DRUG STUDY OF DM 2 WITH DETAILS

1. Aklan State University
School of Arts and Sciences
Bachelor of Science in Nursing
Banga, Aklan
Case Study
Coronary Artery Disease, Hypertensive Cardiovascular Disease, and Diabetes Mellitus Type II
In Partial Fulfillment of the Requirements in
Related Learning Experience
Intensive Nursing Practicum (INP)
Submitted by:
BSN IV-1
Submitted to
Carol B. Silverio, RN
Clinical Instructor
February 2022

2. INTRODUCTION
Coronary Artery Disease (CAD) is characterized by the presence of atherosclerosis in the epicardial
coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis, progressively narrow the coronary
artery lumen and impair myocardial blood flow. The reduction in coronary artery flow may be symptomatic
or asymptomatic, may occur with exertion or at rest, and may culminate in a myocardial infarction,
depending on obstruction severity and the rapidity of development.
Internationally, diseases of the heart are the leading cause of death, causing a higher mortality than
cancer (malignant neoplasms). Some 7,200,000 men and 6,000,000 women are living with some form of
coronary heart disease. 1,200,000 people suffer a coronary attack every year, and about 40% of them die as
a result of the attack. This roughly means that every 65 seconds, an individual dies of a coronary event.
In the Philippines, 92 percent of Filipinos 20 years and above have at least one of the risk factors that may
soon lead to coronary artery disease and cardiovascular disease if not addressed immediately. These risk
factors include diabetes, hypercholesterolemia (high cholesterol levels in 3 the bloodstream), obesity, high
blood pressure and smoking. In addition the National Nutrition and Health Survey (NNHeS) report also
showed that 22 out of 100 Filipino adults are hypertensive (with blood pressure of 140/90 or higher), and 40
percent of those between 20 and 29 already have pre-hypertensive findings.
In 2019, Iloilo had the highest number of heart disease cases in the Philippines' Western Visayas region,
accounting for just over 1.9 thousand out of approximately 10.53 thousand heart disease cases across the
region. On the other hand, the city of Passi only reported 44 cases.
Diabetes mellitus, or diabetes, is a metabolic condition characterized by excessive blood sugar levels. Instead
of moving into your cells, sugar builds up in your bloodstream in type 2 diabetes. The insulin-producing beta
cells in the pancreas produce more insulin when blood sugar levels rise. These cells eventually become
damaged and are unable to produce enough insulin to meet the body's demands, which can result in
circulatory, neurological, and immune system problems.
The rising burden of type 2 diabetes is a major concern in healthcare worldwide. In 2017, approximately
462 million individuals were affected by type 2 diabetes corresponding to 6.28% of the world’s population
(4.4% of those aged 15–49 years, 15% of those aged 50–69, and 22% of those aged 70+), or a prevalence
rate of 6059 cases per 100,000. Over 1 million deaths per year can be attributed to diabetes alone, making it
the ninth leading cause of mortality (Khan, et al., 2020). The burden of diabetes mellitus is rising globally,
and at a much faster rate in developed regions, such as Western Europe.
In the Philippines, the prevalence of diabetes also show an alarming growth rate proportional with an upward
trend in worldwide prevalence. According to the International Diabetes Federation or IDF, the prevalence
rate of diabetes in Filipino adults between the ages of 20 and 79 years is approximately 6.3%. That means
that out of 63 million adults in our country, almost 4 million have diabetes (Bunag, 2020). The highest
prevalence rate was found among the richest in the wealth index, those living in urban areas, and those in the
60- to 69-year age group in both sexes. Although diagnostic tests for diabetes mellitus are becoming more
accessible, around 1.7 million people with type 2 diabetes remain undiagnosed.
In West Visayas. Iloilo City, there is a search for 300K diabetics - DOH Senior Health Program Officer
John Richard Lapascua, in a press conference, said that as of February 2019, they have only recorded 28, 307
diabetic clients. “There is a big disparity in number,” he said. The target he said is supposed to be eight
percent of the 20 years-old and above of the around 7.9 million population of the region for diabetes. He said
granting the age 20 and above is 3.9 million then those at risk for 300,000 for diabetes. One strategy
employed by the DOH is the Philippine Package of Essential NCD Interventions to provide tools such as
glucose meter and glucose strips. “There have to be tests to be conducted to determine whether or not they
are diabetic,” he added.

3. Diabetes and its complications are a major cause of morbidity and mortality in the Philippines. The
prevalence of diabetes in the Philippines has increased from 3.4 million in 2010 to 3.7 million in 2017. The
government has formulated strategies to control this increase, for example, through its non-communicable
disease prevention and control plan. However, there is scarce research on the financial burden of diabetes.
Hypertensive heart disease refers to heart conditions caused by high blood pressure. The heart working under
increased pressure causes some different heart disorders. Hypertensive heart disease includes heart failure,
thickening of the heart muscle, coronary artery disease, and other conditions. Hypertensive heart disease can
cause serious health problems. It’s the leading cause of death from high blood pressure.
Chronic high blood pressure puts a strain on your heart and makes it harder for it to pump your blood. Your
heart muscle can get thick and weak, possibly leading to heart failure. The walls of your blood vessels can
also thicken because of high blood pressure, and this becomes more dangerous when cholesterol collects
inside the blood vessels. Then your heart attack and stroke risks go up. High blood pressure makes men
twice as likely and women three times more likely to get heart failure. However, people who manage their
high blood pressure can greatly reduce their risk of heart failure. People who have hypertensive heart disease
with heart failure have a higher risk for: Decompensated heart failure. Acute coronary syndrome. Sudden
cardiac death.
The global prevalence of hypertensive heart disease has risen steadily over the last 3 decades, as have
the total number of deaths, DALYs, YLLs, and YLDs due to this disease. In 2019, hypertensive heart disease
was the main cause of 1.16 million (95% UI, 0.86-1.28 million) deaths and 21.5 million (95% UI, 16.4-23.9
million) DALYs annually, with a global prevalence of 18.6 million (95% UI, 13.5-24.9 million) cases.
In Western Visayas, the Department of Health (DOH) Region VI 2018 data revealed that Hypertensive
Cardiovascular Diseases (HCVD) is the leading cause of mortality in the region which accounts for 1,033
deaths.
In relation to this case, Patient C.R. is a married 80-year old female, diagnosed with Coronary Artery
Disease (CAD), Hypertensive Cardiovascular Disease (HCVD), and Type 2 Diabetes Mellitus. She had
complaints of chest pain, shortness of breath, headaches, and palpitations. And to further understand and
analyze her condition, the student nurses conducted interviews regarding her daily activities and living,
performed physical examination, and studied her medical and laboratory test results.
STATEMENT OF OBJECTIVES
In order to make a comprehensive Case Study Presentation, the following objectives were formulated:
GENERAL OBJECTIVE
Through this paper, the student nurses will be able to present information about Coronary Artery
Disease, Hypertensive Cardiovascular Disease, and Diabetes Mellitus Type 2, gather necessary and reliable
data through an interview and physical examination with the patient, and extract documentation from the
patient’s hospital and laboratory records. The student nurses will also conduct case analysis and research to
provide comprehensive information about the said conditions. In addition, this case study intends to preserve
and improve the quality of nursing care and responsibilities through rendering care, holistically, and
benevolently that the client, the student nurses and others that would benefit.
SPECIFIC OBJECTIVES
At the end of the second shifting, student nurses will be able to:
KNOWLEDGE
1. Present and discuss the definitions of the complete diagnosis that would explain the illnesses of the
patient.
2. Analyze the history of the patient and consider it as a point of reference that is used for comparison
purposes.
3. Identify the underlying causes and risk factors of Coronary Artery Disease, Hypertensive
Cardiovascular Disease, and Type 2 Diabetes Mellitus.
4. Identify and list the signs and symptoms experienced by the patient.
5. Identify and analyze the epidemiology of the patient’s medical conditions.
6. Identify, analyze, formulate and discuss the pathophysiology of the patient’s medical conditions.

