Case study - DM 2, CKD 4


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Case study - DM 2, CKD 4

  1. 1. Misamis University Ozamiz City Graduate SchoolA Case Study on Diabetes Mellitus-II with Chronic Kidney Disease-IV In partial fulfillment of the requirements in CHN 315 Submitted to: Prof. Maricar M. Mutia, RN, MN-MAN Faculty, Graduate School Submitted by: Reynel Dan L. Galicinao, RN Student, Master in Nursing June 4, 2011
  2. 2. GENERAL CONSIDERATIONSINSULIN SECRETION AND FUNCTION  Insulin is a hormone secreted by the beta cells of the islet of Langerhans in the pancreas.  Small amounts of insulin are released into the bloodstream in response to changes in blood glucose levels throughout the day.  Increased secretion or a bolus of insulin, released after a meal, helps maintain euglycemia.  Through an internal feedback mechanism that involves the pancreas and the liver, circulating blood glucose levels are maintained at a normal range of 60 to 110 mg/dL.  Insulin is essential for the utilization of glucose for cellular metabolism as well as for the proper metabolism of protein and fat. o Carbohydrate metabolism - insulin affects the conversion of glucose into glycogen for storage in the liver and skeletal muscles, and allows for the immediate release and utilization of glucose by the cells. o Protein metabolism - amino acid conversion occurs in the presence of insulin to replace muscle tissue or to provide needed glucose (gluconeogenesis). o Fat metabolism - storage of fat in adipose tissue and conversion of fatty acids from excess glucose occurs only in the presence of insulin.  Glucose can be used in the endothelial and nerve cells without the aid of insulin.  Without insulin, plasma glucose concentration rises and glycosuria results. o Absolute deficits in insulin result from decreased production of endogenous insulin by the beta cell of the pancreas. o Relative deficits in insulin are caused by inadequate utilization of insulin by the cell.CLASSIFICATION OF DIABETESType 1 Diabetes MellitusType 1 diabetes mellitus was formerly known as insulin dependent diabetes mellitus and juvenilediabetes mellitus.  Little or no endogenous insulin, requiring injections of insulin to control diabetes and prevent ketoacidosis.  Five to 10% of all diabetic patients have type 1.  Etiology: autoimmunity, viral, and certain histocompatibility antigens as well as a genetic component.  Usual presentation is rapid with classic symptoms of polydipsia, polyphagia, polyuria, and weight loss.  Most commonly seen in patients under age 30 but can be seen in older adults.Type 2 Diabetes MellitusType 2 diabetes mellitus was formerly known as noninsulin dependent diabetes mellitus or adultonset diabetes mellitus.  Caused by a combination of insulin resistance and relative insulin deficiency - some individuals have predominantly insulin resistance, whereas others have predominantly deficient insulin secretion, with little insulin resistance.  Approximately 90% of diabetic patients have type 2.  Etiology: strong hereditary component, commonly associated with obesity.  Usual presentation is slow and typically insidious with symptoms of fatigue, weight gain, poor wound healing, and recurrent infection.  Found primarily in adults over age 30; however, may be seen in younger adults and adolescents who are overweight.  Patients with this type of diabetes, but who eventually may be treated with insulin, are still referred to as having type 2 diabetes.PrediabetesPrediabetes is an abnormality in glucose values intermediate between normal and overt diabetes.Impaired Fasting Glucose  A new category adopted by the American Diabetes Association in 1997 and redefined in 2004.  Occurs when fasting blood glucose is greater than or equal to 100 but less than 126 mg/dL. 2|Page
  3. 3. Impaired Glucose Tolerance  Defined as blood glucose measurement on a glucose tolerance test greater than or equal to 140 mg/dl but less than 200 in the 2-hour sample.  Asymptomatic; it can progress to type 2 diabetes or remain unchanged.  May be a risk factor for the development of hypertension, coronary heart disease, and hyperlipidemias.Gestational Diabetes Mellitus  Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance occurring during pregnancy.  Occurs in approximately 4% of pregnancies and usually disappears after delivery.  Women with GDM are at higher risk for diabetes at a later date.  GDM is associated with increased risk of fetal morbidity.  Screening for GDM for all pregnant women other than those at lowest risk (under age 25, of normal body weight, have no family history of diabetes, are not a member of an ethnic group with high prevalence of diabetes) should occur between the 24th and 28th weeks of gestation.Diabetes Associated with Other Conditions  Certain drugs can decrease insulin activity resulting in hyperglycemia - corticosteroids, thiazide diuretics, estrogen, phenytoin.  Disease states affecting the pancreas or insulin receptors - pancreatitis, cancer of the pancreas, Cushings disease or syndrome, acromegaly, pheochromocytoma, muscular dystrophy, Huntingtons chorea.DIAGNOSTIC TESTSLABORATORY TESTSLaboratory tests include those tests used to make the diagnosis as well as measures to monitorshort- and long-term glucose control.Blood GlucoseFasting blood sugar (FBS), drawn after at least an 8-hour fast, to evaluate circulating amounts ofglucose; postprandial test, drawn usually 2 hours after a well-balanced meal, to evaluate glucosemetabolism; and random glucose, drawn at any time, nonfasting.Nursing and Patient Care Considerations  For fasting glucose, make sure that patient has maintained 8-hour fast overnight; sips of water are allowed.  Advise patient to refrain from smoking before the glucose sampling because this affects the test results.  For postprandial test, advise patient that no food should be eaten during the 2-hour interval.  For random blood glucose, note the time and content of the last meal.  Interpret blood values as diagnostic for diabetes mellitus as follows: o FBS greater than or equal to 126 mg/dL on two occasions o Random blood sugar greater than or equal to 200 mg/dL and presence of classic symptoms of diabetes (polyuria, polydipsia, polyphagia, and weight loss)  Fasting blood glucose result of greater than or equal to 100 mg/dL demands close follow- up and repeat monitoring.NURSING ALERT  Capillary blood glucose values obtained by finger stick samples tend to be higher than values in venous samples.Oral Glucose Tolerance TestThe oral glucose tolerance test (OGTT) evaluates insulin response to glucose loading. FBS isobtained before the ingestion of a 50- to 200-g glucose load (usual amount is 75 g), and bloodsamples are drawn at ½, 1, 2, and 3 hours (may be 4- or 5-hour sampling).Nursing and Patient Care Considerations  Advise patient that for accuracy in results, certain instructions must be followed: 3|Page
