapeutic relationship with the patient and the family by establishing rapport with the patient and significant others; Gathered information on the demographic data of the patient as to personal history, demographic data, and socio-economic factors; Assessed the contributory factors that are involved in the condition of the patient through the use of history taking of family health illness history, history of past illnesses, and history of present illness; Completed a thorough physical examination to help verify the disease of the patient and identify the different signs and symptoms manifested by the patient, and; Collected and assessed data related to the patients precipitating and predisposing factors that lead to the disease condition through an interview with the patient and significant others. LONG TERM: At the end of the study, the student shall have: Listed and explained the diagnostic and/or laboratory procedures ordered and analyzed their results which may be significant factors in determining clients condition; Identified the nursing responsibilities for every procedure rendered for patients condition; Understood fully the anatomy and physiology of the Endocrine System and Integumentary System;

Understood the pathophysiology of the disease and be able to learn the disease process; Formulated health promotion and preventive aspects of the disease; Prioritized patients problems based from the patients immediate needs; Formulated nursing care plans that will be used in solving the needs of the patient; Implemented the nursing care plans formulated and evaluated if the objectives are met, and; Understood and implemented the medical management and treatment ordered for the patient.

Patient Centered: SHORT TERM: During the course of this study, the patient shall have: Built a trusting relationship with the student nurses as well as with the other health care providers;

Provided the student nurse relevant information on the health history in the provision of health care, and; Determined part of the health history of patient that contributed to patients illness and show understanding of its importance.

LONG TERM: After the end of this study, the patient shall have: Understood current health condition and its signs and symptoms; Followed medical regimen conscientiously to achieve optimum level of functioning; Showed proper compliance to interventions and health teachings given by the student nurse;

Acquired knowledge on the importance of regular check-ups and reinforcement of a balanced diet; Received best possible care having a feeling of security and comfort; Determined factors that may contribute to the occurrence of possible complications; Demonstrated independence on self-care and home management upon discharge, and; Showed improvement relating to the health teachings.

II.

NURSING PROCESS

A. ASSESSMENT

1. PERSONAL HISTORY

a. DEMOGRAPHIC DATA Sugar Daddy, 35 years old, male and a natural born Filipino, was born in San Fernando, Pampanga, on October 30, 1977. He is currently residing at Purok 3 Pulung Santol, Porac, Pampanga. The patient stands 5 ft. 10 inches and weighs 58.6 kg (129 lbs.). He is the second youngest out of six siblings. He is single and still lives with his father, 69 years old, who owns a hardware in Porac, Pampanga. Sugar Daddy was brought to Angeles University Foundation Medical Center last January 28, 2013 with a diagnosis of Non-healing Burn Wound. He undergone surgery (debridement) last February 1, 2013 and was discharged on February 10, 2013.

b. SOCIOECONOMIC FACTORS Sugar Daddy is a single male, who lives with his father in Porac, Pampanga. He is a Roman Catholic who is active in most religious activities of their parish. The patient is a college graduate of computer technician in CSSI, Angeles City. The patient goes to the herbolarios first before going to the hospital and uses herbal medicines such as lagundi, oregano, and ampalaya for common illnesses such as cough, stomach aches, etc. Sugar Daddy is self-employed. The patient together with his father, own a hardware in Porac, Pamapanga where they earn 800 php per day. The patients monthly income would range from 20,000 to 30,000 pesos. The money earned monthly is used for the household expenses such as water bill, electric bill, and food.

According to the patient, he is fond of eating sweet, salty, and fatty foods and eats at least 1-2 cups of rice every meal which gradually increased to 3 cups of rice very recently. He stated that he drinks at least 4 full tall glasses of water a day, however he also stated that recently he has been drinking water more than usual. He reported that he had problems urinating at night in which he has to get up more often than usual to urinate.He likes to drink coffee in the morning. He began drinking alcoholic beverages such as Red Horse beer at a young age of 18 years old at least once a week and only when there is an occasion. He started smoking at around the same time as he started drinking and usually smokes a pack of Marlboro once a week.

2. FAMILY HEALTH ILLNESS HISTORY Tracing his third degree family background, there were histories of illness or condition that may contribute to Sugar Daddys present condition. His grandparents both died of a heart attack. From his fathers side, there are 7 siblings and all have diabetes. While, from his mothers side, there are 9 siblings and all have hypertension. Sugar Daddys father is still alive, but his mother died due to complications of hypertension. Another incident occurred 2 years ago in which he went to the health center due to a feeling of numbness in his legs. His sister-in-law who is a barangay health worker in that health center, checked his blood glucose and told him to take Metformin because the results of that test was very high. According to Mr. Sugar Daddy, he never followed up with a physician for his abnormally high sugar level and continued to take the medication for a month. He stopped taking it because he received information that the medication has a side-effect that can affect his kidneys.

GENOGRAM

GRANDFATHER A unknown

GRANDMOTHER A heart attack

GRANDFATHER B unknown

GRANDMOTHER B unknown

FATHER DM

MOTHER heart attack

SISTER 1 48 years old

BROTHER 1 46 years old

SISTER 2 41 years old

SISTER 3 40 years old

Sugar Daddy 35 years old

SISTER4 33 years old

LEGEND = Death = Female

= Male

= Disease Figure 1

3. HISTORY OF PAST ILLNESS The common illnesses he had during his childhood years were cough and colds accompanied by fever and headache which according to him do not need consultation and could be managed with the use of analgesics such as Paracetamol. He also stated that he had a history of chicken pox, mumps, and measles, but couldnt recall the exact medical management for his condition other than a visit to a family doctor and medications to control his fever such as Paracetamol.

4. HISTORY OF PRESENT ILLNESS Last January 6, 2013, while he was cooking using a charcoal stove, Mr. Sugar Daddy accidently burnt his right foot by stepping on the charcoal that fell from the charcoal stove. According to the patient, he cleaned the wound with betadine and didnt take any medications. From January 6 to January 20, 2013, he stated that he could still walk, but after a few days, he could not walk anymore. So, he went to a doctors clinic in Porac for consultation. He had a chief complaint of paresthesia to his right foot. According to the patient, the physician said that his wound was severe and in need of surgery and requires admission. On January 28, 2013, Sugar Daddy was admitted at Angeles University Foundation Medical Center with an initial diagnosis of Non-Healing Burn Wound. His chief complaint was non-healing burn wound in his right foot. The patient had surgery, debridement of his right foot, last February 1, 2013.

5. PHYSICAL EXAMINATION

Initial nurse-patient interaction began on Wednesday, February 6, 2013. Mr. Sugar Daddy was found lying flat on the bed with his right leg resting on top of the foot of the bed while watching television. The student nurse initiated the conversation by introducing herself and asking the condition of Mr. Sugar Daddy. It was during this time that the student-nurse requested permission to use Mr. Sugar Daddys profile as the

subject for this case study which was granted. A cephalocaudal assessment was performed at the convenience of the patient followed by an interview with the patient.

Initial Physical Assessment:

Vital Signs BP= 130/90 mmHg T= 38.2 C PR=96 bpm RR= 21 bpm

Mental Status Conscious and coherent

Language Hair Scalp Without dandruff or infestation Combed, with white strands Speaks Kapampangan

Skull and Face Smooth skull contour, absence of nodules or masses

Facial features Symmetric facial movements

Eye & Vision Eyebrows Symmetrically aligned

Eyelashes Equally distributed

Eyelids Skin intact, no discharges

Bulbar conjunctiva Slightly pale, anicteric sclera

Palpebral conjunctiva Shiny, smooth, pink in color

Lacrimal sac Cornea Pupils Black in color, (+) PERRLA Transparent, shiny and smooth No tearing and edema

Ears & Hearing Auricle Aligned in the outer cantus of the eye, no tenderness

External Ear Canal/ tympanic membrane Without discharge, without cerumen

Gross hearing acuity Normal voice tone is audible

Watch tick test Able to hear ticking of the watch

Nose and Sinuses Symmetrical, pink mucosa, no discharge or flaring, sinuses not tender

Patency of airway Air moves freely as the patient breath through the nares

Mouth and Pharynx Lips Teeth Gums Pink in color Complete teeth Able to purse the lips

Tongue Palates Smooth and light pink in color Pink in color, no lesions, can move freely

Tonsils Neck Can turn neck side to side and forward Smooth, pink in color, in normal size

Lymph Nodes not palpable

Thyroid Gland Not visible and ascends during swallowing

Chest and Lungs Sub coastal Chest Expansion, no retractions, clear breath sounds, (-) crackle, (-) wheezing

Anterior Thorax Breathing Pattern Bilateral rise and fall of chest

Heart & Vascular System No Pulsation, equal rhythm of heart, (-) murmurs

Apical Area No lift or heave

Carotid artery No sounds around auscultation, full pulsation

Peripheral perfusion Breast Not able to assess Immediate return of blood after blanch test

Abdomen Skin Nails Appears pale, long and slightly dirty Brown complexion No tenderness, normal skin turgor Has uniform temperature Globular in shape. There are no presences of masses or lesions.