4. 7. Identify and prioritize the needs of the patient.
8. Appropriately interpret the patient’s laboratory results.
9. Develop an understanding of the condition along with possible complications and proper treatment.
SKILLS
1. Assess the patient’s condition through interviews and complete physical/head-to-toe examination to
obtain additional data and to identify any underlying problems.
2. Interpret and analyze the laboratory results of the patient.
3. Formulate appropriate nursing care plans based on the conducted assessment.
4. Formulate appropriate nursing interventions according to the patient's needs and medical conditions.
5. Render appropriate health teaching on medications taken by the patient and explain its purpose.
6. Instruct patient on blood glucose and blood pressure monitoring at home.
7. Render additional health teachings as part of the holistic care to alleviate patient’s fear such as about
proper nutrition or diet and exercise.
ATTITUDE
1. Develop good and productive cooperation along with each groupmates.
2. Establish good and effective communication skills within the group along with each groupmates.
3. Establish good and harmonious relationships among the patient, patient’s family, and clinical
instructors.
4. Establish therapeutic communication when interacting with the patient and patient’s family.
5. Establish and develop patience and understanding when interacting and communicating with the
patient and patient’s family.
6. Display appropriate mood, action and response when communicating with the patient and patient’s
family.
7. Display good attitude by providing active listening and making self-open or available for any
concerns or clarifications raised by the patient and family.
8. Enhance interaction in a student nurse - patient relationship.
9. Appreciate CAD, HCVD, and Type 2 DM with the patient and her family members.

5. NURSING PROCESS (Medical-Surgical)
I. VITAL INFORMATION= 5 %
Name (Initials Only): Z.R Date and Time of Interview: 3/25/22 9:00 AM
Age: 80 years old Informant: Patient
Sex: Female
Address: Mabilo, New Washington, Aklan
Civil Status: Married
Date and Time Admitted: February 7,2019
Chief Complaint (Verbatim): “Sakit akon dughan ag likod,nahapo ako”, “Mingko gapagtik ang
ueo,gabug-at ang dughan”
Ward:
Impression/Diagnosis
Final Diagnosis: Coronary Artery Disease, Diabetes Mellitus Type II, Hypertensive Cardiovascular Disease
*If a surgical patient add:
Pre-op Dx.
Operation Performed
No. of days post-op:
II. CLINICAL ASSESSMENT =5%
A.NURSING HISTORY
A1. History of present Illness
 Usual Health Status
“Okay man akong pamatyag pero kunamat ginahapo ako, gasakit ang dughan at gasakit ag gahapdi ang
suksukan” as verbalized by the patient.
 Chronological Story
First, she had high blood pressure; he can't recall the year he was diagnosed with high blood
pressure. He felt and realized that her chest pained in the year 2018, and his partner often carried her
since she was weak.
She felt the pain when benny disappeared. He checked up with his heart doctor Dr. Vim then
prescribed him the medicine " mas naglala pa tag nag take ako it mga boeong" as verbalized by the
client. She was confined to the mission hospital after one year of suffering from chest discomfort till
February 7, 2019 1 week of stay, since she could no longer tolerate the ache of his chest. Her BP raised
the diastolic reading, or the bottom number about 200.
The client recovered first from her hypertension so she went to the laboratory and after she found
out she had diabetes.
A2. Past health problems/Status
A.2.1. Past health problem
During childhood the patient had experienced chicken pox, mumps, sore eyes, fever, and cough.

6. A.2.2. Family History of illness (Genogram)
A.2.3. Obstetrical History
Age of Menarche- The patient was not able to remember
LMP- N/A
GPTPALM- G10PTA1L6M0
Menstrual Cycle
No. of days of menstruation: 5-6 days
No. of pads used per day: 2 per day
Menstrual problems: Dysmenorrhea
Usual Remedy: Rest, Sleep
A2.4. Accidents
The patient had 1 vehicular accident (tricycle) at the year 2017 with head injury which is lump in
the forehead but no bone fracture happened.
A.2.5. Past hospitalization:
The patient was admitted on February 7,2019 due to.

7. A.2.6. Medications
Drug’s Name
Class Dosage Frequency Indications
Generic:
Trimetazidine
Dihydrochloride
Brand:
(Angimax)
Fatty acid
oxidation
inhibitors
35 mg BID Indicated for stable angina. As adjunctive therapy
for symptomatic treatment of patients who are
inadequately controlled by or intolerant to firstline
antianginal therapies.
Generic:
Salbutamol
Sulfate
Brand: Hivent
EM
Bronchodilators 1
mg/ml
PRN Symptomatic relief of bronchospasm in
obstructive airway disease such as bronchial
asthma, emphysema, and chronic bronchitis.
Generic:
Isosorbid-S-
mononitrate
Brand: Montra
Nitrates 30 mg OD Treatment (immediate-release only) and
prevention of angina pectoris due to coronary
artery disease.
Generic:
Isosorbide
Dinitrate
Brand: Isordil
Nitrates 10 mg PRN Prevention and treatment of angina pectoris, for
congestive heart failure, to relieve pain,
dysphagia, and spasm in esophageal spasm and
gastro intestinal reflux.
Generic:
Multi+Iron
Brand: Iberet
Active
Fe 525 mg OD Indicated for prevention and treatment of iron-
deficiency anemia, or for treatment of iron
deficiency, especially when there is a concomitant
need for vitamin C or the B vitamins.
Generic:
Carvedilol
Brand:
Cardipres
Beta-adrenergic
blocking agents
12.5
mg
OD To treat heart failure and hypertension.
Generic:
Losartan
Potassium
Brand: Cozaar
Angiotensin
receptor
blockers
(ARBs)
50 mg OD To treat nephropathy in patients with type 2
diabetes and hypertension.
Generic:
Clopidogrel
Brand: Plogrel
Antiplatelet
medications
75 mg OD Used to lower risk of having stroke, blood clot, or
serious heart problem after you’ve had a heart
attack, severe chest pain (angina) or circulation
problems.