  4. 4. o Usual diet and exercise pattern must be followed for 3 days before OGTT. o During OGTT, the patient must refrain from smoking and remain seated. o Oral contraceptives, salicylates, diuretics, phenytoin, and nicotinic acid can impair results and may be withheld before testing based on the advice of the health care provider.  Diagnostic for diabetes mellitus if 2-hour value is 200 mg/dL or greater.Glycated Hemoglobin (Glycohemoglobin, HbA1c)Measures glycemic control over a 60- to 120-day period by measuring the irreversible reaction ofglucose to hemoglobin through freely permeable erythrocytes during their 120-day lifecycle.Nursing and Patient Care Considerations  No prior preparation, such as fasting or withholding insulin, is necessary.  Test results can be affected by red blood cell disorders (eg, thalassemia, sickle cell anemia), room temperature, ionic charges, and ambient blood glucose values.  Many methods exist for performing the test, making it necessary to consult the laboratory for normal values.C-Peptide Assay (Connecting Peptide Assay)Cleaved from the proinsulin molecule during its conversion to insulin, C-peptide acts as a markerfor endogenous insulin production.Nursing and Patient Care Considerations  Test can be performed after an overnight fast or after stimulation with Sustacal, I.V. glucose, or 1 mg of glucagon subcutaneously.  Absence of C-peptide indicates no beta cell function, reflecting possible type 1 diabetes.Fructosamine AssayGlycated protein with a much shorter half-life than glycated hemoglobin, reflecting control over ashorter period, approximately 14 to 21 days. May be advantageous in patients with hemoglobinvariants that interfere with the accuracy of glycated hemoglobin tests.Nursing and Patient Care Considerations  Note if patient has hypoalbuminemia or elevated globulins because test may not be reliable.  Should not be used as a diagnostic test for diabetes mellitus.  No special preparation or fasting is necessary.GENERAL PROCEDURES AND TREATMENT MODALITIESBLOOD GLUCOSE MONITORINGAccurate determination of capillary blood glucose assists patients in the control and dailymanagement of diabetes mellitus. Blood glucose monitoring helps evaluate effectiveness ofmedication; reflects glucose excursion after meals; assesses glucose response to exerciseregimen; and assists in the evaluation of episodes of hypoglycemia and hyperglycemia todetermine appropriate treatment.Procedure  Guidelines for glucose monitoring are included in Procedure Guidelines 25-1.  The most appropriate schedule for glucose monitoring is determined by the patient and health care provider. o Medication regimens and meal timing are considered to set the most effective monitoring schedule. o Scheduling of glucose tests should reflect cost effectiveness for the patient. Glucose meter test strips may cost up to $1 each. o Glucose monitoring is intensified during times of stress or illness or when changes in therapy are prescribed.  Patients with type 2 diabetes controlled with oral hypoglycemic agents or a single injection of intermediate-acting insulin may test glucose levels before breakfast and before supper or at bedtime (twice-per-day monitoring).  Patients with type 1 diabetes using a multiple-dose insulin regimen may test before meals and at bedtime, occasionally adding a 2 to 3 a.m. test (four to six times daily monitoring). 4|Page
  5. 5.  Alternate site testing has been recommended by some clinicians for patients who complain of painful fingers and for individuals such as musicians, who use their fingertips for occupational activities. However, testing in such sites as the forearm, palm, thigh, and calf have not proved as accurate as fingertip testing in most studies. o If alternate site is used, the area should be rubbed until it is warm before testing. o Do not use an alternate site when accuracy is critical; for example, if hypoglycemia is suspected, before or after exercise, or before driving. o Check with the glucometer manufacturer to see if it is approved for alternate site testing.INSULIN THERAPYInsulin therapy involves the subcutaneous injection of immediate-, short-, intermediate-, or long-acting insulin at various times to achieve the desired effect. Short-acting regular insulin can alsobe given I.V. About 20 types of insulin are available in the United States; most of these arehuman insulin manufactured synthetically. Only about 6% of diabetics are still using beef or porkinsulin due to problems with immunogenicity.Self-Injection of Insulin  Teaching of self-injection of insulin should begin as soon as the need for insulin has been established.  Teach the patient and another family member or significant other.  Use written and verbal instructions and demonstration techniques.  Teach injection first because this is the patients primary concern; then teach loading the syringe.  See Procedure Guidelines 25-2, pages 914 and 915, for technique.  For patients who have difficulty with the injection procedure, newer insulin pens are available that use a prefilled cartridge that automatically delivers the set dose of insulin by jet stream without a needle.Community and Home Care Considerations  Assist the patient in deciding whether to reuse insulin syringe at home. The patient may decide to do so due to cost; however, reuse has become controversial because the newer, finer needles may become dull or bent after one or two injections, causing tearing of tissue, which can lead to lipodystrophy. o Needles should not be reused if painful injection or irritated site results. o Needle should be recapped by patient and stored in a clean place if it is going to be reused.  Assist the patient in obtaining the appropriate syringe size and needle length for injections. o Determine if there are visual or dexterity issues that make a syringe with gradations farther apart more desirable. o Determine if the patient is obese and should continue to use standard ½-inch needles or if 5/16-inch needles will be desirable. Shorter needles are more comfortable for some and prevent inadvertent I.M. injection.  Advise the patient that it is not necessary to use alcohol to wipe off the top of the vial or prepare the skin before injection. It has not proved to result in lower rate of infection and adds cost and time to the procedure. The patient should maintain good hygiene.  Make sure that the patient stores insulin in a clean, secure place away from sunlight and heat. Check manufacturer recommendations for when to discard insulin vials and pens; recommendations may vary from 10 to 30 days after opening.  Check manufacturers recommendations before teaching the patient how to mix insulin; for example, the patient should know that Lantus insulin must never be mixed with any other insulin.  Avoid prefilling syringes if at all possible because manufacturers have no data on the stability of insulin stored in syringes for long periods. If prefilling is the only option, store in refrigerator or suggest an insulin pen injection device.  Help the patient develop a plan for the disposal of needles. There are no federal regulations for discarding needles used at home; however, needles and lancets can be a risk for injury. o Sharps can be placed in a hard plastic or metal container with a tightly secured lid after use. o When one-half to two-thirds full, the container should be secured with duct or masking tape, marked "do not recycle" and placed in the trash. 5|Page
  6. 6. Insulin RegimensNPH Only  Used alone only in type 2 diabetes when patients are capable of producing some exogenous insulin as a supplement for better glucose control.  Traditionally given as a morning dosage to assist with normalization of glucose during the afternoon and evening.  Evening or bedtime dosage can be helpful in controlling early-morning hyperglycemia.  NPH can also be given twice daily (morning and bedtime) to eliminate afternoon hypoglycemia yet provide nighttime coverage. Typically, 2/3 to ¾ of the daily dosage is given before breakfast and 1/3 to ¼ is given at bedtime.NPH/Regular or NPH/Lispro  Short-acting regular insulin or immediate-acting lispro (Humalog) or aspart (Novolog) insulin is added to NPH to promote postprandial glucose control.  Short- or immediate-acting insulin added to morning NPH controls glucose elevations after breakfast.  Increased blood glucose levels after supper can be controlled by the addition of short- or immediate-acting insulin before supper.  NPH and regular, lispro, or aspart insulin given before breakfast and before supper is termed a "split-mix" regimen, providing 24-hour insulin coverage for type 1 diabetes.Intensive Insulin Therapy  Designed to mimic the bodys normal insulin responses to glucose.  Uses multiple daily injections of insulin.  NPH or ultralente or glargine (Lantus) insulin is used for basal insulin control.  