Muscle Strength and Tone Bones No deformities Without tremors and contractures

Sensation With sense of touch, pain and temperature

Genitals No deformities

Extremities Presence of 2nd degree ulcer on the upper 1/3 of the plantar surface of the right foot with serosanguinous drainage packed with sterile dressing. Cranial Nerve Assessment Cranial Nerve 1. Olfactory Type: Sensory Fxn: Sense of smell 2. Optic Type: Sensory Fxn: Sense of vision and visual fields 3. Oculomotor Type: Motor Fxn: Pupil constriction and raising of eyelid Normal Findings Client must be able to identify the scent of alcohol when asked to smell it. Client must see the ballpen or penlight clearly at a given distance. Eyes must follow the direction of the movement of the penlight; In lightly dimmed environment, the pupils of the eyes will dilate but upon the introduction of light, pupils will constrict. The eye must follow the movement of a ballpen in different directions with coordination. The client elicited blinking reflex upon touching the cornea with the use of cotton. Client must be able to follow the index finger of the examiner. Actual Findings Sugar Daddy was able to identify the scent of coffee when asked to smell it. Sugar Daddy could was able to read the newspaper 12 inches away from him. Sugar Daddy eyes were able to follow the movement of the penlight, (+) PERRLA.

4. Trochlear Type: Motor Fxn: Downward inward eye movement 5. Trigeminal Type: Sensory and Motor Fxn: Jaw movements, chewing and mastication 6. Abducens Type: Motor Fxn: Lateral movements of the eyes 7. Facial Type: Motor and Sensory

Sugar Daddy was able to move eyeball laterally and downward. Sugar Daddy elicited blinking reflex upon touching the cornea. Sugar Daddy was able to follow the index finger of the examiner as it moves horizontally. Sugar Daddy was able to raise eyebrows and show

Client must be able to raise eyebrows, show teeth

Fxn: Movement of muscles of the face and sense of taste on the anterior two-thirds of the tongue. 8.Acoustic (Vestibulocochlear) Type: Sensory Fxn: Sense of hearing 9. Glossopharyngeal Type: Motor and Sensory Fxn: Pharyngeal movements and swallowing 10. Vagus Type: Motor and Sensory Fxn: Swallowing and speaking 11. Accessory Type: Motor Fxn: Movement of shoulder muscles 12. Hypoglossal Type: Motor Fxn: Movement of tongue and strength of the tongue Cranial Nerve 1. Olfactory Type: Sensory Fxn: Sense of smell 2. Optic Type: Sensory Fxn: Sense of vision and visual fields 3. Oculomotor Type: Motor Fxn: Pupil constriction and raising of eyelid

and puff out cheeks.

teeth.

Client must be able to hear a tick of watch.

Sugar Daddy was able to hear the tick of watch.

Must be able to swallow foods that were chewed.

Sugar Daddy had no difficulty on swallowing.

Must be able to speak clearly.

Sugar Daddy was able to swallow and demonstrate gag reflex. Sugar Daddy was able to slightly shrug his shoulders against resistance on his right and left upper extremity. Sugar Daddy was able to move his tongue side to side. Actual Findings Sugar Daddy was able to identify the scent of coffee when asked to smell it. Sugar Daddy could was able to read the newspaper 12 inches away from him. Sugar Daddy eyes were able to follow the movement of the penlight, (+) PERRLA.

The client must able to elevate his shoulders against resistance

The client must able to move his tongue side to side and protrude his tongue. Normal Findings Client must be able to identify the scent of alcohol when asked to smell it. Client must see the ballpen or penlight clearly at a given distance. Eyes must follow the direction of the movement of the penlight; In lightly dimmed environment, the pupils of the eyes will dilate but upon the introduction of light, pupils will constrict. The eye must follow the movement of a ballpen in

4. Trochlear Type: Motor

Sugar Daddy was able to move eyeball laterally and

Fxn: Downward inward eye movement 5. Trigeminal Type: Sensory and Motor Fxn: Jaw movements, chewing and mastication 6. Abducens Type: Motor Fxn: Lateral movements of the eyes 7. Facial Type: Motor and Sensory Fxn: Movement of muscles of the face and sense of taste on the anterior two-thirds of the tongue. 8.Acoustic (Vestibulocochlear) Type: Sensory Fxn: Sense of hearing 9. Glossopharyngeal Type: Motor and Sensory Fxn: Pharyngeal movements and swallowing 10. Vagus Type: Motor and Sensory Fxn: Swallowing and speaking 11. Accessory Type: Motor Fxn: Movement of shoulder muscles 12. Hypoglossal Type: Motor Fxn: Movement of tongue and strength of the tongue

different directions with coordination. The client elicited blinking reflex upon touching the cornea with the use of cotton. Client must be able to follow the index finger of the examiner.

downward. Sugar Daddy elicited blinking reflex upon touching the cornea. Sugar Daddy was able to follow the index finger of the examiner as it moves horizontally. Sugar Daddy was able to raise eyebrows and show teeth.

Client must be able to raise eyebrows, show teeth and puff out cheeks.

Client must be able to hear a tick of watch.

Sugar Daddy was able to hear the tick of watch.

Must be able to swallow foods that were chewed.

Sugar Daddy had no difficulty on swallowing.

Must be able to speak clearly.

Sugar Daddy was able to swallow and demonstrate gag reflex. Sugar Daddy was able to slightly shrug his shoulders against resistance on his right and left upper extremity. Sugar Daddy was able to move his tongue side to side.

The client must able to elevate his shoulders against resistance

The client must able to move his tongue side to side and protrude his tongue.

Final Physical Assessment: February 7, 2013 The final nurse-patient interaction was performed on February 7, 2013. Mr. Sugar Daddy was found lying flat on the bed with his right leg resting on top of the foot of the bed while watching television. He has a clean appearance and was cooperative during the assessment.

Vital Signs BP= 130/90 mmHg T= 38.2 C PR=96 bpm RR= 21 bpm

Mental Status Conscious and coherent

Language Hair Scalp Without dandruff or infestation Combed, with white strands Speaks Kapampangan

Skull and Face Smooth skull contour, absence of nodules or masses

Facial features Symmetric facial movements

Eye & Vision Eyebrows Symmetrically aligned

Eyelashes Equally distributed

Eyelids Skin intact, no discharges

Bulbar conjunctiva Slightly pale, anicteric sclera

Palpebral conjunctiva Shiny, smooth, pink in color

Lacrimal sac Cornea Pupils Black in color, (+) PERRLA Transparent, shiny and smooth No tearing and edema

Ears & Hearing Auricle Aligned in the outer cantus of the eye, no tenderness

External Ear Canal/ tympanic membrane Without discharge, without cerumen

Gross hearing acuity Normal voice tone is audible

Watch tick test Able to hear ticking of the watch

Nose and Sinuses Symmetrical, pink mucosa, no discharge or flaring, sinuses not tender

Patency of airway

Air moves freely as the patient breath through the nares

Mouth and Pharynx Lips Teeth Gums Pink in color Complete teeth Able to purse the lips

Tongue Palates Smooth and light pink in color Pink in color, no lesions, can move freely

Tonsils Neck Can turn neck side to side and forward Smooth, pink in color, in normal size

Lymph Nodes not palpable

Thyroid Gland Not visible and ascends during swallowing

Chest and Lungs Sub coastal Chest Expansion, no retractions, clear breath sounds, (-) crackle, (-) wheezing Anterior Thorax Breathing Pattern

Bilateral rise and fall of chest

Heart & Vascular System No Pulsation, equal rhythm of heart, (-) murmurs

Apical Area No lift or heave

Carotid artery No sounds around auscultation, full pulsation

Peripheral perfusion Breast Not able to assess Immediate return of blood after blanch test

Abdomen Skin Nails Appears pale, long and slightly dirty Brown complexion No tenderness, normal skin turgor Has uniform temperature Globular in shape. There are no presences of masses or lesions.