8. A.2.7. Allergies: Pineapple, Mango, Fermented Fish (Ginamos), and Shrimp Paste (Dayok), and
Seafoods (Shrimp and Crabs)
A3. Brief Social, Cultural, and Religious Background
A.3.1. Educational Background
Name of school Educational Level Inclusive Year
Briones Elementary School Elementary Unable to recall
Kalibo Institute Inc. Highschool Unable to recall
A.3.2. Occupation: Farmer (rice and vegetables) & Hilot
A.3.3. Religious practices that can affect health: Believing in faith healers, Abstinence from meat on
Fridays, Binding “Hakos” which helps patient in her
breathing.
A.3.4. Persons significant to patient: Family especially her children
A.3.5. Social Role: The patient is a mother and a grandmother in their family. She is a loving mother to
her children and a good friend in their neighborhood and in the community. She
doesn’t belong to any organizations.
A.3.6. Environmental condition:
Patient Z.R lives in Mabilo, New Washington, Aklan. There is 5 minutes rides away from
Barangay Hall. 16 minutes rides away from Rural Health Unit. Patient lives in 350 square meter land
area where 100 square meter is made of concrete loan for sun-drying their rice grains, 4o square meter
for their water drinking station located in front of their house. Nawasa serves as their main source of
water and they have own supply of purified drinking water. Patient house is made of concrete cement
with floor made of tiles and has color roofing. They have 3-bedrooms and 1 common comfort room.
Patient bed is located at their living room, with standby oxygen tank, bedpan, and small table for
medicine kit and foods.
B. PATTERNS OF FUNCTIONING=5%
B.1. Breathing patterns:
Respiratory problems: Shortness of Breath
Usual Remedy: Rising up, Chest Massage
Manner of Breathing: patient inhale in nose and exhale in nose
B.2. Circulation
Usual Blood Pressure: 130/70 mmHg
Any History of chest pain, headache, gasp for breath, palpitation, coldness of extremities, etc.:
Paresthesia, numbness, varicosities
B.3. Sleeping Patterns
Usual Bedtime: 9:30 PM
Time of rising up: 5:00 AM
Nap Periods: 1 hour
Total number of hours of Sleep: 8 hours
Bedtime rituals: watching television
Problems regarding sleep: Heavy chest
Usual Remedy: Massaging the chest and lower extremities, and adding pillows for elevation
B.4. Drinking patterns
Total amount of fluid/intake/day:
Kinds of fluids usually taken:
Types of Fluids Amount
Water with Miagos 1200 ml per day
Plain Water 250 ml per day

9. B.5. Eating Patterns
Usual foods taken Time
Breakfast 1 cup rice, 1 hardboiled egg, 1 oz
bangus
8: 00 am -9:00 am
Lunch 1 cup rice, 1 cup veggies such as
water spinach, 1 oz of pork
Adobo, 50 ml of soup
11:30 am- 12:00 pm
Dinner 1 cup rice, 1 cup veggies such as
water spinach, 1 oz of pork
Adobo, 50 ml of soup
6:00 pm-7:00 pm
Snacks 1 oz of biscuits or 1 banana 3:00 pm- 4:00 pm
Food likes: Bread, Banana (Kalatunday), Vegetables, and Unripe Mango
Food dislikes: Seafood (Shrimp & Crab), and Fermented Fish (Ginamos), and Shrimp Paste
(Dayok)
B.6. Elimination Patterns
B.6.1. Bowel Movement
Frequency: every other day
Problems or difficulties: None
Usual Remedies: N/A
B.6.2. Urination
Frequency: 5- 6 per day
Problems or difficulties: None
Usual Remedies: N/A
B.7. Exercise: Walking for 15 minutes in the morning
B.7. Personal Hygiene
B.7.1. Bath
Type: Full Bath with assistance
Frequency: Five times a week except Tuesday and Friday
Time of Day: 9:00 or 11:00 AM
B.7.2. Oral Care
Frequency of Brushing: 0-1 times a day
Care of Dentures: None
B.7.3. Shaving
Frequency: None
B.7.4. Use of toiletries/cosmetics: Shampoo, soap, lotion, and tawas
B.8.Recreation: watching television, and socializing with neighbors
B.9. Health Supervision: Doctor and Albularyo
C. CLINICAL INSPECTION=15%
Date and Time Taken: 3/25/22 2:00 PM
C.1.1. Vital Signs:
Temperature: 36.0◦C
Pulse Rate: 80 beats per minute
Respiratory Rate: 25 breaths per minute
Blood Pressure: 130/70 mmHg
C.1.2. Ht.: 153 cm
C.1.3. Wt.: 43 kg
C.1.4. BMI:18.4

10. C.2.1. General Appearance
 Patient wears blue polo with garterized patterned short.
 The patient feels hesitant at first but still choose to cooperate at the end.
 The patient is in sitting position. Posture is properly observed.
Normal Findings Abnormal Findings
A. Skin
 The color of the skin is brown with rough and
dry texture.
 Client has slight or no odor of perspiration
depending on activity.
 Skin is intact.
 Skin is smooth and Freckles is present.
 Skin is normally thin and saggy.
 Moles are scattered over the skin in no
particular pattern.
 Moles are flat and round in shape
 Skin is mobile with elasticity.
 Redness in some areas
(Chest).
 Capillary refill returns for 1-
3 seconds.
B. Hair
 No lice present.
 The patient has short hair touching the
shoulder.
 White hair is dominant and least black hair
color distribution.
 Hair is unevenly distributed and thin strands.
 There is present of dandruff
upon inspection and scalp is
dry upon inspection.
C. Nails
 Nail plate is firmly attached to nail bed.
 No clubbing.
 Nails in hand are hard and basically intact.
 Nails are not properly cut,
with cracks on the left
thumb finger, but clean in
appearance.
 Pale tone is seen.
D. Toenails
 Nail plate is firmly attached to nail bed.
 Nails are hard and basically intact.
 Nails are not properly cut,
with cracks and wound on
right big toe
 Pale tone is seen and dirty.
E. Head
 Head is normally hard and smooth
 No drooping of the face
 Head Circumference of 22 cm.
 Head is slightly tilted on the
left side.
 The face is asymmetric and
oval in appearance.
 Lumps on head upon
palpation.

11. F. Eyes
 Eyelashes are not visible.
 Eyelashes are black and thin strands.
 Pupils is equally round, reactive to light, and
accommodation
 The upper and lower lids close easily and meet
completely when closed. Eyeballs are
symmetrically aligned in sockets without
protruding or sinking.
 6 cardinal of gaze performed without difficulty
and pain verbalized upon assessment.
 Eye bugs present
 No secretions noted.
 Eye vision on the left eye 20
over 25, right 20 over 20.
 Arcus Senilis is present.
G. Ears
 Both ears are dry, brown in color, and presence
of freckles.
 No odor noted.
 No Tenderness, lesions and masses upon
palpation of tragus and mastoid process.
 No pain upon pulling ears.
 Upon performing Rinne test, Air Conduction is
greater than Bone Conduction.
 Ears on the left side is
bigger than the right ear.
 There is presence of large
solid cerumen on both ears.
 The canal walls cannot be
seen due to presence of
cerumen.
 Upon performing whisper
test patient was not able to
hear repeated words in both
ears.
 Upon performing weber
test, unilateral sound is
heard on the right ear.
H. Nose
 The client’s nasolabial fold is normal, septum
is medially located.
 The nose is in midline of the face.
 Able to identify the smell of alcohol place in
her nose while the eyes are close.
 Presence of cilia inside the nose.
 Color is the same as the rest of the face. The
nasal structure is symmetric.
 Client is able to sniff through each nostril while
other is occluded.
 Nasal flaring is noted
 With redness and dry mucus
present.
I. Mouth/Throat
 The mucosa and gums of the client are pinkish
 Her tongue is medially located
 She has no difficulty of swallowing and no
halitosis and no bleeding noted upon
observation.
 Tongue is pink and moist. Tongue moved with
ease. No lesions are present. Gag reflex is
present.
 Able to identify the food she eat and its taste.
 Tongue offers strong resistance. Uvula is a
fleshy, solid structure that hangs freely in the
midline. Throat is pink without exudate or
lesions.
 Lips are dry.
 Teeth were yellowish in
color with loose teeth, she
do not use dentures.
 Tooth decay, tartar, and
cavity are present.
 Teeth are yellow and black
in color. 16 teeth are noted.