Regular insulin acts as a premeal bolus given 30 minutes before each meal. Lispro or aspart insulin may be used instead of regular and is taken just before eating.  24-hour insulin coverage designed in this way can be flexible to accommodate mealtimes and physical activity.Sliding Scale Versus Algorithm Therapy  Sliding scale therapy uses regular insulin to retrospectively correct hyperglycemia.  Algorithm therapy prospectively determines regular insulin dosages, taking into account meal content and physical activity.  Individualization of regular insulin dosages is the most important aspect of sliding scale and algorithm therapy. o The patient is encouraged to test blood glucoses to analyze insulin dose response. o A pattern of increased blood glucose associated with certain foods (eg, pasta, pizza) can help determine the appropriate regimen of insulin dosage. o Physical activity, which enhances insulin activity and decreases serum glucose, may indicate the need to reduce the dosage of premeal regular insulin.Continuous Subcutaneous Insulin Infusion and Insulin Pump Therapy  Continuous subcutaneous insulin infusion (CSII) and insulin pump therapy provide continuous infusion of regular, lispro, or aspart insulin via subcutaneous catheter inserted in the abdomen. Regular insulin is used during pregnancy.  The catheter should be replaced every 72 hours or sooner if the site becomes painful or inflamed. o Frequently, the insulin pump is removed for bathing, and tubing and catheter are changed at that time. o To reduce tubing and catheter blockage, diluted insulin is used.  Intensive insulin management by pump therapy requires patient motivation. o Blood glucose monitoring must be done at least four to six times each day. o Frequent contact with health care team is necessary to adjust insulin dosage. o Careful recordings of diet, insulin, and activity are required to evaluate adjustments. o Increased cost of insulin pump and infusion set compared to usual syringe method. o Heightened risk of hypoglycemia with tighter glucose control. o Danger of hyperglycemia exists should insulin pump fail to deliver correct insulin dosage. o Increased visibility of diabetes by use of an external device.  Advantages of CSII in improving blood glucose control: 6|Page
  7. 7. o Insulin pump can deliver basal insulin at individualized programmed rates throughout a 24-hour period. o Bolus injections of regular insulin given 30 minutes before eating and lispro or aspart immediately before a meal allow for flexibility in meal content and timing. o Correction supplements of regular, lispro, or aspart insulin are easily given to rapidly correct elevated glucose levels.Combination Oral Agent and Insulin Therapy  Appropriate only in type 2 diabetes.  Intermediate-acting insulin (NPH) is given in the evening and an oral sulfonylurea agent in the morning - called BIDS therapy (Bedtime Insulin, Daytime Sulfonylurea). o No oral antidiabetic agent is given at bedtime. o Controlling hepatic glucose production overnight with evening insulin helps to start the day with a lower FBS. o Daytime antidiabetic agent (usually sulfonylurea), along with diet and exercise, controls daytime blood glucose levels. o Some patients may require regular/NPH insulin injected before supper to assist with elevated postprandial evening glucoses.  Combination therapy may also include the use of a thiazolidinedione (pioglitazone [Actos], rosiglitazone [Avandia]), metformin (Glucophage), or other agents.DIABETES AND RELATED DISORDERSDIABETES MELLITUSDiabetes mellitus is a metabolic disorder characterized by hyperglycemia and results fromdefective insulin production, secretion, or utilization.Pathophysiology and Etiology  There is an absolute or relative lack of insulin produced by the beta cell, resulting in hyperglycemia.  Defects at the cell level, impaired secretory response of insulin to rises in glucose, and increased nocturnal hepatic glucose production (gluconeogenesis) are seen in type 2 diabetes.  Etiology of type 1 diabetes is not well understood; viral, autoimmune, and environmental theories are under review.  Etiology of type 2 diabetes involves heredity, genetics, and obesity.Clinical ManifestationsOnset is abrupt with type 1 and insidious with type 2.Hyperglycemia  Weight loss, fatigue  Polyuria, polydipsia, polyphagia  Blurred visionAltered Tissue Response  Poor wound healing  Recurrent infections, particularly of the skinDiagnostic Evaluation  Diabetes can be diagnosed in any of the following ways (and should be confirmed on a different day by any of these tests): o FBS of greater than or equal to 126 mg/dL o Random blood glucose of greater than or equal to 200 mg/dL with classic symptoms (polyuria, polydipsia, polyphagia, weight loss) o OGTT greater than or equal to 200 mg/dL on the 2-hour sample  Tests for glucose control over time are glycated hemoglobin and fructosamine assay (see pages 911 to 912). These tests are not used for diagnosis.ManagementDiet 7|Page
  8. 8.  Dietary control with caloric restriction of carbohydrates and saturated fats to maintain ideal body weight.  The goal of meal planning is to control blood glucose and lipid levels (see Table 25-1).  Weight reduction is a primary treatment for type 2 diabetes.ExerciseRegularly scheduled, moderate exercise performed for at least 30 minutes most days of the weekpromotes the utilization of carbohydrates, assists with weight control, enhances the action ofinsulin, and improves cardiovascular fitness.Medication  Oral antidiabetic agents for patients with type 2 diabetes who do not achieve glucose control with diet and exercise only (see Table 25-2). o Act by a variety of mechanisms, including stimulation of insulin secretion from functioning beta cells, reduction of hepatic glucose production, enhancement of peripheral sensitivity to insulin, and reduced absorption of carbohydrates from the intestine. o Sulfonylureas and meglitinide analogues may cause hypoglycemic reactions. o Biguanides, alpha-glucosidase inhibitors, and meglitinide analogues may cause significant flatus and GI adverse effects.  Insulin therapy for patients with type 1 diabetes who require replacement (see Table 25-3, page 920). o May also be used for type 2 diabetes when unresponsive to diet, exercise, and oral antidiabetic therapy. o Hypoglycemia may result as well as rebound hyperglycemia (Somogyi effect). o Commonly results in increased appetite and weight gain.General HealthRigid prevention and management guidelines have been established for glycemic control, bloodpressure (BP), lipid values, and kidney function to prevent complications. The American DiabetesAssociation (2003) recommends the following goals of treatment.  Glycemic control o HbA1c < 7% o Preprandial glucose 90 to 130 mg/dL o Peak postprandial glucose < 180 mg/dL  BP < 130/80 mm Hg  Lipid control o Low-density lipoprotein < 100 mg/dL o High-density lipoprotein > 40 mg/dL o Triglycerides < 150 mg/dL  Microalbumin (spot urine) < 30 mcg/mg creatinineNURSING ALERT  Regular insulin is the only insulin that may be administered I.V.; all other insulin formulations are suspensions. Lispro insulin and aspart are for subcutaneous injection only and are not approved for use in pregnancy.ComplicationsAcute  Hypoglycemia occurs as a result of an imbalance in food, activity, and insulin/oral antidiabetic agent.  Diabetic ketoacidosis (DKA) occurs primarily in type 1 diabetes during times of severe insulin deficiency or illness, producing severe hyperglycemia, ketonuria, dehydration, and acidosis.  Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) affects patients with type 2 diabetes, causing severe dehydration, hyperglycemia, hyperosmolarity, and stupor.Chronic Chronic Complications of Diabetes Mellitus ASSESSMENT INTERVENTION PREVENTION/TEACHINGMacroangiopathy 8|Page