Muscle Strength and Tone Bones No deformities Without tremors and contractures

Sensation With sense of touch, pain and temperature

Genitals No deformities

Extremities Presence of 2nd degree ulcer on the upper 1/3 of the plantar surface of the right foot with serosanguinous drainage packed with sterile dressing.

Cranial Nerve Assessment Cranial Nerve 1. Olfactory Type: Sensory Fxn: Sense of smell 2. Optic Type: Sensory Fxn: Sense of vision and visual fields 3. Oculomotor Type: Motor Fxn: Pupil constriction and raising of eyelid Normal Findings Client must be able to identify the scent of alcohol when asked to smell it. Client must see the ballpen or penlight clearly at a given distance. Eyes must follow the direction of the movement of the penlight; In lightly dimmed environment, the pupils of the eyes will dilate but upon the introduction of light, pupils will constrict. The eye must follow the movement of a ballpen in different directions with coordination. The client elicited blinking reflex upon touching the cornea with the use of cotton. Client must be able to follow the index finger of the examiner. Actual Findings Sugar Daddy was able to identify the scent of coffee when asked to smell it. Sugar Daddy could was able to read the newspaper 12 inches away from him. Sugar Daddy eyes were able to follow the movement of the penlight, (+) PERRLA.

4. Trochlear Type: Motor Fxn: Downward inward eye movement 5. Trigeminal Type: Sensory and Motor Fxn: Jaw movements, chewing and mastication 6. Abducens Type: Motor Fxn: Lateral movements of the eyes 7. Facial Type: Motor and Sensory Fxn: Movement of muscles of the face and

Sugar Daddy was able to move eyeball laterally and downward. Sugar Daddy elicited blinking reflex upon touching the cornea. Sugar Daddy was able to follow the index finger of the examiner as it moves horizontally. Sugar Daddy was able to raise eyebrows and show teeth.

Client must be able to raise eyebrows, show teeth and puff out cheeks.

sense of taste on the anterior two-thirds of the tongue. 8.Acoustic (Vestibulocochlear) Type: Sensory Fxn: Sense of hearing 9. Glossopharyngeal Type: Motor and Sensory Fxn: Pharyngeal movements and swallowing 10. Vagus Type: Motor and Sensory Fxn: Swallowing and speaking 11. Accessory Type: Motor Fxn: Movement of shoulder muscles 12. Hypoglossal Type: Motor Fxn: Movement of tongue and strength of the tongue

Client must be able to hear a tick of watch.

Sugar Daddy was able to hear the tick of watch.

Must be able to swallow foods that were chewed.

Sugar Daddy had no difficulty on swallowing.

Must be able to speak clearly.

Sugar Daddy was able to swallow and demonstrate gag reflex. Sugar Daddy was able to slightly shrug his shoulders against resistance on his right and left upper extremity. Sugar Daddy was able to move his tongue side to side.

The client must able to elevate his shoulders against resistance

The client must able to move his tongue side to side and protrude his tongue.

6. DIAGNOSTIC AND LABORATORY PROCEDURES A. RADIOGRAPHIC REPORT DIAGNOSTIC/ LABORATORY PROCEDURES KUB DATE ORDERED DATE RESULTS IN DO: 1-30-13 DI: 1-30-13 A radiologic exam where images of the kidneys, ureters, and bladder are produced in a special type of film. KUB radiography is often used as a first step in diagnosing problems of the urinary system. In this study, it was ordered to determine the size, shape, and position of the kidneys and bladder as well as to further investigate the suspicion of nephrotic syndrome Both kidneys are Kidneys are normal within normal size in size and with normal unremarkable. cortical thickness and echo genocity. The right kidney measures 10.08 cm x 4.54 cm x 4.79 cm with costical thickness of 1.84 cm while the left measures 10.26 cm x 4.91 cm x 4.20 cm with cortical thickness of 1.59 cm. Both pelvo calyces are not dilated. No lithiasis seen. Renal outlines are regular. Para renal spaces INDICATIONS RESULTS NORMAL VALUES ANALYSIS AND INTERPRETATION (Patient-Based) The findings indicate that the kidneys are not yet affected in terms of physical structure are concerned as a result of the increase in serum sugar level that can cause complications such as nephromegaly.

that is associated are not remarkable. with diabetes mellitus along with serum albumin, calcium, coagulation factors, lipid profile, 24hour urine total protein and creatinine. Nursing Responsibilities: Prior: Explain the procedure. Explain the purpose and what to expect. No food or fluid restrictions. Remove all metal objects from the body. Check that the patient has emptied the bladder before the test commences. Allow the patient to use a protective lead shield.

During: Instruct the client to remain still during the procedure. Instruct client to inspire deeply and hold the breath. After:

After the test, the patient should be returned to their normal activities if these have been disturbed, i.e. eating and drinking, as quickly as possible. Keep the past records especially the latest ones. Document.

DIAGNOSTIC/ LABORATORY PROCEDURES Arteries of Lower Extremities Duplex Ultrasound

DATE ORDERED DATE RESULTS IN DO: 2-5-13 DI: 2-5-13

INDICATIONS

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION (Patient-Based)

A form of ultrasonography that uses sound waves that bounce off blood vessels to create pictures. Doppler ultrasound records sound waves reflecting off moving objects, such as blood, to measure their speed and other aspects of how they flow. In this study, it was ordered to determine development of Peripheral Artery Disease (PAD), which is common among patients with

Peripheral Arterial Disease of the lower extremities with 1-19% stenosis in the bilateral distal external iliac down to the trifurcation (anterior tibial, posterior tibial and peroneal arteries)

Peripheral arteries are not stenosed and there is freeflow of blood to these arteries.

The findings indicate that there is narrowing of the arteries in the lower extremities. According to the American Diabetes Association (2013), the abnormal metabolic state accompanying diabetes results in changes in the state of arterial structure and function. The onset of these changes may even predate the clinical diagnosis of diabetes. Relatively little is known about the biology of PAD in individuals with diabetes in particular. Its a huge possibility that the development of PAD in the patient

diabetes mellitus.

is a result of diabetes. The narrowing of the peripheral arteries contributed to the poor healing of the wound as well as the absence of pain.

Nursing Responsibilities: Prior: Explain the procedure. Explain the purpose and what to expect. No food or fluid restrictions. Expose the extremity to be evaluated for the procedure.

During: Instruct the client to remain still during the procedure.

After: After the test, the patient should be returned to their normal activities if these have been disturbed, i.e. eating and drinking, as quickly as possible. Keep the past records especially the latest ones. Document.

B. CLINICAL CHEMISTRY (FLUID AND ELECROLYTES)

DIAGNOSTIC/ LABORATORY PROCEDURES

DATE ORDERED DATE RESULTS IN

INDICATIONS

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION (Patient-Based) Mr. Sugar Daddys potassium level is within normal range.

Potassium

DO: 1-28-13 DI: 1-28-13

Sodium

DO: 1-28-13 DI: 1-28-13 DO: 1-29-13 DI: 1-30-13

A potassium test checks how much potassium is in the blood. Potassium is both an electrolyte and a mineral. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Potassium is also important in how nerves and muscles work. A sodium test checks how much sodium is in the blood. Sodium is both an electrolyte and mineral. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Sodium is also important in how nerves

4.29

3.50-5.50 mmol/L

120.3

133.6

135-150 mmol/L There is a decrease in serum sodium level in Mr. Sugar Daddy. This is expected in a patient with diabetes where sodium is eliminated as a result of damage to the filtration of the kidneys caused by the

and muscles work.