12. J. Neck
 Trachea is in the midline. No presence of
scars, masses, glandular or nodal enlargement
but with freckles and moles.
 The neck movement was coordinated and
smooth with no discomfort.
 No tenderness and enlarged lymph nodes
palpated. Thyroid gland is palpable and rises
along with thyroid and cricoid cartilage during
swallowing. Carotid artery was also palpable.
 There are no signs of abnormal growth or
enlargement of the nodes of the neck of the
client.
 Uneven skin color is noted.
K. Chest/ Thorax
 The shape of thorax is symmetrical from
posterior and lateral views. Normal chest
shape with presence of freckles.
 Full and symmetric chest expansion.
 No crackles and wheezing sound was heard
during auscultation.
 Respiratory rate of 25
breathes per minute.
 Use of accessory, neck,
shoulder, or abdominal
muscles during respirations.
L. Breast
 No Abnormalities in the overall shape of the
breasts.
 Lighter color is present and presence of moles
and red colored moles is noted.
 Saggy breast with smooth surface and freckles
are noted.
 The areolas are bilaterally the same and are
dark brown in color.
 There are no masses, lesions or tenderness
noted on these areas.
 No skin dimpling / retractions. No
spontaneous nipple discharge.
 No pain and no masses palpated.
M.Abdomen
 There are no visible lesions or scars.
 The skin in this area has uniform color
 And presence of borborygmus sound is heard
with a count of 9 bowel sounds per minute.
 Abdomen is warm and soft to touch,
symmetric, and non-tender without distention.
 Binding or hakos is noted.
N. Genito-Anal area
 The client refuses to be examined in the area.

13. O. Upper Extremities
 No presence of lesions but freckles is seen
 Skin is elastic.
 Patient was able to perform ROM of the hands,
arms, shoulders and forearms without
discomfort.
 With sagging and wrinkles of skin is present.
Skin color is symmetrical to body.
 No tenderness, swelling, and inflammation
palpated.
 Radial and brachial pulse is palpable.
 Strong pulse.
 Skin is warm to touch and dry.
 Poor skin turgor a
 Capillary refill of 3 seconds
 Pale palms noted.
P. Back
 Moles are symmetrical and round in shape,
black in color, small and flat and is scattered
over the skin in no particular pattern.
 Moles are symmetrical and round in shape,
black in color, small and flat and is scattered
over the skin in no particular pattern.
 Normal skin temperature and moisture.
 Client needs assistance
upon moving around and in
doing activities of daily
living.
Q. Lower Extremities
 White spot in legs is present and dry skin is
observed.
 Untrimmed nails and
presence of lesions.
 Capillary refill is delayed (3
seconds).
 Weakness upon movement
is noted.
 with knee joint pain when
standing on the left and
right knee.
 Coldness of right foot.
D. GENERAL APPRAISAL
A. Handicaps and limitations
1. Social- The patient is cooperative during the interview and physical assessment.
2. Physical- The patient has no activity restrictions.
B. Speech-
The patient’s speech is clear and understandable. She speaks clearly in Akeanon, Filipino, and English.
She also has no difficulties in completing a sentence and was able to speak in a slow and coherent
manner.
C. Language- The patient speaks Akeanon and Filipino.
D .Emotional Status- The patient presented an appropriate mood, feeling, and expression when
asked.

14. E. LABORATORY DATA=10%
III. TEXTBOOK DISCUSSION=20%
A. Definition
Coronary artery disease (CAD)
Coronary artery disease is a narrowing or blockage of coronary arteries usually caused by the
buildup of fatty material called plaque. Coronary artery disease is also called coronary heart disease,
ischemic heart disease and heart disease.
Coronary artery disease (CAD) is the most prevalent type of cardiovascular disease in adults. For
this reason, nurses must recognize various manifestations of coronary artery conditions and evidence-
based methods for assessing, preventing, and treating these disorders.
The most common cause of cardiovascular disease in the United States is atherosclerosis, an abnormal
accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls.
These substances block and narrow the coronary vessels in a way that reduces blood flow to the
myocardium. Atherosclerosis involves a repetitious inflammatory response to injury of the artery wall
and subsequent alteration in the structural and biochemical properties of the arterial walls. New
information that relates to the development of atherosclerosis has increased the understanding of
treatment and prevention of this progressive and potentially life threatening process.
Coronary artery disease (CAD) causes changes in both structure and function of the blood
vessels. Atherosclerotic processes cause an abnormal deposition of lipids in the vessel wall, leukocyte
infiltration and vascular inflammation, plaque formation and thickening of the vessel wall. These
changes lead to a narrowing of the lumen (i.e., stenosis), which restricts blood flow. There are also
subtle, yet functionally important changes that can occur before overt changes in structure are observed.
Early in the disease process, the endothelial cells that line the coronary arteries become dysfunctional.
Because the endothelium produces important substances such as nitric oxide and prostacyclin that are
required for normal coronary function, endothelial dysfunction can lead to coronary vasospasm,
impaired relaxation, and formation of blood clots that can partially or completely occlude the vessel.
Diabetes Mellitus Type II
Diabetes is a group of metabolic diseases characterized by increased levels of glucose in the
blood resulting from defects in insulin secretion, insulin action, or both.
Normally a certain amount of glucose circulates in the blood. This glucose is formed in the liver from
ingested food. Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by
regulating the production and storage of glucose.
In diabetes the body’s ability to respond to insulin may decrease or the pancreas may stop producing
insulin entirely. This leads to hyperglycemia, which may result in acute metabolic complications such as
diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic (HHNK) syndrome. Long – term
hyperglycemia may contribute to chronic microvascular complications (kidney and eye disease) and
neuropathic complications (diseases of the nerves). Diabetes is also associated with an increased
occurrence of macrovascular diseases, including myocardial infarction, strokes, and peripheral vascular
disease.
Type 2 diabetes affects approximately 95% of adults which the disease ( CDC, 2014). It occurs
commonly among people who are older than 30 years old and obese, although its incidence is rapidly
increasing in younger people because of the growing epidemic of obesity in children, silent, and young
adults.

15. B. Manifestations
Coronary Artery Disease
S/S Found in the Book Manifested by the Patient
Fatigue (+)
Chest pain or discomfort during activity or
stress
(+)
Chest pain that radiate to the shoulders and
arms, especially on the left side, or to the jaw,
neck, or teeth
(-)
Shortness of Breath (+)
Dizziness, lightheadedness (-)
Nausea (-)
The pulse may be high at rest and become
irregular with exercise
(-)
Arcus Senilis (+)
Xanthelasma (-)
Diabetes Mellitus Type II
S/S Found in the Book Manifested by the Client
Polyuria (+)
Polydipsia (-)
Poliphagia (-)
Fatigue and weakness (+)
Sudden vision changes (-)
Tingling or numbness in hands or feet (-)
Dry skin (+)
Skin lesions or wounds that are slow to heal (-)
Recurrent infections (-)
Weight loss (-)
Nausea and vomiting (-)
Abdominal pain (-)
HCVD
A. Pathophysiology DOLINOG & ARJE
B. Management
CAD
A. Medical Management
All patients with stable coronary artery disease require medical therapy to prevent disease
progression and recurrent cardiovascular events. Three classes of medication are essential to
therapy: lipid-lowering, antihypertensive, and antiplatelet agents. Lipid-lowering therapy is
necessary to decrease low-density lipoprotein cholesterol to a target level of less than 100 mg per
dL, and physicians should consider a goal of less than 70 mg per dL for very high-risk patients.
Statins have demonstrated clear benefits in morbidity and mortality in the secondary prevention of
coronary artery disease; other medications that can be used in addition to statins to lower cholesterol
include ezetimibe, fibrates, and nicotinic acid. Blood pressure therapy for patients with coronary