  9. 9. Cerebrovascular Disease  Incidence: Twice as frequent in diabetes  Hypertension, increased lipids, smoking, and uncontrolled blood glucose increase risk ofstroke and transient ischemic attack.  Increased blood pressure  Check blood glucose level  Maintain target goals of blood(BP) to differentiate signs and glucose avoiding severe  Change in mental status symptoms of stroke versus hypoglycemia and hyperglycemia,  Hemiparesis hypoglycemia. If stroke is which predispose the patient to  Aphasia suspected, do not give fast- stroke. In hypoglycemia, increased  Clinical presentation acting carbohydrate as levels of adrenalin andmimics that of nondiabetic increased levels contribute to catecholamines can produce cardiacpatient. recurrence and high mortality arrhythmias. of strokes in patients with  Hyperglycemia can lead to diabetes. Monitor for bleeding dehydration, which affects platelet if aspirin or other platelet- aggregation. active medicine is used. Coronary Artery Disease (CAD)  Incidence: Increased vessel disease with more vessels affected in diabetes. Higher incidenceof "silent" myocardial infarctions (MIs).  Hyperglycemia contributes to atherosclerosis and vessel deterioration.  Severe CAD is commonly  Usual medical treatment  Emphasis must be placed onasymptomatic, seen only in for angina prevails - reducing cardiac risk factors, eg,electrocardiogram (ECG) sublingual nitroglycerin, oral cigarette smoking, hypertension,changes. ECG changes may nitrates. Beta-adrenergic hyperlipidemia. Avoid wideindicate silent MI. blockers and calcium channel fluctuations in blood glucose. Patients  Symptoms can also blockers can also be used. with autonomic neuropathy, whichpresent as pain in the jaw, can cause orthostatic hypotension,neck, or epigastric area. should be carefully monitored when cardiac drug therapies are introduced. Beta-adrenergic blockers can blunt or eliminate the clinical signs and symptoms of hypoglycemia. Peripheral Vascular Disease  Incidence: 50% of nontraumatic amputations are related to diabetes.  Intermittent claudication, absent pedal pulses, and ischemic gangrene are increased indiabetes.  Physical examination of  Any lesion, decrease in  Foot care guidelines and smokingthe lower extremities may peripheral pulses, or change cessation must be stressed. Safereveal changes in skin in skin color, temperature or exercise guidelines and weightintegrity associated with sensation should be reduction as appropriate will furtherdiminished circulation. evaluated within 24-48 hours. reduce risk of foot injury.  Decreased lower leg hair, To ensure proper healing andabsent or decreased anterior prevent infection, treatmenttibial or dorsal pedis pulses, should begin as soon aspoor capillary refill of possible and be carefullytoenails may occur. The monitored. Mildextremity may appear antiseptics/antibioticpale/cool. Further preparations are used toexamination for neurologic avoid further damage to thechanges is indicated. surrounding skin. Avoid the use of surgical tape to skin. Rest affected leg to promote circulation and wound healing. Microangiopathy Retinopathy  Incidence: Type 1 - 10 years postdiagnosis 60% have some degree of retinopathy. Type 2 -approximately 20% present with retinopathy at diagnosis, which increases to 60% -85% after 15years.  Appearance of hard exudates, blot hemorrhages, and microaneurysms on the retina inbackground retinopathy. Progresses to neurovascularization in proliferative diabetic retinopathy. 9|Page
  10. 10.  Usually asymptomatic in  Laser therapy  Stress importance of annual eyethe early stages. Symptoms (photocoagulation) can be examination with an ophthalmologistoccurring with acute visual helpful in macular edema (preferably retina specialist). Optimalproblems (floaters), flashing (focal laser) and proliferative glucose control can prevent or slowlights, blurred vision may retinopathy (panretinal laser). the progression of retinopathy.indicate hemorrhage or Reduction of active Maintaining normal BP also reducesretinal detachment. neovascularization by laser the risk of retinopathy.Funduscopic examination therapy reduces the risk ofshould be done by an vitreous hemorrhage.ophthalmologist for full Vitrectomy may be needed toretinal visualization. treat retinal detachment or remove vitreous hemorrhage.  During the acute phase, before laser therapy, patients must avoid activities that increase the chances of vitreous hemorrhage (eg, weight lifting, high-impact aerobics). Nephropathy  Incidence: Type 1 - with > 20 years history of diabetes, approximately 40% will have renaldisease. Type 2 - 5-10 years after diagnosis 5% -10% of patients develop nephropathy, withhigher incidence in Native Americans, Hispanics, and Blacks.  Thickening of the glomerular basement membrane, mesangial expansion, and renal vesselsclerosis are caused by diabetes.  Subsequently, diffuse and nodular intercapillary glomerulosclerosis diminishes renal function.  Evidence of increased  Hypertension control,  Frequent hypertension screening,glomerular filtration rate. blood glucose control, and noting any deviation from patients  Microalbuminuria is the reduction of protein and normal reading. Early initiation of BPfirst clinical sign of renal sodium are essential. control to prevent kidney damage.disease. Angiotensin-converting Excellent glucose control with  Elevation in blood urea enzyme inhibitors are the insulin/oral agent adjustment tonitrogen and creatinine drugs of choice to control BP. compensate for reduced kidneyindicate advanced renal Calcium channel blockers function, which predisposes thedisease. may also be used. In end- patient to hypoglycemia. Avoidance  Gross proteinuria is stage renal disease dialysis of nephrotoxic drugs, dyes, or renalfurther indication of renal or transplantation may be procedures that may cause infection.deterioration. necessary. Immediate treatment for any urinary tract infections. Peripheral Neuropathy  In general, neuropathy affects 60% of persons with diabetes, with nearly 100% showing signsand symptoms of slowing nerve conduction velocity.  It can affect almost every organ system with varying specific symptoms.  Distal symmetrical polyneuropathy involving the lower extremities is most commonly seen.  In conjunction with peripheral vascular disease, neuropathy to the feet increases susceptibilityto trauma and infection.  Three clinical syndromes of distal symmetrical polyneuropathy are seen: acute painful, smallfiber, and large fiber neuropathy.  Decreased light touch,  All foot wounds or injuries  In general, blood glucose control isvibratory, temperature are immediately evaluated. recommended, avoiding widesensation. Loss of foot Culture and sensitivity tests fluctuations. In patients who areproprioception, followed by ordered for any drainage poorly controlled, care must be takenataxia, gait disturbances. present. Affected foot is to correct glucoses slowly to avoid  Diminished ankle jerk elevated - avoid weight- increasing symptoms of neuropathy.response. bearing. Wet to dry dressings  Foot care guidelines.  Formation of “hammer applied as ordered. Avoid use  Smoking cessation.toes”, Charcot joint disease, of caustic chemicals,  Frequent evaluation by podiatristwhich predispose patient to dressing tapes. for modified foot wear, eg, orthotics,new pressure point areas.  Use of systemic antibiotics extra-depth shoes.  Hypersensitivity or other as needed.  Safe exercise guidelines.dysesthetic symptoms are  Medication for painful  Weight reduction as necessary.experienced, followed by neuropathy may include usehypnoanesthesia or of the tricyclic antidepressant 10 | P a g e