Creatinine

DO: 1-28-13 DI: 1-28-13

To monitor renal function, specifically the ability of the kidney to excrete waste products. In this study, it was ordered to investigate the possible occurrence of nephritic syndrome.

177.04

70-138 mmol/L

Hba1c

DO: 1-28-13 DI: 1-29-13

HbA1c is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months. In this study, it was ordered due to suspicion of diabetes as manifested by the poor healing of the right foot which is typical in the condition. It is also a diagnostic tool for diabetes. (WHO, 2011)

13.6

4.40-6.40%

secretion of excess of glucose via the urinary system. An increase in serum creatinine may indicate that the kidneys have deficient filtration mechanism since there shouldnt be no tubular reabsorption of creatinine. This is an important determinant of glomelular filtration rate which is a measurement of kidney function. The result indicate that the client had increase serum levels in the past 3 months. The result supported the Diagnosis of Diabetes Mellitus Type II.

HGT

DO: 1-28-13 DI: 1-29-13

DO: 2-4-13 DI: 2-4-13

Also known as hemoglucose test, it determines the current blood glucose of the patient. It requires fasting for two hours.

126

90-110 mg/dl

116

The result indicate that the current serum glucose level of the patient is high which may indicate that there is not enough insulin in the body or insulin function is impaired which may warrant insulin medications.

Nursing Responsibilities: Prior: Define and explain the test. State the specific purpose of the test. Explain that there is no special preparation.

During: Use the sterile technique. After: Keep the past records especially the latest ones. Document.

C. COMPLETE BLOOD COUNTDIAGNOSTTIC/ LABORATORY PROCEDURES DATE ORDERED DATE RESULT(S) IN INDICATION(S) RESULTS NORMAL VALUES1 ANALYSIS AND INTERPRETATION

Hematocrit (Hct)

DO: 1-30-13 DI: 1-30-13

DO: 1-30-13 DI: 1-30-13

The hematocrit shows the oxygen-carrying capacity of the blood. This value also tells whether the blood is too thick or too thin. Useful as a measurement of red blood cells only if the hydration of the client is normal.

0.32

0.36-0.45

0.30

Hemoglobin (Hgb)

DO: 1-30-13 DI: 1-30-13

DO: 1-30-13

This is a test of measure of the total amount of hemoglobin in the blood. It is used as a rapid direct measurement of the red blood cell count.

102

123-153 g/L

Mr. Sugar Daddys hematocrit is below normal which may indicate that there is a decrease in red blood cells in the circulatory system since RBCs are one of the components that makes up the hematocrit level. The decrease in RBCs can be the result of impaired erythropoietin production of the kidneys as a complication of diabetes. Mr. Sugar Daddy has a below hemoglobin level which may indicate that there is a decrease in red blood cells in the circulatory system since hemoglobin is only

DI: 1-30-13

Leukocytes

DO: 1-30-13 DI: 1-30-13

DO: 1-30-13 DI: 1-30-13

It is repeated serially in patients with on going bleeding or as a routine part of the complete cell blood count. It is an integral part of the evaluation of anemic patients. Hemoglobin acts as an important acidbase buffer system. WBC or leukocytes are cells of the immune system which defend the body against both infectious disease and foreign materials. It evaluates the body capacity to resist and overcome infection It also determines severity of infection. A neutrophils test helps us detect the levels of neutrophils in our body. These neutrophils are an integral part of our immune system and

97

present in RBCs. A decrease in Hgb can significantly pose a problem in the healing process of the patient since cells require oxygen to carry out cellular processes.

20.90

4.50-11x10^9/L

19.68

Neutrophils

DO: 1-30-13 DI: 1-30-13

0.88

0.18-0.70

Mr. Sugar Daddys leukocyte count is considered high which may indicate that there is an ongoing infection. Most likely entry of pathogens in the patient is through the open wound in the right foot of the client. This was aggravated by the poor healing capability of the body due to diabetes. There is an increase in neutrophils which may indicate that there is an acute infection in the body. This is expected in the patient due to the open

DO: 1-30-13 DI: 1-30-13

Lymphocytes

DO: 1-30-13 DI: 1-30-13

DO: 1-30-13 DI: 1-30-13

through a process called chemotaxis, they reach any place where an infection has occurred. These cells take about an hour to reach the site of infection. In fact, they are one of the main components of pus and are to blame for its whitish color. It is also important to go in for a high neutrophils blood test as they are indicative of extremely high levels of stress in an individual. This test measures the number of lymphocytes (a type of white blood cell) in blood. It is used to evaluate and manage disorders of the blood or the immune system. It is also used to evaluate and manage certain types of cancer and tumors.

wound on his right foot. 0.86

0.10

0.10-0.48

His lymphocyte count is within normal range.

0.10

Monocytes

DO: 1-30-13 DI: 1-30-13

DO: 1-30-13 DI: 1-30-13

Platelet Count

DO: 1-28-13 DI: 1-28-13

DO: 1-30-13 DI: 1-30-13

This test measures the amount of monocytes in blood. Monocytes are a type of white blood cell (WBC). This test is used to evaluate and manage blood disorders, certain problems with the immune system, and cancers, including monocytic leukemia. This test may also be used to evaluate for the risk of complications after a heart attack. A platelet count may be used to screen for or diagnose various diseases and conditions that affect the number of platelets in the blood. It may be used as part of the workup of a bleeding disorder, bone marrow disease, or excessive clotting disorder, to name just

0.03

0.00-0.04

His monocyte count is within normal range.

0.03

364

150-400x10^9L

424

His platelet count is slightly elevated due to the presence of an open wound in his right foot. The poor healing state of the foot will be a factor in the increase production of platelets as it tries to stop the bleeding and seal the point of entry.

a few. The test may used as a monitoring tool for people with underlying conditions or undergoing treatment with drugs known to affect platelets. It may also be used to monitor those being treated for a platelet disorder to determine if therapy is effective.

Nursing Responsibilities: Prior: Explain the procedure. Explain the purpose and what to expect. No food or fluid restrictions. Check the doctor's order.

During: Do not take the blood sample from hand or arm with receiving IVF. The tourniquet should be less on a minute. Do not squeeze the punctured site rightly. Wipe away the first drop of blood. After: Label the specimen. Secure the results. Note for inflammation of punctured site. Document.

7. ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The bodys primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

Anatomy of the pancreas: The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail).

The pancreas is made up of two types of tissue:

Exocrine tissue The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas.

Endocrine tissue The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas: The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum.

The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones.

Anatomy of kidney The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells.

The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the

renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term "renal" is derived from the Latin name for kidney.) The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine (Cr). Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells.

8. THE PATIENT AND HIS ILLNESS

A. Pathophysiology a. Schematic Diagram (bookbased)

1. 2. 3. 4.

Precipitating factors: obesity environmental factors Inactive lifestyle diet

Insulin resistance

Predisposing factors: 1. family history of DM 2. race 3. age above 40

Exhaustion of beta cells

Insulin production/ decrease secretion of insulin Absorption of glucose by the cell

A

Degradation of proteins

Cell starvation

Hunger

B

B

POLYPHAGIA

HYPERGLYCEMIA

Nerve Demyelinization

Kidney filtration mechanism impaired GLYCOSURIA Capillary basement membrane thickening

NEUROPATHY Acidity of urine Paresthesias & numbness Impaired pain sensation Delayed wound healing Urethral flora Diffuse glomerular sclerosis

NEPHROPATHY UTI Circulating blood volume Hypovolemia Vaginitis POLYURIA & ALBUMINURIA Renal failure

NON-HEALING ULCERS

End-Stage Renal Disease

GangreneHYPOTENSION & TACHYCARDIA

C

D

C

D

F & E imbalance

Number of solute relative to water Potassium ion retention Sodium ions lost

Cardiac arrythmias

Tissue dehydration

DEATH

POLYDIPSIA

Increase viscosity of blood

Capillary basement membrane thickening Abnormal retinal vascular permeability

Thickening of blood vessel walls Occlusion of plaque

Musculoskeletal effects

Impaired glucose absorption in the muscle tissue G

E

F

E

F

G

RETINOPATHY

Blood flow blocked

Joint contractures

Blurring of vision

Blood pressure

Myocardial ischemia Myocardial infarction

Diminished peripheral pulse

FATIGUE

blindness

HYPERTENSION

Stroke Heart Failure A Breakdown of fat Fatty acids & glycerol Fat content of the blood