16. artery disease should start with beta blockers and angiotensin-converting enzyme inhibitors. If these
medications are not tolerated, calcium channel blockers or angiotensin receptor blockers are
acceptable alternatives. Aspirin is the first-line antiplatelet agent except in patients who have
recently had a myocardial infarction or undergone stent placement, in which case clopidogrel is
recommended. Anginal symptoms of coronary artery disease can be treated with beta blockers,
calcium channel blockers, nitrates, or any combination of these. Familiarity with these medications
and with the evidence supporting their use is essential to reducing morbidity and mortality in
patients with coronary artery disease.
b) Surgical management
BYPASS SURGERY
Coronary artery bypass grafting, or "CABG" (pronounced "cabbage"), is a common heart
procedure. Patients undergoing bypass are put under general anesthetic and are not awake during
surgery. Two bypass surgical procedures for coronary artery disease are
Beating heart surgery – Also known as off-pump surgery, beating heart surgery is done while the
heart is beating. This often requires special equipment that allows the surgeon to operate on the
heart while it is moving. Beating heart surgery is appropriate for certain patients.
Arrested heart surgery – Most CABG surgeries are done through an incision in the chest while the
heart is stopped and a heart-lung machine takes over the job of circulating the blood. This is called
arrested heart surgery or conventional bypass surgery.
MINIMALLY INVASIVE TREATMENTS
For some patients, minimally invasive coronary artery surgery is an alternative to the CABG
surgery. Three minimally invasive treatments for coronary artery disease (CAD) are
Coronary balloon angioplasty – Coronary balloon angioplasty, also referred to as percutaneous
(through the skin) coronary intervention (PCI), uses a tiny balloon to widen the inside channel of the
artery and enable blood to flow at a normal or near-normal rate.
Stenting – Stenting uses a device called a stent to restore blood flow in the coronary artery. A stent
is a tiny, expandable, mesh-like tube made of a metal such as stainless steel or cobalt alloy. Like in
an angioplasty procedure, a stent mounted onto a tiny balloon is opened inside of an artery to push
back plaque and to restore blood flow.
MICS CABG – The beating heart procedure described above can be performed through a small rib
incision rather than through a median sternotomy.
In some cases, stents and balloons are used together in a procedure called stent and balloon therapy.
https://www.aafp.org/afp/2011/0401/p819.html
medtronic.com/us-en/patients/treatments-therapies/heart-surgery-cad/treatment-options.html
c) Nursing Management
NURSING INTERVENTIONS
• Assess cardiovascular status, vital signs, and hemodynamic variables to detect evidence of
compromise.
• Administer sublingual nitroglycerin and oxygen for anginal episodes to provide pain relief as
ordered.
• Monitor intake and output to detect changes in fluid status.
• Monitor laboratory studies. Evaluate cardiac enzymes to rule out MI. Obtain lipid panel to
determine need for diet changes and lipid-lowering drugs.
• Encourage the client to express anxiety, fears, or concerns to help him cope with his illness.
Teaching topics
• Explanation of the disorder and treatment plan
• Medications and possible adverse effects
• Limiting activity, alcohol intake, and dietary fat
• Smoking cessation, if appropriate
• Taking nitroglycerin for chest pain
NURSING EDUCATION
1. Teach signs and management of cardiac ischemia (e.g., rest; nitrates; seek emergency care if
ineffective)
2. Encourage prophylactic administration of nitrates

17. 3. Reinforce need to avoid exertion (e.g., shoveling snow) and exposure to cold; however,
emphasize the need for regular exercise approved by health care provider or participation in cardiac
rehabilitation program
4. Support involvement in smoking cessation, weight control, and exercise programs
5. Encourage following dietary program
a. Low cholesterol, low fat (substitute unsaturated fat for saturated fat), low sodium (2 g daily)
b. Replace vegetable oils high in polyunsaturated fatty acids with those high in monounsaturated
fatty acids, such as olive oil and canola oil
c. Eat fish high in omega-3 fatty acids several times per week (e.g., salmon, tuna, halibut)
d. Follow DASH diet; increase intake of high-fiber foods such as fruits, vegetables, cereal grains,
and legumes; soluble fiber is particularly effective in reducing blood lipid levels (e.g., oat bran,
legumes); low-fat dairy
e. Eliminate stimulants such as caffeine (e.g., coffee, tea, chocolate, colas, energy drinks) that can
precipitate dysrhythmias
6. Educate about medications
7. Provide emotional support regarding alteration in lifestyle 8. Provide care after an acute MI
a. Document dysrhythmia and respond per protocol: medication, defibrillation, or CPR
b. Reduce cardiac demand: administer oxygen, analgesics, vasodilators, and other medications as
prescribed
c. Reduce risk for sensory overload: orient to unit and equipment; allow time to express feelings;
encourage short visits by significant others
d. Use measures to prevent sequelae of diminished activity: thrombophlebitis, pneumonia,
constipation, skin breakdown, deconditioning
HCVD
D. Management
a) Medical Management
The medications used for treating hypertension decrease peripheral resistance, blood
volume, or the strength and rate of myocardial contraction.
For uncomplicated hypertension, the initial medications recommended are diuretics and beta
blockers.
 Only low doses are given, but if blood pressure still exceeds 140/90 mmHg, the dose is increased
gradually.
 Thiazide diuretics decrease blood volume, renal blood flow, and cardiac output.
 ARBs are competitive inhibitors of aldosterone binding.
 Beta blockers block the sympathetic nervous system to produce a slower heart rate and a lower
blood pressure.
 ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II and lowers peripheral
resistance.
Stage 1 Hypertension
 Thiazide diuretic is recommended for most and angiotensin-converting enzyme-1, aldosterone
receptor blocker, beta blocker, or calcium channel blocker is considered.
Stage 2 Hypertension
 Two-drug combination is followed, usually including thiazide diuretic and angiotensin-converting
enzyme-1, or beta-blocker, or calcium channel blocker.

b) Surgical Management
 In more extreme cases, you may need surgery to increase blood flow to your heart. If you need help
regulating your heart’s rate or rhythm, your doctor may surgically implant a battery-operated device
called a pacemaker in your chest. A pacemaker produces electrical stimulation that causes cardiac
muscle to contract. Implantation of a pacemaker is important and beneficial when cardiac muscle
electrical activity is too slow or absent.