  11. 11. anesthesia, which is not drugs (eg, amitriptylinereversible. [Elavil], a serotonin and epinephrine reuptake inhibitor (duloxetine [Cymbalta]), or topical application of capsaicin (Zostrix) ointment. Autonomic Neuropathy Gastroparesis  Incidence: Occurs in 25% of people with diabetes  Characteristics: Delayed gastric emptying, prolonged pylorospasms and loss of the powerfulcontractions of the distal stomach to grind and mix foods.  Typical symptoms may  Excellent glucose control  Maintenance of excellent glucoseinclude nausea/vomiting, to avoid hyperglycemia, control. Regular exerciseearly satiety, abdominal which interferes with gut improves/maintains GI motility. Avoidbloating, epigastric pain, contractility. Avoidance of use of laxatives. Small, frequentchange in appetite. Wide severe postmeal meals may help.fluctuations in blood hypoglycemia by small,glucoses and postmeal frequent meals, low fat andhypoglycemia caused by low fiber. This diet is alsopoor glucose absorption. helpful in bloating/earlyVisualization of the gut by satiety. Medication to improveupper GI barium series may gut motility is metoclopramideshow retained food after an (Reglan).8-12-hour fast. Diarrhea  Incidence: Approximately 5% of diabetic patients  Characteristics: Frequent, watery movements  Mild steatorrhea  Can be intermittent, persistent, or alternate with constipation.  Diarrhea occurs without  Dietary changes may  Routine bowel elimination habits.warning, frequently at night include increased fiber,  Maintenance of adequateor after meals. Fecal elimination of milk products. hydration.incontinence may be caused Sphincter-strengthening  Excellent blood glucose controlby loss of internal sphincter exercises may help. reduces dehydration.control and anorectal Medications: For diarrhea  Inclusion of dietary fiber in the dailysensation. Other causes, hydrophilic fiber supplement diet.such as celiac sprue, (Metamucil), cholestyramine  Daily exercise program thatpancreatic insufficiency, and (Questran), or synthetic includes walking or swimming haslactose intolerance, must be opiates are used. been effective in encouraging bowelinvestigated. Bacterial  Tetracycline, ampicillin are regularity.overgrowth in the bowel is used for bacterial overgrowth.also suspected. Impotence/Sexual Dysfunction  Incidence is not well documented due to inhibitions about reporting this problem to health careproviders.  Sexual dysfunction can involve changes in erectile ability, ejaculation, or libido.  Men: History of poor  Men: Referral to urologist  Reduce consumption of alcohol,erectile function despite for full examination is which may hasten or contribute tostimulation. Absence of early indicated. Treatment options neuropathy.morning erection in may include injection of  Maintain target ranges of bloodresponse to increased alprostadil (a prostaglandin), glucose control to reduce likelihood ofhormonal levels. inflatable penile prosthesis, or vaginal infections.  Women: May experience oral sildenafil (Viagra).  Discuss alternative ways ofdecreased vaginal  Women: Increase maintaining intimacy.lubrication and dyspareunia. lubrication with use of water-  Screening for use of based lubricant (K-Y jelly) orethanol or other medications estrogen creams, which mayassociated with impotence also help thicken the vaginal(eg, antidepressants, mucosa, affectingantihypertensives). dyspareunia. Orthostatic Hypotension  One of three syndromes associated with cardiovascular autonomic neuropathy, orthostatic 11 | P a g e
  12. 12. hypotension occurs when the "postural reflex", which increases heart rate and peripheralvascular resistance is dysfunctional.  Patients may report  Improvement in blood  Encourage increased fluid intake toepisodes of syncope, glucose control to prevent maintain hydration.weakness, or visual fluid loss from glycosuria.  Caution should be used inimpairment particularly with Moderate amounts of sodium changing position from lying topositional changes. Evaluate may be used in the diet to standing. Dangling is recommendedBP and pulse in lying and encourage fluid retention until BP stabilizes.standing position at each during hot weather or  Avoid standing in one position,visit. BP changes that strenuous exercise. which may increase venous pooling.indicate neuropathic Mechanical devices such asinvolvement: fall in systolic support stockings (full hose topressure of > 30 mm Hg or waist) may decrease venousfall in diastolic pressure of > pooling. Drugs to enhance10 mm Hg with change from volume expansion may belying to standing position. used (eg, fludrocortisone [Florinef]).  In type 1 diabetes, chronic complications usually appear about 10 years after the initial diagnosis.  The prevalence of microvascular complications (retinopathy, nephropathy) and neuropathy is higher in type 1 diabetes.  Because of its insidious onset, chronic complications can appear at any point in type 2 diabetes.  Macrovascular complications - in particular cardiovascular disease, occurring in type 1 and type 2 diabetes - are the leading cause of morbidity and mortality among persons with diabetes.Nursing Assessment  Obtain a history of current problems, family history, and general health history. o Has the patient experienced polyuria, polydipsia, polyphagia, and any other symptoms? o Number of years since diagnosis of diabetes o Family members diagnosed with diabetes, their subsequent treatment, and complications  Perform a review of systems and physical examination to assess for signs and symptoms of diabetes, general health of patient, and presence of complications. o General: recent weight loss or gain, increased fatigue, tiredness, anxiety o Skin: skin lesions, infections, dehydration, evidence of poor wound healing o Eyes: changes in vision - floaters, halos, blurred vision, dry or burning eyes, cataracts, glaucoma o Mouth: gingivitis, periodontal disease o Cardiovascular: orthostatic hypotension, cold extremities, weak pedal pulses, leg claudication o GI: diarrhea, constipation, early satiety, bloating, increased flatulence, hunger or thirst o Genitourinary (GU): increased urination, nocturia, impotence, vaginal discharge o Neurologic: numbness and tingling of the extremities, decreased pain and temperature perception, changes in gait and balanceNursing Diagnoses  Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures  Fear related to insulin injection  Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat  Activity Intolerance related to poor glucose control  Deficient Knowledge related to use of oral hypoglycemic agents  Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities  Ineffective Coping related to chronic disease and complex self-care regimenOther Nursing Diagnoses  Deficient fluid volume 12 | P a g e
  13. 13.  Disabled family coping  Disturbed sensory perception: Visual, tactile  Imbalanced nutrition: Less than body requirements  Impaired skin integrity  Impaired urinary elimination  Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral  Risk for infection  Sexual dysfunctionNursing InterventionsSTANDARDS OF CARE GUIDELINESCaring for Patients with Diabetes MellitusWhen caring for patients with diabetes mellitus:  Assess level of knowledge of disease and ability to care for self  Assess adherence to diet therapy, monitoring procedures, medication treatment, and exercise regimen  Assess for signs of hyperglycemia: polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision  Assess for signs of hypoglycemia: sweating, tremor, nervousness, tachycardia, light- headedness, confusion  Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral vascular disease and any injury to the feet or lower extremities  Assess for trends in blood glucose and other laboratory results  Make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercise  Make sure patient has adequate knowledge of diet, exercise, and medication treatment  Immediately report to health care provider any signs of skin or soft tissue infection (redness, swelling, warmth, tenderness, drainage)  Get help immediately for signs of hypoglycemia that do not respond to usual glucose replacement  Get help immediately for patient presenting with signs of either ketoacidosis (nausea and vomiting, Kussmaul respirations, fruity breath odor, hypotension, and altered level of consciousness) or hyperosmolar hyperglycemic nonketotic syndrome (nausea and vomiting, hypothermia, muscle weakness, seizures, stupor, coma).Improving Nutrition  Assess current timing and content of meals.  Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. Reducing intake of carbohydrates may benefit some patients; however, fad diets or diet plans that stress one food group and eliminate another are generally not recommended.  Discuss the goals of dietary therapy for the patient. Setting a goal of a 10% (of patients actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters.  Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life.  Explain the importance of exercise in maintaining/reducing body weight. o Caloric expenditure for energy in exercise o Carryover of enhanced metabolic rate and efficient food utilization  Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them.  Strategize with patient to address the potential social pitfalls of weight reduction.Teaching About Insulin  Assist patient to reduce fear of injection by encouraging verbalization of fears regarding insulin injection, conveying a sense of empathy, and identifying supportive coping techniques.  Demonstrate and explain thoroughly the procedure for insulin self-injection (see page 914).  Help patient to master technique by taking a step-by-step approach. o Allow patient time to handle insulin and syringe to become familiar with the equipment. 13 | P a g e
  14. 14. o Teach self-injection first to alleviate fear of pain from injection. o Instruct patient in filling syringe when he or she expresses confidence in self- injection procedure.  Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen.GERONTOLOGIC ALERT  Assess elderly patients for sensory deficits, such as impaired vision, hearing, fine touch, and tremors that may have an impact on learning and ability to self-administer insulin. Suggest use of an insulin pen or magnifying glass to assist with drawing up insulin. Pen must be inverted 10 times to ensure mixing.Preventing Injury Secondary to Hypoglycemia  Closely monitor blood glucose levels to detect hypoglycemia.  Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid hypoglycemia.  Assess patient for the signs and symptoms of hypoglycemia. o Adrenergic (early symptoms) - sweating, tremor, pallor, tachycardia, palpitations, nervousness from the release of adrenalin when blood glucose falls rapidly o Neurologic (later symptoms) - light-headedness, headache, confusion, irritability, slurred speech, lack of coordination, staggering gait from depression of central nervous system as glucose level progressively falls  Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates. o Half cup (4 oz) juice, 1 cup skim milk, three glucose tablets, four sugar cubes, five to six pieces of hard candy may be taken orally. o Nutrition bar specially designed for diabetics - supplies glucose from sucrose, starch, and protein sources with some fat to delay gastric emptying and prolong effect; may prevent relapse. Used after hypoglycemia treated with fact-acting carbohydrate. o Glucagon 1 mg (subcutaneously or I.M.) is given if the patient cannot ingest a sugar treatment. Family member or staff must administer injection. o I.V. bolus of 50 mL of 50% dextrose solution can be given if the patient fails to respond to glucagon within 15 minutes.  Encourage patient to carry a portable treatment for hypoglycemia at all times.  Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin.  Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia.  Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency.DRUG ALERT  If the patient is taking an alpha-glucosidase inhibitor, he must use a monosaccharide (glucose tablets) to treat hypoglycemia because sucrose will not be broken down to an absorbable sugar.Improving Activity Tolerance  Advise patient to assess blood glucose level before and after strenuous exercise.  Instruct patient to plan exercises on a regular basis each day.  Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia.  Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia.  Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present. Patient should contact health care provider if levels remain elevated.  Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised.Providing Information About Oral Antidiabetic Agents  Identify barriers to learning, such as visual or hearing impairments, low literacy, distractive environment.  Encourage active participation of the patient and family in the educational process.  Teach the action, use, and adverse effects of oral antidiabetic agents. 14 | P a g e
  15. 15. o Sulfonylurea compounds promote the increased secretion of insulin by the pancreas and partially normalize both receptor and postreceptor defects. Many drug interactions exist, so patient should alert all health care providers of use. Potential adverse reactions include hypoglycemia, photosensitivity, GI upset, allergic reaction, reaction to alcohol, cholestatic jaundice, and blood dyscrasias. o Metformin (Glucophage), a biguanide compound, appears to diminish insulin resistance. It decreases hepatic glucose production and intestinal reabsorption of glucose and increases insulin reception and glucose transport in cells. Many drug interactions exist, so patient should alert all health care providers of its use. Metformin must be used cautiously in renal insufficiency, conditions that may cause dehydration, and hepatic impairment. Potential adverse reactions include GI disturbances, metallic taste, and lactic acidosis (rare). o Alpha-glucosidase inhibitors (acarbose [Precose] and miglitol [Glyset]) delay the digestion and absorption of complex carbohydrates (including sucrose or table sugar) into simple sugars, such as glucose and fructose, thereby lowering postprandial and fasting glucose levels. o Thiazolidinedione derivatives (rosiglitazone [Avandia] and pioglitazone [Actos]) primarily decrease resistance to insulin in skeletal muscle and adipose tissue without increasing insulin secretion. Secondarily, they reduce hepatic glucose production. They should be used cautiously in liver disease and heart failure. Liver function tests should be monitored periodically. Ovulation may occur in anovulatory premenopausal women. Adverse reactions include edema, weight gain, anemia, and elevation in serum transaminases. o Meglitinide analogues (repaglinide [Prandin]) and amino acid derivatives (nateglinide [Starlix]) stimulate pancreatic release of insulin in response to a meal. They have a more rapid onset and shorter duration than sulfonylureas. They should not be taken when a meal is skipped or missed. They should be used cautiously in patients with renal and hepatic dysfunction, and may cause hypoglycemia.DRUG ALERT  Lactic acidosis is a rare but potentially fatal complication of metformin. The drug should be discontinued for conditions that predispose to lactic acidosis, including dehydration, alteration in renal function, vomiting and diarrheal illnesses, fasting for surgery and other procedures, imaging studies requiring I.V. iodinated contrast media, septicemia, heavy alcohol use, and hemodynamic instability.  Alpha-glucosidase inhibitors are contraindicated in inflammatory bowel disease and other conditions of the intestinal tract. They are used cautiously in renal insufficiency and with several other drugs. Flatulence, abdominal pain, and diarrhea are common.  Thiazolidinediones themselves do not cause hypoglycemia; when administered with insulin or oral medications that increase the secretion of insulin, however, they increase the risk of hypoglycemia. Be aware that insulin requirements will drop with therapy, so glucose monitoring and insulin adjustments should be done regularly.Maintaining Skin Integrity  Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes. o Use a monofilament to test sensation of the feet and detect early signs of peripheral neuropathy (see Figure 25-2). o Test vibratory sense over interphalangeal joints of the feet using a low-frequency tuning fork. Vibratory sense is typically lost before tactile sensation.  Maintain skin integrity by protecting feet from breakdown. o Use heel protectors, special mattresses, foot cradles for patients on bed rest. o Avoid applying drying agents to skin (eg, alcohol). o Apply skin moisturizers to maintain suppleness and prevent cracking and fissures.  Instruct patient in foot care guidelines (see Procedure Guidelines 25-2).  Advise the patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral blood flow. Help patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program.Improving Coping Strategies 15 | P a g e
  16. 16.  Discuss with the patient the perceived effect of diabetes on lifestyle, finances, family life, occupation.  Explore previous coping strategies and skills that have had positive effects.  Encourage patient and family participation in diabetes self-care regimen to foster confidence.  Identify available support groups to assist in lifestyle adaptation.  Assist family in providing emotional support.Community and Home Care Considerations  A home care or visiting nurse referral can be initiated to follow up on patient education initiated in the hospital or clinic and ensure that the patient has the resources to care for self at home.  Patient should be checking fingerstick glucose at home, and glucometer should be checked by home care or clinic nurse periodically to make sure it is properly calibrated and correlates with meter used at clinic or hospital.  As long as the home is clean and the patient uses reasonable hygiene, procedures for glucose self-monitoring and insulin injection do not need to be sterile. No alcohol preparation of the skin or insulin vial is needed.  Insulin syringes may be reused, so long as the needle is kept clean and no pain or signs of skin irritation develop after multiple use.  Although urine glucose testing is no longer recommended to monitor diabetic condition, the patient may benefit from urine ketone testing, especially when ill. Teach the patient how to test urine with ketone test strip and to notify health care provider if ketosis persists.  Make sure that all patients have a handy source of glucose for hypoglycemic episodes. A small tube of glossy decorating gel for cakes, easily carried in a pocket or purse, contains about 15 g glucose and can be squirted in the mouth for fast absorption during a hypoglycemic attack.  Draw blood work on a fasting basis (no food or fluids other than water for 8 hours) or ensure that patients attend laboratory appointments for drug monitoring. o For patients taking thiazolidinediones, serum transaminases (aspartate aminotransferase, alanine aminotransferase) should be monitored every 2 months for a year and then periodically. If levels rise, more frequent monitoring and possibly drug discontinuation will be necessary. o Renal function tests (blood urea nitrogen [BUN] and serum creatinine) and urine for microalbumin or microalbumin/creatinine ratio will be monitored periodically. o Fasting plasma glucose and glycated hemoglobin are followed regularly. o Fasting lipid panel (12 to 14 hours fasting) is done periodically.  Address safety issues if patient has hypoglycemic attacks - driving, operating machinery, and exertional activity.Patient Education and Health Maintenance  Ongoing education of patient to include advanced skills and rationales for treatment, prevention, and management of complications.  Educational focus - lifestyle management issues, to include sick-day management (see Patient Education Guidelines), exercise adjustments, travel preparations, foot care guidelines, intensive insulin management, and dietary considerations for dining out.  For additional information and support, refer to drug manufacturers Web sites for special programs for diabetics and to agencies, such as American Diabetes Association, Inc.,; and American Dietetic Association, Expected Outcomes  Maintains ideal body weight with body mass index less than 25  Demonstrates self-injection of insulin with minimal fear  Hypoglycemia identified and treated appropriately  Exercises daily  Verbalizes appropriate use and action of oral hypoglycemic agents  No skin breakdown  Verbalizes initial strategies for coping with diabetesNURSING HEALTH ASSESSMENTDEMOGRAPHIC DATA 16 | P a g e
  17. 17. Name: Poong KulzAddress: Poblacion, Iligan City, Lanao del NorteAge: 49 yrs oldSex: MaleStatus: MarriedReligion: Roman CatholicOccupation: Government employeeHEALTH HISTORYA. Chief Complaint/s: Difficulty of breathingB. Admitting Diagnosis: T/C CKD, DM II, T/C CHF, S/P AKA (2005)C. History of Present Illness: 1 month prior to admission, patient started to have 2-3 pillows orthopnea and difficulty ofbreathing even at rest. He was admitted in Dr. Uy Hospital 13 days prior to admission due todifficulty of breathing and oliguria for 3 days. He was discharged apparently well, but not until 1day PTA until DOB reassured associated with dry productive cough with yellowish phlegm, notassociated with fever. These prompted admission.D. History of Past Illness/es: Patient had cataract surgery on left eye 5 yrs ago. Hospitalized 4 yrs ago due to diabeticfoot and eventual AKA amputation of the left leg. Diagnosed with Diabetes mellitus type 2 for 9yrs maintaining meds. Diagnosed with kidney disease 4 years ago. Left eye is totally blind due toglaucoma. Right eye is diagnosed with cataract. Patient claimed to be completely immunized. Noasthma, TB, or allergy to any food or drug. Prefers non-salty and non-fatty foods. Quit smokingand drinking alcohol 10 years ago.E. Health Habits Frequency Amount PeriodTobacco Every day 10 sticks/day 21 yearsAlcohol 2-4x/ week 1000 ml 21 yearsOTC drugs/non-prescription drugs N/A N/A N/A Specify: noneF. Family History with GenogramHistory of Heredo-familial diseases: Cancer x DM √ Asthma x Hypertension √ Cardiac Disease x Mental Disorder xG. Patient’s Perception of Present Illness: Patient feels hopeless and verbalized: “unsaon ta man in-ani man jud. Dili man takabayad mag sige ug pa dialysis. Naa man gyud ning sakita sa linya sa among dugo”H. Summary of Interaction Patient and SO are very cooperative. Answered the questions well and without hesitation.Interview and assessment went on smoothly.GORDON’S ASSESSMENT Normal Pattern Before Hospitalization Clinical Appraisal1. Activities – Rest a. Activities a. Pt. was able to perform ADLs a. Pt. was able to perform ADLs b. Sleeping pattern with wife’s assistance and he with wife’s assistance and most c. Rest was able to work inside the of the time stays on the bed. office. Pt. had intermittent 17 | P a g e