Weight Loss

ketone bodies in the general circulation hydroxybutyric acid acetoacetic acid acetone

Hyperlipidemia

Formation of fatty deposits on the walls of the blood vessels Acetone breath Atherosclerosis

Convulsions

Metabolic acidosis

Nausea and vomiting

Abdominal pain

Cellular Potassium Cardiac arrhythmias

Body attempts to prevent further decrease in pH Kussmauls respirations

Depressed central nervous system Headache

Poor appetite

1. Definition of the disease Diabetes Mellitus Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly known as adult-onset diabetes, it usually affects people aged over 40 and progresses gradually. In this type the pancreas has not ceased to produce insulin, but the quantity is insufficient, or the hormone is not stimulating the glucose uptake in muscles and tissues required for energy. The result is a build-up of glucose in blood and urine. Although the cause of this malfunctioning is unclear, non-insulin

dependent diabetes mellitus tends to run in families. Other risk factors, such as increasing age, obesity, and a sedentary lifestyle, probably contribute to its increased incidence in developed countries. Non-insulin dependent diabetes mellitus can often be controlled initially by diet alone, or in combination with tablets that reduce the amount of blood glucose. There are two main types of blood glucose-reducing drugs: sulphonylureas work mainly by stimulating the pancreass islet cells (known as the islets of Langerhans) to produce more insulin and biguanides increase the effectiveness of insulin on cells. Eventually, however, patients may need insulin injections.

Diabetic Foot Ulcer Diabetic foot ulcer is a major complication of diabetes mellitus, and probably the major component of the diabetic foot. It occurs in 15% of all patients with diabetes and precedes 84% of all lower leg amputations. Major increase in mortality among diabetic patients, observed over the past 20 years is considered to be due to the development of macro and micro vascular complications, including failure of the wound healing process. Wound healing is a make-up phenomenon for the portion of tissue that gets destroyed in any open or closed injury to the skin. Being a natural phenomenon, wound healing is usually taken care of by the bodys innate mechanism of action that works reliably most of the time. Key feature of wound healing is stepwise repair of lost extracellular

matrix (ECM) that forms largest component of dermal skin layer. Therefore controlled and accurate rebuilding becomes essential to avoid under or over healing that may lead to various abnormalities. But in some cases, certain disorders or physiological insult disturbs wound healing process that otherwise goes very smoothly in an orderly manner. Diabetes mellitus is one such metabolic disorder that impedes normal steps of wound healing process. Many histopathological studies show prolonged inflammatory phase in diabetic wounds, which causes delay in the formation of mature granulation tissue and a parallel reduction in wound tensile strength.

b.2. Predisposing Factors

Age - Type 2 DM usually occurs at the age 40 years old and above. Type 2 DM occurs most commonly in people older than 30 years who are obese.

Family history of DM - Type 2 DM has a strong genetic component. Although the major gene that places the patient at risk is not yet identified, it is clear that the disease is polygenic and multifactorial. Individuals with a parent with type 2 DM have an increased risk for diabetes. Genetic factors are thought to play a role in insulin rsistance and impaired insulin secretion in type 2 DM.

Race (African-Americans, Hispanic-Americans) - The risk for type 2 diabetes varies among population groups. Diabetes also seems to pose higher or lower risks for specific complications among racial groups.

Precipitating Factors

Obesity - Elevated levels of free fatty acids, a common feature of obesity, may contribute to the pathogenesis of type 2 DM. It can impair glucose utilization in skeletal muscles, promote glucose production by the liver and impair beta cell function.

Environmental Factors/Stress An increase in stress hormone triggers the release of epinephrine and norepinephrine which will promote the secretion of glucose leading to hyperglycemia.

Inactive Lifestyle A risk factor that had contributed in the occurrence of DM due to the fact that lack of muscle activities decreases the need for the body to utilize glucose as a form of energy.

Diet Foods rich in carbohydrates can easily promote the increasing level of glucose along the bloodstream.

b.3. Signs and Symptoms with Rationale Diabetes Mellitus HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) May be due to lack of physiologically active insulin that transports glucose from extracellular to intracellular leading to accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams. POLYURIA

Increased frequency of urination. This may be due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination.

POLYDIPSIA

Increased thirst and fluid intake. This may be due to the activation of the thirst center in the hypothalamus resulting form the intracellular dehydration or volume depletion.

POLYPHAGIA

Increased hunger and food intake. This may be due to the decrease glucose uptake by the cells leading the stimulation of the satiety center in the hypothalamus resulting to the hunger sensation.

WEAKNESS/ FATIGUE

This is due to the decreased glucose uptake by the cells leading to decreased energy production.

GLYCOSURIA

The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine.

Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine.

NAUSEA/ VOMITING Due to stomach fullness, there will be an involuntary emptying of stomach contents that are forcefully expelled by the mouth. A compensatory mechanism due to acidity of body because of decrease excretion of metabolic waste.

a. Schematic Diagram (clientbased)

Precipitating factors: 1. environmental factors 2. Inactive lifestyle 3. diet

Insulin resistance

Predisposing factors: 1. family history of DM 2. race

Exhaustion of beta cells

Insulin production/ decrease secretion of insulin Absorption of glucose by the cell

Degradation of proteins

Increase breakdown of fats

Cell starvation

WEIGHT LOSS 70kg to 58kg Weighed on 1-28-13 A

A POLYPHAGIA (November 2012) HYPERGLYCEMIA HGT 129 MG/DL 01/29/2013 Nerve Demyelinization Kidney filtration mechanism impaired Capillary basement membrane thickening

NEUROPATHY

Paresthesias & numbness Impaired pain sensation Delayed wound healing Circulating blood volume POLYURIA (November 2012)

Diffuse glomerular sclerosis

NON-HEALING ULCERS 1-06-13

Gangrene

B

C

B

C

F & E imbalance

Number of solute relative to water

Sodium ions lost

Tissue dehydration POLYDIPSIA (November, 2012)

Increase viscosity of blood Thickening of blood vessel walls Occlusion of plaque

D

D Blood flow blocked

Blood pressure

HYPERTENSION BP: 130/90 on 02/06/2012

b.1. Predisposing/ Precipitating Factors Predisposing Factors

Age- 35 years old. Heredity- father has DM

Precipitating Factors

Sedentary lifestyle Diet- Mr. Sugar Daddy was fond of eating sweets and fatty foods.

b.2. Signs and Symptoms Hyperglycemia o January 29, 2013 o Due to lack of physiologically active insulin that transports glucose from extracellular to intracellular will lead to

accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams. HGT monitoring results revealed 126 mg/dl on January 29, 2013

Hypertension o February 06, 2013 130/90 mmHg o Due to increase in osmotic pressure, fluid goes to the vascular space increasing the blood volume.

Non-healing Ulcer o January 06, 2013 o He accidentally stepped on a hot charcoal while cooking. He managed his wound by himself by cleaning it with betadine everyday, but it is not getting any better.

Polyuria o November 2012 o He reported getting up in the middle of the night to urinate.

Polydipsia o November 2012o

He reported drinking more water than usual

V. PATIENT AND HIS CARE 1. Medical Management a. IVFMEDICAL MANAGEMENT/TREATMENT DATE ORDERED DATE PERFORMED DATE CHANGED/ D/C PNSS/ 0.9 NaCl DO: 1-28-13 DP: 1-28-13 #1-#16 DC: Normal Saline is a It is indicated as a The patient GEBERAL DESCRIPTION INDICATON(S) CLIENTS RESPONSE TO THE TREATMENT

sterile, nonpyrogenic source of water and responded well to solution for fluid and electrolytes. It is also the treatment and electrolyte replenishment. contains for fluid and did not manifest any signs of dehydration as of patient effective entire therapy. electrolyte The an fluid had for imbalances. It electrolyte no replenishment well as medication administration.

antimicrobial agents.

balance during the

Nursing Responsibilities: Prior: Explain the procedure to the client to ensure her cooperation and to reduce anxiety. Check the information on the label of the IV infusion container, including the patients name and room number, type of solutions, time and date of each preparation, preparers name and order infusion rate. Compare the doctors order with the solution label to verify that the solution is the correct one. Wash hands thoroughly before and after the procedure. Select the smaller gauge device that is appropriate to the infusion. Place the IV solution with attached primed administration set on the IV pole. Hang the IV solution with attached primed administration set on the IV pole. Verify the patients identity by comparing the information on the solution container with patients wristband or any identification item. During: Select the puncture site. Place the patient in a comfortable, reclining position, leaving the arm in a dependent position to increase capillary refill of the lower hands and arms. Apply a tourniquet about 4-6 inches above the intended puncture site to dilate the vein. Check for the radial pulse. Lightly palpate the vein with the index and middle fingers of your non-dominant hand. Leaving the tourniquet in place for no longer than 3 minutes.

Clean the site with alcohol pads. Work in a circular motion outward from the site to a diameter of 2-4 inches. Allow the anti-microbial solution to dry. Grasp the access cannula. Using the thumb of your non-dominant hand, stretch the skin taut below the puncture site to stabilized the vein. Tell the patient when you are about to insert the device. Hold the needle bevel up and enter the skin directly over the vein at a 15-25 degree angle. Aggressively push the needle directly though the skin and into the vein in one motion. Grasp the cannula hub to hold it in the vein and withdraw the needle. To advance the cannula while infusing the IV solution, releases the tourniquet and remove the inner needle. Using the sterile technique attached the IV tubing and begins the infusion. While stabilizing the vein with one hand, use the other to advance the catheter into the vein. When the catheter is advanced, decreases the IV flow rate. After: After the venous access device has been inserted, clean the skin completely. Then regulate the flow rate. Cover the site with a sterile gauze pad or small adhesive bandage. Label the last piece of tape with the type, gauge of the needle and length of cannula, date and time of insertion and your initials. Check frequently for impaired circulation to the infusion site.

b. DrugsNAME OF DRUGS; GENERIC NAME AND BRAND NAME DATE ORDERED DATE TAKEN/GIVEN DATE CHANGED/ D/C ROUTE OF ADMINISTRATION, DOSAGE AND FREQUENCY GEN. ACTION FUNCTIONAL CLASSIFICATION MECHANISM OF ACTION INDICATION(S) CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECT. GENERIC NAME: Humulin R BRAND NAME: Lantus DO: 1-28-13 DT/DG: 1-29-13 DC: 40 units/day

Antidiabetic Treatment of The patients Metabolic acidosis serum glucose Its a hormone level decreased secreted by beta from 126 mg/dL cells of the to 116 mg/dL pancreas that , by receptor-mediated effects, promotes the storage of the bodys fuels, facilitating the transport of metabolites and ions through cell membranes and stimulating the synthesis of

glycogen.NAME OF DRUGS; GENERIC NAME AND BRAND NAME GENERIC NAME: Cilosterol BRAND NAME: Pletal DATE ORDERED DATE TAKEN/GIVEN DATE CHANGED/ D/C DO: 2-5-13 DT/DG: 2-5-13 DC: 100 mg BID PO ROUTE OF ADMINISTRATION, DOSAGE AND FREQUENCY GEN. ACTION FUNCTIONAL CLASSIFICATION MECHANISM OF ACTION INDICATION(S) CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECT.

phosphodiesterase inhibitor a selective inhibitor of 3-type phosphodiesterase (PDE3) with therapeutic focus on increasing cAMP. prevents the activation of an enzyme (myosin light-chain kinase) that is important in the contraction of smooth muscle cells, thereby

a quinolinonederivative medication used in the alleviation of the symptom of intermittent claudication in individuals with peripheral vascular disease.

Immediate effect is not determined. Patient did not experience any side effect

exerting vasodilatory effect. Nursing Responsibilities: Prior to Administration -Check patients name before administration -Check the doctors order -Prepare the medication as ordered.

its

-Explain the purpose, indication and possible adverse effects of the medication. After Administration -Monitor bowel movement. -Instruct patient not to drink alcohol during therapy.NAME OF DRUGS; GENERIC NAME AND BRAND NAME GENERIC NAME: Meropenem BRAND NAME: DATE ORDERED DATE TAKEN/GIVEN DATE CHANGED/ D/C DO: 8-2-12 DT/DG: 8-2-12 DC: 500mg IV q8 ROUTE OF ADMINISTRATION, DOSAGE AND FREQUENCY GEN. ACTION FUNCTIONAL CLASSIFICATION MECHANISM OF ACTION Antibiotic Treatment of complicated Bactericidal: skin and skin Inhibits synthesis structure INDICATION(S) CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECT. The patient did not anymore manifest any signs and symptoms of

Carbapenem

of bacterial cell wall, causing cell death.

infections due infection. Patient to was afebrile since Staphylococcu treatment began. s aureus

Nursing Responsibilities: Prior: Read carefully the doctors order. Obtain ANST before administering. Review methods of administration/storage. Consume fluids; ensure adequate hydration. Take for prescribed number of days even if symptoms subside. Note history of sensitivity/reactions to this or related drugs. During Observe patients reaction to drug. Monitor for nephrotoxicity. After Note characteristics of signs and symptoms. Identify onset, severity, location, and other association factors. Instruct patient to avoid alcohol while taking this drug and for 3 days after because severe reactions often occur.

Report severe diarrhea, difficulty of breathing, unusual tiredness or fatigue, pain at injection site. Document.

NAME OF DRUGS; GENERIC NAME AND BRAND NAME GENERIC NAME: Sitagliptin BRAND NAME: Januvia

DATE ORDERED DATE TAKEN/GIVEN DATE CHANGED/ D/C DO: 1-28-13 DT/DG: 1-29-13 DC:

ROUTE OF ADMINISTRATION, DOSAGE AND FREQUENCY 30 mg IV q6 (-) ANST

GEN. ACTION FUNCTIONAL CLASSIFICATION MECHANISM OF ACTION

INDICATION(S)

CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECT. Patient tolerated the drug well. Serum glucose level was controlled.

Antidiabetic Adjunct to Slows activation diet and of the incretin exercise to hormones, improve increasing these glycemic hormone levels control in and prolonging patients their activity. with type 2 diabetes mellitus, as monothera py or with other oral antidiabetic s.

Nursing Responsibilities: Prior: Read carefully the doctors order. Obtain ANST before administering. Review methods of administration/storage. Consume fluids; ensure adequate hydration. Take for prescribed number of days even if symptoms subside. Note history of sensitivity/reactions to this or related drugs. During Observe patients reaction to drug. Monitor for nephrotoxicity. After Note characteristics of signs and symptoms. Identify onset, severity, location, and other association factors. Instruct patient to avoid alcohol while taking this drug and for 3 days after because severe reactions often occur.

NAME OF DRUGS; GENERIC NAME AND BRAND NAME GENERIC NAME: Losartan BRAND NAME: Cozaar

DATE ORDERED DATE TAKEN/GIVEN DATE CHANGED/ D/C DO: 1-28-13 DT/DG: 1-29-13 DC:

ROUTE OF ADMINISTRATION, DOSAGE AND FREQUENCY 50 mg PO daily

GEN. ACTION FUNCTIONAL CLASSIFICATION MECHANISM OF ACTION

INDICATION(S)

CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECT. The blood pressure stabilized to 130/80 after administration of medication.

Antihypertensive Treatment of ARB hypertension, Selectively alone or in blocks the combination binding of with other anti angiotensin II to hypertensives. specific tissue receptors found in the vascular smooth muscle and adrenal gland.

a. Diet

Type of Diet

Date started/ Date changed

General Description

Indication

CLIENTS RESPONSE

Diabetic diet

DO: 2-1-13 DT/DG: 2-1-2013

Type 2 diet focus on controlling weight in

order to improve the body's ability to utilize insulin. In most cases Type 2 diabetes can be controlled proper diet through and

To control serum Patient was able to glucose level and consume entire meal. maintain it at a therapeutic level.

exercisealone. 1,900 kcal diet was given.b.

Nursing Responsibilities Prior Verify doctors order. Explain the diet prescribed to the patient. Instruct patient to withhold oral fluids and foods. During Ensure that the patient strictly follow the diet. After Assess for patients condition; how he responds to the diet.

d. Exercise/ Activity

Date Ordered, Type of exercise General description Indication or Purpose Date Started, Date Changed or D/C Complete Bed Rest with Bathroom Privileges An activity where strenuous activities should be avoided. Bed rest should be implemented but with assisted bathroom privilege to avoid further aggravation of the gangrene and to reduce pain as well. Indicated to avoid fatigue. 02-01-13 Patient responded to doctors order and stated decreased body weakness. Clients Response and/or reaction to activity

Nursing Responsibilities Prior

Check doctors order for any other considerations needed. Explain the activity to the patient. Explain why it is important and what it could improve in her condition. During Assess patients present condition. Reinforce information as appropriate. After Note patients response to activity.

3. SURGICAL MANAGEMENT Debridement is the medical removal of dead, damaged, or infected tissue to improve the

healing potential of the remaininghealthy tissue. Removal may be surgical, mechanical, and

chemical, autolytic (self-digestion),

by maggot therapy, where certain species of livemaggots selectively eat only necrotic tissue. It is an important part of the healing process for burns and other serious wounds; it is also used for treating some kinds of snake and spider bites. Sometimes the boundaries of the problem tissue may not be clearly defined. For example, when excising a tumor, there may be micrometastases along the edges of the tumor that are too small to be detected, and if not removed, could cause a relapse. In such circumstances, a surgeon may opt to debride a portion of the surrounding healthy tissue, as little as possible to ensure that the tumor is completely removed.

Surgical debridement Sharp surgical debridement and laser debridement under anesthesia are the fastest methods of debridement. They are very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind. Surgical debridement can be performed in the operating room or at bedside, depending on the extent of the necrotic material. This method works best on wounds with a large amount of necrotic tissue in conjunction with infected tissue. Patients Response The patient undergone the procedure in an operating room. Debridement was performed by a surgeon and OR nurses. Patient able to tolerate the procedure well.

V.

PATIENTS DAILY PROGRESS IN THE HOSPITAL 1. Clients Daily Progress Chart

DAYS

ADMISSION (1-28-13)

2ND DAY (1-29-13)

3RD DAY (1-30-13)

4th day (1-30-13)

5th day (1-30-13)

6th day (1-30-13)

7th day (1-30-13)

8th day (1-3013)

9th day (13013)

10th day (1-3013)

11th day (1-30-13)

Nursing Problems 1. 2. Anxiety Risk for fluid volume deficit 3. 4. Risk for injury Impaired skin integrity Vital Signs PR: RR: BP: T: OXC/Lab. Procedures 2. Clinical Chemistry (Fluid and Electrolytes) 3. Complete Blood Count Medical Management 4. IVFs D5LRS PNSS Voluven 81 bpm 21 cpm 150/80 mmHg 36c/axilla 80 bpm : 22 cpm 130/70 mmHg 36.3c/axilla 78 bpm 24 cpm 130/80 mmHg 36.6c/axilla 78 bpm 24 cpm 130/80 mmHg 36.6c/axilla 78 bpm 24 cpm 130/80 mmHg 36.6c/axilla

5.

D5NM BT Fresh Whole Blood (FWB) DRUGS

Nalbuphine Cefoxitin Ketoroloac

Stat Meds Omeprol Dulcolax Metronidazole Fleet Enema Cefoxitin Hydrocorstisone Famotidine Lasix Ca Gluconate MgSO4 Diet NPO NPO Foods rich in Protein and Vitamin C once on DAT Activity/Exercise ---Deep breathing and coughing exercise with proper splinting Deep breathin g and coughing exercise with proper splinting

Problem #1: Risk for infection related to high glucose levels, decreased leukocyte function. ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE DIAGNOSIS EXPLANATIO INTERVENTI N ON Subjective: Objective: manifested Flushed appearance. Wound drainage. V/S taken as follows: T:37.4 P:87 R:19 BP: 120/90 May manifest: - Pus discharge - Increased WBC in blood profile Risk for infection related to high glucose levels, decreased leukocyte function. Type 2 diabetes mellitus occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated. Short Term: After 4 hours of nursing interventions, the patient will identify interventions to prevent or reduce risk of infection. Long Term: After 3 days of nursing interventions, the patient will demonstrate techniques, lifestyle changes to promote safe environment Independent: 1. Establish rapport 1. To gain clients trust in order to gain enough details or information needed for assessment. 2. To assess contributing factors and to know focus of interventions . 3. To obtain vital signs fluctuation and for baseline data. 4. To note for presence of edema and

EXPECTED OUTCOME Short Term: After 4 hours of nursing interventions the patient shall have identified interventions to prevent or reduce risk of infection. Long Term: After 3 days of nursing interventions, the patient shall have demonstrated techniques, lifestyle changes to promote safe environment.

2. Observe clients general condition and behavior. 3. Monitor vital signs.

4.

Observe for signs of infection and inflammation. 5. Promote good handwashing by nurse and patient. 6. Maintain aseptic

technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated. 7. Keep the linens dry and wrinkle free. 8. Place in semi fowlers position. 9. Encourage adequate dietary and fluid intake of 3000 ml per day. Collaborative: 10. Obtain specimen for culture and sensitivities as indicated.

drainage. 5. Reduces the risk of crosscontaminati on. 6. High glucose in the blood creates an excellent medium for bacterial growth. 7. To avoid inappropriate and unclean envt 8. Facilitates lung expansion and reduces risk of aspiration.. 9. Decrease susceptibility to infection. 10. Identifies organisms so

that most appropriate drug therapy can be instituted.

PROBLEM #:2 Risk for infection related to decreased wound healing time. ASSESSMENT NURSING DIAGNOSIS S= Risk for O= Patient manifested: infection Foot ulceration on the right foot. Irritability Presence of dry skin on both lower extremities Pale lips Good skin turgor Decreased wound healing time related to decreased wound healing time. Delayed wound healing time is caused by decreased oxygenation on the affected part. In this case decreased oxygenation is caused by the patients condition which is DM. Because of increased glucose in the blood, it becomes viscous therefore RBCs (which transport Long term: After 1-2 days of nursing interventions the patient would achieve timely wound healing. For wound 3. Emphasize AM care In order to prevent microorganism infect the wound. Short term : After 2 hrs of nursing interventions the patient will identify interventions to prevent the risk of infection. 2. Obtain and maintain vital signs To have a SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS 1. Establish rapport with the patient. To have a good working relationship with the patient. Short term: After 2 hrs of nursing interventions the patient shall have identified interventions to RATIONALE EXPECTED OUTCOMES

baseline data for prevent the risk comparison. of infection.

Long term: After 1-2 days of nursing interventions the patient shall have achieved timely wound healing.

Patient may manifest: S/SX of infection such as: Body weakness Fever Redness or excessive swelling on the wound area. Foul odor of the wound Pus or watery discharge collected beneath the skin or draining from the wound Red streaks in the skin around the wound or progressing away from the

O2 and CO2) can readily pass through and cannot deliver oxygen in the affected part. Oxygen is needed for proper wound healing. Infection may be manifested because of delayed wound healing of the patient.

4. Emphasize use of foot cream

healing.

Protein helps in 5. Emphasize intake of protein To know signs 6. Review medication regimen and symptoms of overdosage to watch for. And to help the client to know what are the therapeutic effects of the drug. wound healing.

Preventive skin 7. Assess skin for for color, assessment protocol,

wound Throbbing pain or tenderness in the wound area

moisture, texture, and turgor.

including documentation, assists in the prevention of skin breakdown. Intact skin is nature's first line of defense against microorganisms entering the body.

Problem #3: Risk for impaired skin integrity related to developmental factors ASSESSMEN T NURSING DIAGNOSI S Impaired skin integrity related to development al factors SCIENTIFIC EXPLANATIO N Infection elevates the Glucose level of a person with diabetes. This is largely because; High blood sugar causes the loss of sensation (neuropathy) and impedes circulation throughout the body (specially the feet). Diminished sensation can interfere with the bodys injury warning system, pain. Thus, Small cuts, abrasions and other skin alterations may go unnoticed and become OBJECTIVE NURSING S INTERVENTION RATIONALE EXPECTE D OUTCOM E Short term: After 4 hours of nursing intervention s the patient shall have maintained optimal nutrition. Long Term: After 3 days of nursing intervention the pt. shall have participated in prevention measures and treatment program.

S= O= V/S: T=36.2 P=82 RR=19 High Glucose level RBS by hgt: 01/29/13 : 126 mg/dl Lesions noted on right foot Normal Value: HGT : 80 110 mg/dl

Short term: After 4 hours of nursing interventions the patient will maintain optimal nutrition. Long Term: After 3 days of nursing intervention the pt. will participate in prevention measures and treatment program.

Independent: 1. Establish rapport 2. Observe clients general condition and behavior. 3. Monitor vital signs. 1. To gain clients trust in order to gain enough details or information needed for assessment. 2. To assess contributing factors and to know focus of intervention s. 3. To obtain vital signs fluctuation and for baseline data.

4. Anticipate and use preventive measure in pts who are at risk for skin breakdown, such as anyone who is thin,

infected. (Wolfe, L.) .

obese, aging, or debilitated. 5. Maintain strict skin hygiene, using mild, nondetergen t soap (if any), drying gently and thoroughly, and lubricating with lotion or emollient. 6. Massage bony prominence gently with lotion or cream. 7. Inspect skin surface/folds and bony prominences

4. Decubitus ulcers are difficult to heal, and prevention is the best treatment.

5. A daily bath Is usually not necessary in erderly patients because there is atropy of sebaceous and sweat glands, and bathing may create dry-skin problems. However, as epidermis thins with age, cleansing

and use of lubricants is needed to keep skin soft/pliable and protect susceptible skin from breakdown. 6. Enhances circulation to tissues, increases vascular tone, and reduces tissue edema. (contraindic ated if area pink/red, as cellular damage may occur.) Gentle massage around area may stimulate circulation to impaired tissues.

7. Skin breakdown can occur quickly with potential

4. ACTUAL SOAPIERS February 06, 2012

S:

O: Received patient lying on bed; awake; conscious and coherent with an ongoing intravenous fluid of #16 PNSS 1L regulated 30-31 gtts @ 700cc level infusing well on the right metacarpal vein; with an intact dry wound dressing on the right foot; with good skin turgor; afebrile; with pinkish palpebral conjunctiva; with Vital signs taken and recorded as follows: T 38.2 PR 96bpm RR - 21 cpm BP 130/90 mmHg

A: Hyperthermia

P: After 3-4 hours of Nursing Interventions the patient will manifest decrease in temperature from 38.2 to 37

I: Monitored and recorded vital signs q4 Provided safety measures Provided safety measures Kept back dry Instructed to increase oral fluid intake Encouraged diabetic diet Instructed to elevate the foot at least 2 pillows to prevent edema Advised to use closed shoes when ambulating to prevent injury Encouraged proper hand washing technique Encouraged to avoid foods rich in glucose or sweets Loosened patient clothing Advised to have clean environment to prevent infections

Provided wound care Due medications given Regulated IVF as ordered

E: Goal met after 3-4 hours of Nursing Interventions the patient will manifest decrerase in temperature from 38.2 to 37.

February 07, 2013

S:

0: Received patient lying supine on bed awake; conscious and coherent with an ongoing intravenous of #14 PNSS 1L regulated @ 30-31 ggts @700 cc level infusing well on left metacarpal vein with an intact dry wound dressing on the right foot; with good skin turgor; afebrile; with pinkish palpebral conjunctiva; with vital signs taken and recorded: T 36.2 C PR 96 bpm RR 22 cpm BP 120/80 mmHg

A: Impaired Skin Integrity related to thermal factor secondary to burn

P: After 3-4 hours of nursing interventions the patient will be able to participate in prevention measures and treatment.

I: Monitored and recorded vital signs q4 Provided safety measures Provided safety measures Kept back dry Instructed to increase oral fluid intake Encouraged diabetic diet

Instructed to elevate the foot at least 2 pillows to prevent edema Advised to use closed shoes when ambulating to prevent injury Encouraged proper hand washing technique Loosened patient clothing Advised to have clean environment to prevent infections Provided wound care Due medications given Regulated IVF as ordered E: Goal met the patient participated in prevention measures and treatment program.

VII. DISCHARGE PLANNING 1. General Condition of the Client Mr. Sugar Daddy was seen lying on his bed wearing a shirt and pants, with hair disheveled, with an IV fluid of 0.9 NaCl 1L regulated 40gtts/min infusing well at left hand. He reported that he had already two bowel movements. 2. METHODS M-edication Metoprolol 1tab PO,OD Losartan 1tab PO,OD Metformin 1tab PO,OD

E-xercise Instruct to exercise at least 3 days a week and avoid strenuous activity. >Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes T-reatment Follow-up check up on his private doctor.

H Instruct pt. to comply with the given diet. Explain the importance of exercise in maintaining or losing weight. Advise patient to check blood glucose level before doing any activities and to eat carbohydrate snack before exercising to avoid hypoglycemia. >Blood glucose levels should be monitored before and after exercise to establish blood glucose response patterns to the exercise regimen. If blood glucose is >250 mg/dl, the patient should delay the exercise session. O-PD follow-up D-iet Diabetic Diet >Carbohydrates should provide 45 - 65% of total daily calories. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Carbohydrate counting or meal planning exchange lists. >Fats should provide 25 - 35% of daily calories. Limit saturated fat. >Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient individual health requirements Avoid eating too much sweet foods. Eat foods rich in fiber such as banana.

III.

CONCLUSION In this study, the student nurses aim is to understand the disease more, manifestations,

risk factors and complications. Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Mr. Sugar Daddys diabetes mellitus was caused mainly by his sedentary lifestyle, his food preference and due to hereditary factor since his grandfather and his father both had diabetes. Diabetic retinopathy, a complication of diabetes mellitus, also occurred and Mr. Sugar Daddy opted to undergo laser therapy a month ago. It is best managed with a team approach to empower the client to successfully manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines involved; provides care and education and promotes the clients health and well being. Diabetes is a major public health worldwide. Its complications cause many devastating health problems. Through this case study, we should be able to learn and understand the disease Diabetes Mellitus type 2 and therefore give us knowledge in proper management, prevention and treatment. As a student nurse, it is very important to know many things including the said disease condition. After the hardships of completing our case study, a reward of self-fulfillment and credential to our knowledge and skills has been added to us being student nurses as well as professionals in the near future.

IV. RECOMMENDATION The researchers would recommend the further study of this case as this is a disease that is interesting. It would be better if another causative factor would be studied to be able to provide diverse information about this disease and to be able to compare to spot similarities and differences in the manifestations of this disease if there is a different causative factor. To be able to appreciate the physical manifestations of this disease, we advise future researchers to investigate this case on the onset of the disease to be able to assess and note more overt manifestations both for educational and documentation purposes.

V.

LEARNING DERIVED

Over the past year of our exposure to clinical area I have encountered varying patients with different conditions and diseases. Being a student nurse is such a great feeling in our life and made me realize that caring is our passion. Giving the best care to our patient is such a fulfillment without expecting for anything in return and I was able to be a part of their lives.

Nothing can be as great experience on the things that we have learned on our case presentation from the everyday interaction to our patient, the knowledge and learning we gained outside the classroom and from the tender love and care we give, certainly caring is the essence of nursing. Truly, this duty is memorable, it is because the lesson that Ive learned in the Case Study. This experienced of having a submissive knowledge made me realized that our chosen profession is to help patient who are ill. Giving them our service is so much for them. In relation with nursing, Ive learned a lot such as proper assessment of the patients physical examination. Our skills in giving health teaching and communicating with patients in therapeutic way were also improved.

VI.

VI. BIBLIOGRAPHY

http://en.wikipedia.org/wiki/Diabetes_mellitus#Causes http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-thephilippines-and-worldwide/ http://nursingcrib.com/diabetes-mellitus-case-study/ Brunner&Suddarth.Textbook of medical-surgical nursing.2008.Lippincott Williams & Wilkins.