18.  Cardioverter-defibrillators (ICDs) are implantable devices that can be used to treat serious, life-
threatening cardiac arrhythmias.
 Coronary artery bypass graft surgery (CABG) treats blocked coronary arteries. This is only done
in severe CHD. A heart transplant or other heart-assisting devices may be necessary if your
condition is especially severe.
 Recovering from hypertensive heart disease depends on the exact condition and its intensity.
Lifestyle changes can help keep the condition from getting worse in some cases. In severe cases,
medications and surgery may not be effective in controlling the disease.
c) Nursing Management
The goal of nursing management is to help achieve a normal blood pressure through
independent and dependent interventions.
I. Nursing Assessment
Nursing assessment must involve careful monitoring of the blood pressure at frequent and routinely
scheduled intervals.
 If patient is on antihypertensive medications, blood pressure is assessed to determine the
effectiveness and detect changes in the blood pressure.
 Complete history should be obtained to assess for signs and symptoms that indicate target organ
damage.
 Pay attention to the rate, rhythm, and character of the apical and peripheral pulses.
II. Nursing Diagnosis (Diagnosis) based on case*
Based on the assessment data, nursing diagnoses may include the following:
 Deficient knowledge regarding the relation between the treatment regimen and control of the
disease process.
 Noncompliance with the therapeutic regimen related to side effects of the prescribed therapy.
 Risk for activity intolerance related to imbalance between oxygen supply and demand.
 Risk-prone health behavior related to condition requiring change in lifestyle.
III. Nursing Care Plan and Goals
The major goals for a patient with hypertension are as follows:
 Understanding of the disease process and its treatment.
 Participation in a self-care program.
 Absence of complications.
 BP within acceptable limits for individual.
 Cardiovascular and systemic complications prevented/minimized.
 Disease process/prognosis and therapeutic regimen understood.
 Necessary lifestyle/behavioral changes initiated.
 Plan in place to meet needs after discharge.
Nursing Priorities
 Maintain/enhance cardiovascular functioning.
 Prevent complications
 Provide information about disease process/prognosis and treatment regimen.
 Support active patient control of condition.
IV. Nursing Interventions
The objective of nursing care focuses on lowering and controlling the blood pressure without
adverse effects and without undue cost.
 Encourage the patient to consult a dietitian to help develop a plan for improving nutrient intake or
for weight loss.
 Encourage restriction of sodium and fat
 Emphasize increase intake of fruits and vegetables.
 Implement regular physical activity.
 Advise patient to limit alcohol consumption and avoidance of tobacco.

19.  Assist the patient to develop and adhere to an appropriate exercise regimen.
V. Evaluation
At the end of the treatment regimen, the following are expected to be achieved:
 Maintain blood pressure at less than 140/90 mmHg with lifestyle modifications, medications, or
both.
 Demonstrate no symptoms of angina, palpitations, or visual changes.
 Has stable BUN and serum creatinine levels.
 Has palpable peripheral pulses.
 Adheres to the dietary regimen as prescribed.
 Exercises regularly.
 Takes medications as prescribed and reports side effects.
 Measures blood pressure routinely.
 Abstains from tobacco and alcohol intake.
 Exhibits no complications.
E. Discharge Planning and Health Teaching
Following discharge, the nurse should promote self-care and independence of the patient.
 The nurse can help the patient achieve blood pressure control through education about managing
blood pressure.
 Assist the patient in setting goal blood pressures.
 Provide assistance with social support.
 Encourage the involvement of family members in the education program to support the patient’s
efforts to control hypertension.
 Provide written information about expected effects and side effects.
 Encourage and teach patients to measure their blood pressures at home.
 Emphasize strict compliance of follow-up check up.
Lifestyle changes including:
 Diet: If heart failure is present, you should lower your daily intake of sodium to 1,500 mg or 2 g or
less per day, eat foods high in fiber and potassium, limit total daily calories to lose weight if
necessary, and limit intake of foods that contain refined sugar, trans fats, and cholesterol.
 Monitoring your weight: This involves daily recording of your weight, increasing your activity level
(as recommended by your doctor), resting between activities more often, and planning your
activities.
 Avoiding tobacco products and alcohol
 Regular medical checkups: During follow-up visits, your doctor will make sure you are staying
healthy and that your heart disease is not getting worse.
Monitoring and preventing your blood pressure from getting too high is one of the most important
ways to prevent hypertensive heart disease. Lowering your blood pressure and cholesterol by eating
a healthy diet and monitoring stress levels are possibly the best ways to prevent heart problems.
Maintaining a healthy weight, getting adequate sleep, and exercising regularly are common lifestyle
recommendations. Talk to your doctor about ways to improve your overall health.
DM
D. Management
a) Medical Management
 Normalize insulin activity. This is the main goal of diabetes treatment — normalization of blood
glucose levels to reduce the development of vascular and neuropathic complications.
 Intensive treatment. Intensive treatment is three to four insulin injections per day or continuous
subcutaneous insulin infusion, insulin pump therapy plus frequent blood glucose monitoring and
weekly contacts with diabetes educators.

20.  Exercise caution with intensive treatment. Intensive therapy must be done with caution and must be
accompanied by thorough education of the patient and family and by responsible behavior of
patient.
 Diabetes management has five components and involves constant assessment and modification of
the treatment plan by healthcare professionals and daily adjustments in therapy by the patient.
Nutritional Management
 The foundations. Nutrition, meal planning, and weight control are the foundations of diabetes
management.
 Consult a professional. A registered dietitian who understands diabetes management has the major
responsibility for designing and teaching this aspect of the therapeutic plan.
 Healthcare team should have the knowledge. Nurses and other health care members of the team
must be knowledgeable about nutritional therapy and supportive of patients who need to implement
nutritional and lifestyle changes.
 Weight loss. This is the key treatment for obese patients with type 2 diabetes.
 How much weight to lose? A weight loss of as small as 5% to 10% of the total body weight may
significantly improve blood glucose levels.
 Other options for diabetes management. Diet education, behavioral therapy, group support, and
ongoing nutritional counselling should be encouraged.
Meal Planning
 Criteria in meal planning. The meal plan must consider the patient’s food preferences, lifestyle,
usual eating times, and ethnic and cultural background.
 Managing hypoglycemia through meals. To help prevent hypoglycemic reactions and maintain
overall blood glucose control, there should be consistency in the approximate time intervals between
meals with the addition of snacks as needed.
 Assessment is still necessary. The patient’s diet history should be thoroughly reviewed to identify
his or her eating habits and lifestyle.
 Educate the patient. Health education should include the importance of consistent eating habits, the
relationship of food and insulin, and the provision of an individualized meal plan.
 The nurse‘s role. The nurse plays an important role in communicating pertinent information to the
dietitian and reinforcing the patients for better understanding.
Other Dietary Concerns
 Alcohol consumption. Patients with diabetes do not need to give up alcoholic beverages entirely, but
they must be aware of the potential adverse of alcohol specific to diabetes.
 If a patient with diabetes consumes alcohol on an empty stomach, there is an increased likelihood of
hypoglycemia.
 Reducing hypoglycemia. The patient must be cautioned to consume food along with alcohol,
however, carbohydrate consumed with alcohol may raise blood glucose.
 How much alcohol intake? Moderate intake is considered to be one alcoholic beverage per day for
women and two alcoholic beverages per day for men.
 Artificial sweeteners. Use of artificial sweeteners is acceptable, and there are two types of
sweeteners: nutritive and nonnutritive.
 Types of sweeteners. Nutritive sweeteners include all of which provides calories in amounts similar
to sucrose while nonnutritive have minimal or no calories.
 Exercise. Exercise lowers blood glucose levels by increasing the uptake of glucose by body muscles
and by improving insulin utilization.
 A person with diabetes should exercise at the same time and for the same amount each day or
regularly.
 A slow, gradual increase in the exercise period is encouraged.
Using a Continuous Glucose Monitoring System