  18. 18. nausea and vomiting. b. Patient usually sleeps about 6- b. Pt. often had frequent 7 hours; sleeping time: 10:30- awakening between 12 AM to 6 11:30 PM and waking time: 4:30- AM 5:30 AM c. Pt. was able to rest in the c. Pt. preferred to rest on bed afternoon for 30 minutes to 1 most of the day. hour.2. Nutrition – Metabolic a. Typical intake a. After diagnosis of DM, pt was a. The intake of pt. was ½ cup of (food or fluid) advised to eat a diabetic diet but rice, fish, 1 banana, and 6-8 b. Diet was noncompliant. Pt. often eats glasses of water. c. Diet restriction a 1 ½- 2 cups of rice, high-fat d. Weight pork and often drinks soft drinks. e. Medication/Suppl Pt. consumes 5-6 glasses of ement food water per day. Pt. was an alcoholic drinker. The pt. also smokes. b. High fat, high sugar diet. b. The diet followed is diabetic diet, low salt, low fat diet. c. Pt. was advised to avoid fatty c. The pt. avoided fatty and salty and sweet foods but was not foods. compliant. d. The pt. stated that he weighs 70 kg d. Weight was not taken e. After diagnosis of DM, pt. was able to take oral diabetic agents e. Allopurinol 100 mg 1 tab BID but has stopped taking medicine Vessel due 1 cap BID with no consultation and had not Iberet & Folic acid 1 cap OD recalled medicines taken due to NaHCO3 1 tab BID the long period of time.3. Elimination a. Urine (frequency, a. Usually, pt. urinates 5 times a a. Pt was catheterized, with color, day, with a yellowish, cloudy yellowish, cloudy characteristic transparency) characteristic at 800 mL/ day. at 1300 mL. b. Bowel (frequency, b. Patient defecates 1-2 times a b. Pt. defecates every other day, color) day, with a dark, formed with semi-formed, brown stool. characteristic.4. Ego Integrity a. Perception of Self a. Pt. verbalized, “makatrabaho a. Pt. verbalized, “naglisod ani b. Coping ra bisag naay sakit.” akong sakit…” Mechanism b. The coping mechanism used b. Pt. often talks with his wife. c. Support often by the client were crying or Mechanism talking with his wife. d. Mood/Affect c. He sees his wife, son, c. Pt’s wife was there to take care brothers, and sisters as his of him. support mechanism. d. Pt. was often calm. d. Pt. was calm.5. Neuro-Sensory a. Mental State a. Pt. was conscious, coherent, a. Pt. was conscious, coherent, b. Condition of 5 oriented to time, date, place, oriented to time, date, place, senses (sight, person, and day. person, and day. hearing, smell, b. Sight: OS- totally blind with b. Sight: OS- totally blind with taste, touch) glaucoma, OD-PERRLA, blurred glaucoma, OD-PERRLA, blurred vision vision Hearing: slight hearing difficulty Hearing: slight hearing difficulty on both ears on both ears Smell: able to smell food, or other Smell: able to smell food, or other things with odor things with odor Taste: able to taste food Taste: able to taste food 18 | P a g e
  19. 19. Touch: able to feel decreased Touch: able to feel decreased sensation to pain, pressure, sensation to pain, pressure, warmth, and cold. warmth, and cold.6. Oxygenation and Vital Signs a. Unable to assess a. RR: 25 cpm a. Respiratory rate b. Unable to assess b. PR: 86 bpm b. Pulse rate c. Unable to assess c. HR: 86 bpm c. Heart Rate d. Unable to assess d. BP: 140/80 mmHg d. Blood pressure e. Unable to assess e. Upon auscultation, fine e. Lung sounds crackles all over lung fields were f. History of heard. respiratory f. Pt. had pneumonia 1 year ago, f. Pt. had pneumonia 1 year ago, problems no asthma. no asthma.7. Pain – Comfort a. Pain (location, a. Relapsing phantom limb pain a. Relapsing phantom limb pain onset, intensity, on left lower extremity lasting for on left lower extremity lasting for duration, a few seconds at a scale of 5/10. a few seconds at a scale of 5/10. associated b. Comfort measures used by the b. Comfort measures used by the symptoms, client were massaging and client were massaging and aggravation) cutaneous stimulation on application of eucalyptus oil on b. Comfort amputated area. area. measures/allevi c. Pt. took no medications for his c. Pt. took no medications for his ation phantom pain. phantom pain. c. Medication/s8. Hygiene and activities The pt. usually takes a bath and Pt. was given sponge bath by his of daily living change clothes once or twice a wife every day during day. hospitalization and assisted in changing his clothes every day; pt. brushes his teeth only once a day.9. Sexuality a. Male Pt. is a male, circumcised, Pt. is a male, circumcised, (circumcision, married, and has 1 son. married, and has 1 son. civil status, number of children)PHYSICAL EXAMINATION AND REVIEW OF SYSTEMSGeneral Pt. is a 49 yrs. old Filipino, male with amputated left leg due to gangrene of diabetic foot.Patient is conscious, coherent, not in respiratory distress. He has symmetrical facial features,bilaterally equal body parts except left lower extremities amputated on mid-thigh. Left eye non-reactive to light and accommodation. +2 edema noted on right leg. Patient has large body frame.Pt. uses crutches for ambulating. Weight loss was not monitored.HEENT Head: graying hair equally distributed symmetrical facial features; no headache anddizziness. Eyes: OS totally blind, nonreactive to light and accommodation, with glaucoma. OD-PERRLA, blurred vision with cataract. Cataract surgery on OS 5 yrs ago. Ears: no discharges,symmetric in size and shape, with auricles mobile, and firm. Earwax noted on both ears.Responsive to sound. Nose: symmetric and straight, no discharges or flaring of all nares, septumis intact and in midline. Throat: no tonsillo-pharyngeal erythema and congestion, lips are dry. Nocervical lymphadenopathy.Integumentary System Patient has brown skin, warm to touch with a temperature of 37.8 °C, has a poor skinturgor, dry, itchy and scaly skin with even pigmentation. Body hair evenly distributed on bilateral 19 | P a g e
  20. 20. parts of the body. Noted +2 pedal pitting edema on right leg. Pale nail beds with a capillary refilltime of 2-3 seconds. No wounds noted. Scar noted on stump on left lower extremities.Respiratory System Tachypneic at 25 cpm, equal chest expansion noted. Fine crackles auscultated over alllung fields. No intercostal retractions noted. No wheezing noted. Equal diaphragmatic excursion.Not in respiratory distress. No hemoptysis. No history of PTB or asthma. Chest X-ray resultshows possible pneumonia.Cardiovascular System PR=86 bpm, strong pulse. HR=86 bpm, regular. PMI noted @ 5th ICS left MCL. No jugularvein distention, no precordial bulge, heaves, thrills, or murmurs noted. Hypertensive @ 140/80mmHg. Pale nail beds. Good peripheral pulses. Noted +2 pedal edema on right side. Chest x-rayresult shows enlarged heart shadow with impression of cardiomegaly. Blood studies showsdecreased hemoglobin 100 g/L, and decreased hematocrit 0.30.Digestive System Abdomen has unblemished skin and uniform in color, soft. Symmetric abdominalmovement upon respiration. Normoreactive bowel sounds ranges from 1-2 BS / 15 sec., negativefluid volume test, no tenderness upon palpation. No organomegaly or masses noted. Nausea andvomiting was noted before hospitalization. No abdominal pain. Weight loss was not monitored.Patient experienced a decrease in appetite. Patient is on diabetic diet with low salt and low fat but.Semi formed brown stool. No parasites on stool exam.Excretory System Patient has patent anal opening and urethral meatus. Foley catheter inserted. Yellowishcloudy urine. Urinates 1,300 ml/day. Urinalysis results specific gravity of 1.015 with pus 18-56 /hpf and RBC 2-4 / hpf. With increase serum creatinine to 12.3 mg/dL. Urinalysis showsproteinuria and ketones-rare.Musculoskeletal System Pt has approximately equal bilateral size of muscles on peripheries. Undergone AKA onleft side 4 yrs. ago. Relapsing phantom pain on left lower extremity with pain scale of 5/10, for fewseconds relieved by massage and application of eucalyptus oil. +2 pedal pitting edema noted onright side. Large body frame. Able to ambulate with crutches. Patient has complaints of weakness.Functional level 3- requires help from another person and equipment device. Muscle strength +4on all extremities. Grip is equal on both arms, but weak.Nervous System Patient is conscious, coherent, and oriented to place, person, and time. OS nonreactive tolight and accommodation. OD- pupil equally round, equally reactive to light and accommodation.GCS of 14/15 (eye response is 3, motor response is 6, verbal response is 5). Intact cranial nerves.Positive gag reflex. Decreased sensation on lower extremities, paresthesia reported.Endocrine System Patient has equal hair distribution on bilateral parts of the body. Patient is diagnosed withDM type 2 (adult onset diabetes). No recent weight loss or gain. No heat or cold intolerance. Nothyroid enlargement noted. Decreased appetite. Increased thirst. HGT shows hyperglycemia 162mg/dl.Reproductive System Patient is male, circumcised, married with one son. Grossly male. Testes descended.Patient has decreased libido. No masses, unusual discharges on genital area. Pt reported erectiledysfunction. 20 | P a g e