21. A continuous glucose monitoring system is inserted subcutaneously in the abdomen and
connected to the device worn on a belt. This can be used to determine whether treatment is adequate
over a 24-hour period. Blood glucose readings are analyzed after 72 hours when the data has been
downloaded from the device.
Testing for Glycated Hemoglobin
Glycated hemoglobin or glycosylated hemoglobin, HgbA1C, or A1C reflects the average blood
glucose levels over a period of approximately 2 to 3 months. The longer the amount of glucose in
the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated
hemoglobin becomes. Normal values typically range from 4% to 6% and indicate consistently near-
normal blood glucose concentrations.
Pharmacologic Therapy
 Exogenous insulin. In type 1 diabetes, exogenous insulin must be administered for life because the
body loses the ability to produce insulin.
 Insulin in type 2 diabetes. In type 2 diabetes, insulin may be necessary on a long-term basis to
control glucose levels if meal planning and oral agents are ineffective.
 Self-Monitoring Blood Glucose (SMBG). This is the cornerstone of insulin therapy because
accurate monitoring is essential.
 Human insulin. Human insulin preparations have a shorter duration of action because the presence
of animal proteins triggers an immune response that results in the binding of animal insulin.
 Rapid-acting insulin. Rapid-acting insulins produce a more rapid effect that is of shorter duration
than regular insulin.
 Short-acting insulin. Short-acting insulins or regular insulin should be administered 20-30 minutes
before a meal, either alone or in combination with a longer-acting insulin.
 Intermediate-acting insulin. Intermediate-acting insulins or NPH or Lente insulin appear white and
cloudy and should be administered with food around the time of the onset and peak of these
insulins.
 The rapid-acting and short-acting insulins are expected to cover the increase in blood glucose levels
after meals; immediately after the injection.
 Intermediate-acting insulins are expected to cover subsequent meals, and long-acting insulins
provide a relatively constant level of insulin and act as a basal insulin.
 Approaches to insulin therapy. There are two general approaches to insulin therapy: conventional
and intensive.
 Conventional regimen. Conventional regimen is a simplified regimen wherein the patient should not
vary meal patterns and activity levels.
 Intensive regimen. Intensive regimen uses a more complex insulin regimen to achieve as much
control over blood glucose levels as is safe and practical.
A more complex insulin regimen allows the patient more flexibility to change the insulin doses from
day to day in accordance with changes in eating and activity patterns.
Methods of insulin delivery. Methods of insulin delivery include traditional subcutaneous injections,
insulin pens, jet injectors, and insulin pumps.
 Insulin pens use small prefilled insulin cartridges that are loaded into a pen-like holder. Insulin is
delivered by dialing in a dose or pushing a button for every 1- or 2-unit increment administered.
 Jet injectors deliver insulin through the skin under pressure in an extremely fine stream.
 Insulin pumps involve continuous subcutaneous insulin infusion with the use of small, externally
worn devices that closely mimic the function of the pancreas.
 Oral antidiabetic agents may be effective for patients who have type 2 diabetes that cannot be
treated by MNT and exercise alone.
 Oral antidiabetic agents. Oral antidiabetic agents include sulfonylureas, biguanides, alpha-
glucosidase inhibitors, thiazolidinediones, and dipeptidyl-peptidase-4. Half of all the patients who
used oral antidiabetic agents eventually require insulin, and this is called secondary failure. Primary
failure occurs when the blood glucose level remains high 1 month after initial medication use.
b) Surgical Management

22. N/A
c) Nursing Management
Nurses should provide accurate and up-to-date information about the patient’s condition so that
the healthcare team can come up with appropriate interventions and management.
I. Nursing Assessment
The nurse should assess the following for patients with Diabetes Mellitus:
 Assess the patient’s history. To determine if there is presence of diabetes, assessment of history of
symptoms related to the diagnosis of diabetes, results of blood glucose monitoring, adherence to
prescribed dietary, pharmacologic, and exercise regimen, the patient’s lifestyle, cultural,
psychosocial, and economic factors, and effects of diabetes on functional status should be
performed.
 Assess physical condition. Assess the patient’s blood pressure while sitting and standing to detect
orthostatic changes.
 Assess the body mass index and visual acuity of the patient.
 Perform examination of foot, skin, nervous system and mouth.
 Laboratory examinations. HgbA1C, fasting blood glucose, lipid profile, microalbuminuria test,
serum creatinine level, urinalysis, and ECG must be requested and performed.
II. Diagnoses
The following are diagnoses observed from a patient with diabetes mellitus.
 Risk for unstable blood glucose level related to insulin resistance, impaired insulin secretion, and
destruction of beta cells.
 Risk for infection related to delayed healing of open wounds.
 Deficient knowledge related to unfamiliarity with information, lack of recall, or misinterpretation.
 Risk for disturbed sensory perception related to endogenous chemical alterations.
 Impaired skin integrity related to delayed wound healing.
 Ineffective peripheral tissue perfusion related to too much glucose in the bloodstream
III. Planning and Goals
Achievement of goals is necessary to evaluate the effectiveness of the therapy.
 Acknowledge factors that lead to unstable blood glucose.
 Maintain glucose in satisfactory range.
 Verbalize plan for modifying factors to prevent or minimize shifts in glucose levels.
 Achieve timely wound healing.
 Identify interventions to prevent or reduce Risk for Infection.
 Regain or maintain the usual level of cognition.
 Homeostasis achieved.
 Causative/precipitating factors corrected/controlled.
 Complications prevented/minimized.
 Disease process/prognosis, self-care needs, and therapeutic regimen understood.
 Plan in place to meet needs after discharge.
Nursing Priorities
 Restore fluid/electrolyte and acid-base balance.
 Correct/reverse metabolic abnormalities.
 Identify/assist with management of underlying cause/disease process.
 Prevent complications.
 Provide information about disease process/prognosis, self-care, and treatment needs.
IV. Nursing Interventions
The healthcare team must establish cooperation in implementing the following interventions.

23.  Educate about home glucose monitoring. Discuss glucose monitoring at home with the patient
according to individual parameters to identify and manage glucose variations.
 Review factors in glucose instability. Review client’s common situations that contribute to glucose
instability because there are multiple factors that can play a role at any time like missing meals,
infection, or other illnesses.
 Encourage client to read labels. The client must choose foods described as having a low glycemic
index, higher fiber, and low-fat content.
 Discuss how client’s antidiabetic medications work. Educate client on the functions of his or her
medications because there are combinations of drugs that work in different ways with different
blood glucose control and side effects.
 Check viability of insulin. Emphasize the importance of checking expiration dates of medications,
inspecting insulin for cloudiness if it is normally clear, and monitoring proper storage and
preparation because these affect insulin absorbability.
 Review type of insulin used. Note the type of insulin to be administered together with the method of
delivery and time of administration. This affects timing of effects and provides clues to potential
timing of glucose instability.
 Check injection sites periodically. Insulin absorption can vary day to day in healthy sites and is less
absorbable in lipohypertrophic tissues.
V. Evaluation
To check if the regimen or the interventions are effective, evaluation must be done afterward.
 Evaluate client’s knowledge on factors that lead to an unstable blood glucose level.
 Evaluate the client’s level of blood glucose.
 Verbalized achievement of modifying factors that can prevent or minimize shifts in glucose level.
 Achieved timely wound healing.
 Identified interventions that can prevent or reduce risk for infection.
 Evaluate maintenance of the usual level of cognition.
E. Discharge and Home Care Guidelines
The responsibility of the healthcare team members does not end when the patient is discharged.
The following are guidelines that should be discussed before the patient is discharged from the
hospital.
 Patient empowerment is the focus of diabetes education.
 Patient education should address behavior change, self-efficacy, and health beliefs.
 Address any underlying factors that may affect diabetic control.
 Simplify the treatment regimen if it is difficult for the patient to follow.
 Adjust the treatment regimen to meet patient requests.
 Establish as specific plan or contract with the patient with simple, measurable goals.
 Provide positive reinforcement of self-care behaviors performed instead of focusing on behaviors
that were neglected.
 Encourage the patient to pursue life goals and interests, and discourage an undue focus on diabetes.
 Educate client on wound care, insulin preparation, and glucose monitoring.
 Instruct client to comply with the appointment with the healthcare provider at least twice a year for
ongoing evaluation and routine nutrition updates.
 Remind the patient to participate in recommended health promotion activities and age-appropriate
health screenings.
 Encourage participation in support groups with patients who have had diabetes for many years as
well for those who are newly diagnosed.
Documentation Guidelines
 The following should be documented for patients with diabetes mellitus.
 Document findings related to individual situation, risk factors, current caloric intake and dietary
pattern, and prescription medication use.
 Document results of laboratory tests.

24.  Document the teaching plan and those involved in the planning.
 Document individual responses to interventions, teaching, and actions performed.
 Document specific actions and changes made.
 Document progress towards desired outcomes.
 Document modifications in the plan of care, if any.
Health Teachings
 Educate patient about the tips for managing diabetes identified and developed by the American
Association of Diabetes Educators (AADE, 2011; AADE, 2014):
 Healthy Eating
 Instruct patient to reduce carbohydrate intake because it increases the amount of glucose inside the
body.
 Instruct patient to reduce or limit consumption of fatty foods like fried foods and those that are from
fast food chains.
 Instruct patient to use or consume healthy vegetable-based fats such as avocado, nuts, canola oil, or
olive oil.
 Instruct patient to increase intake or consumption of fruits and vegetables.
 Encourage patient to consume a diet that includes carbohydrates from fruits, vegetables, whole
grains, legumes, and low-fat milk. People with diabetes are advised to avoid sugar-sweetened
beverages (including fruit juice).
 Instruct patient to consume protein from lean meats, fish, eggs, beans, soy, and nuts, and to limit the
amount of red meat.
 Exercise
 Instruct patient to engage in at least 30-minute light exercise daily like jogging and brisk walking.
 Instruct patient to drink adequate liquids before, during, and after exercise to prevent dehydration,
which can upset blood sugar levels.
 Monitoring
 Instruct patient to always monitor her blood glucose levels to keep track with her health and medical
condition.
 Reducing Risks
 Educate and instruct patient about the risk factors contributing to her diabetes for her to avoid it and
reduce chances for possible further complications.
 Foot Care
 Instruct patient to avoid activities that can injure the feet. Certain activities increase the risk of
foot injury or burns and are not recommended. These include walking barefoot, using a heating pad
or hot water bottle on the feet, and stepping into a hot bath before testing the temperature.
 Instruct to use care when trimming the nails. Trim the toenails straight across, and avoid cutting
them down the sides or too short. Use a nail file to remove any sharp edges to prevent the toenail
from digging into the skin. Never cut cuticles or allow anyone else to do so. Instruct patient to see a
foot care provider if she needs treatment of an ingrown toenail or callus.
 Instruct to wash and check feet daily. Use lukewarm water and mild soap to clean the feet. Use
soft washcloth or sponge. Thoroughly dry the feet, paying special attention to the spaces between
the toes, by gently patting them with a clean, absorbent towel. Check for cuts, blisters, redness, and
swelling or nail problems. Apply a moisturizing cream or lotion on feet but not between toes
because it could cause fungal infection.
 Keep feet warm and dry. Consider using an antiperspirant for excessive sweating of feet. Wear
socks to bed when feet get cold at night.

25.  Instruct to choose socks and shoes carefully. Wear cotton socks that fit loosely, and be sure to
change socks every day. Select shoes that are snug but not tight, with a wide toe box, to prevent any
blisters. Always inspect the inside of the shoes for pebbles or other foreign object before wearing it.
 Get periodic foot exams. Visit a doctor for a complete exam that will include checking for feeling
and blood flow in the feet.
 Improve blood flow. Put the feet up when sitting and wiggle toes for a few minutes several times
throughout the day.
 Provide basic information and educate patient about:
 Basic definition of diabetes.
 Normal blood glucose ranges and target blood glucose levels.
 Effects of insulin and exercise.
 Effects of food and stress, including illness and interaction.
 Basic treatment approaches
 Administration of insulin and oral antidiabetic medications.
 Meal planning
 Monitoring of blood glucose
 Recognition, treatment, and prevention of acute complications such as hypo- and hyperglycemia.
 Preventive measures for avoiding long-term complications such as foot care, eye care, general
hygiene (skin care and oral hygiene), and risk factor management (blood pressure control, blood
glucose normalization and cholesterol/lipid control).
 Where to buy and proper storage of insulin, syringes, and glucose monitoring supplies.
 When and how to contact the primary care provider.
 Educate patient how to self-administer insulin:
 Storing of insulin:
Instruct patient that/to:
 Insulin vials should be kept at room temperature (between 56°F and 80°F) to reduce local irritation
at the injection site.
 It must not be exposed to extreme hot or cold temperature to preserve the insulin’s effectiveness.
Any vials exposed to extremes of temperature may appear to have flocculation (a frosted, whitish
coating inside the bottle).
 Inspect expiration dates.
 Selecting syringes:
Educate and instruct patient that syringes must be matched with the insulin concentration.
 1-mL syringe, 100-unit capacity
 0.5-mL syringe, 50-unit capacity
 0.3-mL syringe, 30-unit capacity
 Mixing of insulin:
Instruct patient that cloudy insulin must be mixed thoroughly by gently inverting the vial or rolling
it between the hands before drawing the solution into a syringe or pen.
 Withdrawing insulin:
Instruct patient to inject air into the bottle of insulin equivalent to the number of units of insulin to
be withdrawn. This is to prevent the formation of vacuum inside the bottle which would make it
difficult to withdraw the proper amount of insulin.
 Selecting and rotating injection site:

26.  Educate patient that the speed of absorption is greatest in the abdomen and decreases progressively
in the arm, thigh and hips respectively.
 Instruct patient to practice systematic rotation of injection sites within an anatomic area to prevent
localized changes in fatty tissue (lipodystrophy).
 Encourage patient to use all available injection sites within one area. For example, in abdominal
area, administering each injection must be 0.5 to 1 inch away from the previous injection.
 Encourage patient to always use the same area at the same time of day. For example, patient may
inject morning doses into the abdomen and evening doses into the arms and legs.
 Instruct patient not to use the same injection site more than once in 2 to 3 weeks. Insulin must not be
injected to the site to be exercised because it will cause rapid drug absorption which may result to
hypoglycaemia.
 Preparing the skin:
 Patient must wipe the injection site with wet cotton balls (use 70% alcohol) and allow it to naturally
dry.
 Inserting the needle:
 Educate patient that 90-degree angle is the best insertion angle.
 Disposing of syringe and needle:
 Sharps must be disposed in a hard container with label.
IV. CONCLUSION
References: