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This is a case of a 77-year-old child who was diagnosed

 
  
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Diabetes mellitus is a condition in which the pancreas no longer produces


enough insulin or cells stop responding to the insulin that is produced, so that glucose in
the blood cannot be absorbed into the cells of the body. Symptoms include frequent
urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet,
oral medications, and in some cases, daily injections of insulin.

There are various types of Diabetes Mellitus and this would include the following:

     

Type 1 diabetes is an autoimmune disease. An autoimmune disease results


when the body's system for fighting infection (the immune system) turns against
a part of the body. In diabetes, the immune system attacks the insulin-producing
beta cells in the pancreas and destroys them. The pancreas then produces little
or no insulin. A person who has type 1 diabetes must take insulin daily to live.

At present, scientists do not know exactly what causes the body's immune
system to attack the beta cells, but they believe that autoimmune, genetic, and
environmental factors, possibly viruses, are involved. Type 1 diabetes accounts
for about 5 to 10 percent of diagnosed diabetes in the United States. It develops
most often in children and young adults, but can appear at any age.

Symptoms of type 1 diabetes usually develop over a short period, although beta
cell destruction can begin years earlier. Symptoms include increased thirst and
urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not
diagnosed and treated with insulin, a person with type 1 diabetes can lapse into a
life-threatening diabetic coma, also known as diabetic ketoacidosis.

     

The most common form of diabetes is type 2 diabetes. About 90 to 95 percent of


people with diabetes have type 2. This form of diabetes is associated with older
age, obesity, family history of diabetes, previous history of gestational diabetes,
physical inactivity, and ethnicity. About 80 percent of people with type 2 diabetes
are overweight.

Type 2 diabetes is increasingly being diagnosed in children and adolescents.


However, nationally representative data on prevalence of type 2 diabetes in
youth are not available.

When type 2 diabetes is diagnosed, the pancreas is usually producing enough


insulin, but for unknown reasons, the body cannot use the insulin effectively, a
condition called insulin resistance. After several years, insulin production
decreases. The result is the same as for type 1 diabetes--glucose builds up in the
blood and the body cannot make efficient use of its main source of fuel.

The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden
as in type 1 diabetes. Symptoms may include fatigue or nausea, frequent
urination, unusual thirst, weight loss, blurred vision, frequent infections, and slow
healing of wounds or sores. Some people have no symptoms.

 !   "  

Gestational diabetes develops only during pregnancy. Like type 2 diabetes, it


occurs more often in African Americans, American Indians, Hispanic Americans,
and among women with a family history of diabetes. Women who have had
gestational diabetes have a 20 to 50 percent chance of developing type 2
diabetes within 5 to 10 years.
The most common form of diabetes is Type II, It is sometimes called age-onset or
adult-onset diabetes, and this form of diabetes occurs most often in people who are
overweight and who do not exercise. Type II is considered a milder form of diabetes
because of its slow onset (sometimes developing over the course of several years) and
because it usually can be controlled with diet and oral medication. The consequences of
uncontrolled and untreated Type II diabetes, however, are the just as serious as those
for Type I. This form is also called noninsulin-dependent diabetes, a term that is
somewhat misleading. Many people with Type II diabetes can control the condition with
diet and oral medications, however, insulin injections are sometimes necessary if
treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear, however, there seem to be both
hereditary (genetic factors passed on in families) and environmental factors involved.
Research has shown that some people who develop diabetes have common genetic
markers. In Type I diabetes, the immune system, the body¶s defense system against
infection, is believed to be triggered by a virus or another microorganism that destroys
cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family
history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have
become resistant to the insulin produced and it may not work as effectively. Symptoms
of Type II diabetes can begin so gradually that a person may not know that he or she
has it. Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms
may include sudden weight loss, slow wound healing, urinary tract infections, gum
disease, or blurred vision. It is not unusual for Type II diabetes to be detected while a
patient is seeing a doctor about another health concern that is actually being caused by
the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include
people who:

are obese (more than 20% above their ideal body weight)

have a relative with diabetes mellitus

belong to a high-risk ethnic population (African-American, Native


American, Hispanic, or Native Hawaiian)

have been diagnosed with gestational diabetes or have delivered a baby


weighing more than 9 lbs (4 kg)

have high blood pressure (140/90 mmHg or above)


have a high density lipoprotein cholesterol level less than or equal to 35
mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL

have had impaired glucose tolerance or impaired fasting glucose on


previous testing

Diabetes mellitus is a common chronic disease requiring lifelong behavioral and


lifestyle changes. It is best managed with a team approach to empower the client to
successfully manage the disease. As part of the team the, the nurse plans, organizes,
and coordinates care among the various health disciplines involved; provides care and
education and promotes the client¶s health and well being. Diabetes is a major public
health worldwide. Its complications cause many devastating health problems.

I¶ve chosen this as my case study because nowadays Diabetes Mellitus is rampant
in our society thus, most of the people that are affected develops complications that
most likely the reason in their earlier death. Furthermore, the main objective is to
develop my independent nursing interventions in order to manage the underlying
disease thus, promoting wellness to the client. Moreover, the main reason of having this
case study is to have an ample information regarding the disease condition the
precipitating factors that would worsen the illness.


















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As a student nurse of this institution, Capitol University, I solemnly aim to develop
essential as well as skillful nursing care specifically medical cases which are based on
the better and effective approach ---- that will serve as a catalyst to promote health,
reduce illness and/or completely eliminate such diseases. It¶s also my responsibility to
know the nature of the disease and on how to manage it in such a way that it would be
therapeutic to both patient as well as to their significant others.


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By the end of this whole rotation, Capitol University, will be able to:

Enhance my ability to come up with the appropriate and effective


management of the identified disease condition.

Develop a dependent and collaborative work together with the


medical health team members.

Prioritize things which are essential in assessing and developing


proper interventions in treating or alleviating the illness.

Improve the use of the nursing process that would include


assessment, diagnosis, planning, implementation and evaluation into a
more useful and more effective in doing the patient¶s care.

Apply the core and fundamental systematic approach of the nursing


profession in promoting health unto the clients, reduce the precipitating
condition and/or completely eliminate patients¶ underlying disease.







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#  % -  

Patient X is a 77-year-old Filipino male who is living with her family at Pagatpat,
Cagayan de Oro city. His religion is Roman Catholic. He¶s a high school graduate with
no reported any language and learning deficits. He has no allergies reported. Patient
has a punctured wound at the right foot and suspected to have a Diabetes Mellitus Type
II.

Patient X was admitted last June 25, 2010 at NMMC-A3F2 Medical Ward because of
the delayed healing of the punctured wound caused by an unknown object, (+) increase
of HGT result, and (+) increase in BP of 160/100 mmHg.

) " 

The patient vital signs are the basis in determining any risk factors
towards the patient, thus, it should be done accurately to come up with an
eefective and the appropriate nursing intervention. The increase and
decreased of the vital sign of the patient must be monitored in order to
determined what are the essential management should be done in order
promote wellness to the patient being taken care of.

The patient had the following vital signs (during the hospital stay) : PR
- 83 bpm ; RR - 28 cpm; temp - 36.7°C ; and BP ± 140/80 mmHg.













&   "#- 

This part of the documentation process is to have a sequential approach in
determining the patient¶s existing problems as well as to the risk factors in the
occurrence of complications of the underlying cause. Physical Assessment is made in a
cephalocaudal approach in order to establish a more convenient, organized, easy yet
comprehensive way in giving out necessary information for the patient to achive his
optimum health.

."     - -   / "0  1

He was hospitalized due to delayed healing of his punctured wound at the right
foot with (+) increase in HGT level as well (+) increase in BP of 160/100mmHg. Four
days prior to admission (PTA) patient presented that he was punctured by an
unknown object associated with swelling and severe pain at the right foot, no fever,
increase severity of swelling and pain prompted to admission. He was once
hospitalized year 1998 due to increase blood glucose level.


   "    /"   1

Patient was in a modified diet due to his disease condition ---- DIABETIC DIET,
which is low in carbohydrate diet. He has a good appetite yet it is limited to avoid
further increase in his blood glucose level. The patient is neither nauseated nor
vomiting and has no history of food discomforts. Pallor in both upper and lower
extremities specifically in the toes and fingers are noted due to sluggish flow of the
blood.

("-     /"   1

The patient defecates once a day but failed to excrete enough urine within 8-hour
shift which was accompanied by increased in fluid intake (polydipsia). There is
always an excess in his body fluids. Other than that, there is no further abnormalities
was observed within the elimination pattern of the patient
# 2 ""2 /#$1/ "0  1

Prior to admission, patient was well and able to do various activities of daily living
like eating, clothing and feeding his pigs. He worked things independently like meal
preparation, grooming, bathing, eating and even toileting.

%"    "     /"   1


The client self-perception was fully and strongly established. He always thought
that he will be well soon recover with his condition and enjoy his leisure activities
together with his family and relatives. The client was satisfied in all the achievements
that he had as evidenced by the great joy and happiness he felt together with her
spouse, children, in-laws and most especially to hi grandchildren with a big smile in
his face every time I¶m taking good care of him.



# 2 " (3   /"   1


The patient was unable to walk independently because of his punctured wound
at the right foot yet he insisted to do so using his wooden stuff and assistance
coming from his family members in order to ambulate to defecate, he also needed
assistance in other activities like eating, dressing, grooming, and meal preparation.
On the other hand, the client was still able to do bed mobilization like turning to sides
and sitting, and can do active Range of Motion (ROM). The client has a capillary
refill of 4 seconds due to the increase viscosity of the blood of the patient because of
DM ± Type II.


%"   /"   1


He was sleeping adequately except in the nights that his punctured wound at the
right foot aches that he can¶t sleep properly. He usually prays before going to sleep.
He has no history of sleeping disturbances.

  2    /"   1


The patient was conscious and was oriented to time, person, place. Sometimes
he is anxious for the possibility that his foot will be amputated due to poor healing
that might lead to tissue death. He was very friendly and concern to his other people
as well. He has blurry vision that made him risk for any forms of falls due to his old
age to the disease condition that lacks tissue perfusion going to the eyes. Whenever
his wounded foot aches, his mood is starting to change.

""     /"   1


The patient has good sound relationship with his children together with his in
laws and grandchildren as observed during the assessment and 8-hour duty shift, he
boast to the achievement of his children. His family fully supported him even in
financial status.

)"
4&"   
The client is a Roman Catholic and always thought that God he has been
blessed with great life through the presence of his family during his hospitalizations.
He also believes that he will pass these trials in life through intensive prayers and
strong faith together with his family.


" "#- 

    Fully oriented


# 25 --
    Responsive and coherent
$2"  
  Conscious
(-  "%   Anxious (sometimes)

%6 

! "" Pallor
3
 rough

 elastic
-
 Warm

 Dry


.

, "2-  Symmetrical
,  " Closed
. Fine
% " Clean

(

$ Symmetrical
 "  Intact/full
 7
2 Pale
% " Anicteric
   "  R- Brisk
L- Brisk
    --   Uniform constriction / Convergence
)
"#
  blurry
")  limited



%
- Midline

 Pinkish
   Both patent
!%-"" Normal/symmetrical
%
 Non-tender

(

(3  "   Normoset; Symmetrical


-  -  Intact
!.  Decreased






$ Pallor

 Pinkish
 
 Midline
  Missing teeth
!
- Pinkish

 6

  Midline


 Non-palpable
  Normal ROM

 3

2
" Midline
 " Not Inflamed
   3 Not Inflamed

 Pinkish



#- 

! " Normal
 
   Symmetrical
&"%
 Normoactive

  Tympanitic

& 6 (3 - 

Range of Motion Normal


Muscle tone and strength Fair
Spine Midline
Gait Not fully coordinated
2
"% 


Precordial Area Flat


Point of Maximal Impulse (PMI) 5th ICS, midclavicular line
Heart Sounds Regular
Peripheral Pulses Regular
Capillary Refill 4 seconds



 % 


Breathing Pattern Irregular


Shape of Chest AP:L:2:1
Lung Expansion Symmetrical
Vocal/Tactile Fremitus Symmetrical
Percussion Resonant
Breath Sounds normal
Cough None



















c) ##8# .8%c$!8

Every cell in the human body needs energy in order to function. The body¶s
primary energy source is glucose, a simple sugar resulting from the digestion of foods
containing carbohydrates (sugars and starches). Glucose from the digested food
circulates in the blood as a ready energy source for any cells that need it. Insulin is a
hormone or chemical produced by cells in the pancreas, an organ located behind the
stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to
open a doorway into the cell through which glucose can enter. Some of the glucose can
be converted to concentrated energy sources like glycogen or fatty acids and saved for
later use.

  (Figs. 1097, 1098) is a compound racemose gland, analogous in its


structures to the salivary glands, though softer and less compactly arranged than those
organs. Its secretion, the     7
  carried by the pancreatic duct to the
duodenum, is an important digestive fluid. In addition the pancreas has an important
internal secretion, probably elaborated by the cells of Langerhans, which is taken up by
the blood stream and is concerned with sugar metabolism. It is long and irregularly
prismatic in shape; its right extremity, being broad, is called the  and is connected
to the main portion of the organ, or  by a slight constriction, the  69 while its left
extremity gradually tapers to form the " It is situated transversely across the posterior
wall of the abdomen, at the back of the epigastric and left hypochondriac regions. Its
length varies from 12.5 to 15 cm., and its weight from 60 to 100 gm.
The duodenum and pancreas:


FIG. 1099± The pancreas and duodenum from behind. (From model by His.)

"  ²The . (a  a  ) is flattened from before backward, and
is lodged within the curve of the duodenum. Its upper border is overlapped by the
superior part of the duodenum and its lower overlaps the horizontal part; its right
and left borders overlap in front, and insinuate themselves behind, the
descending and ascending parts of the duodenum respectively. The angle of
junction of the lower and left lateral borders forms a prolongation, termed the

     In the groove between the duodenum and the right lateral
and lower borders in front are the anastomosing superior and inferior
pancreaticoduodenal arteries; the common bile duct descends behind, close to
the right border, to its termination in the descending part of the duodenum.

# %
  ²The greater part of the right half of this surface is in contact
with the transverse colon, only areolar tissue intervening. From its upper part the
 6 springs, its right limit being marked by a groove for the gastroduodenal
artery. The lower part of the right half, below the transverse colon, is covered by
peritoneum continuous with the inferior layer of the transverse mesocolon, and is
in contact with the coils of the small intestine. The superior mesenteric artery
passes down in front of the left half across the uncinate process; the superior
mesenteric vein runs upward on the right side of the artery and, behind the neck,
joins with the lienal vein to form the portal vein.
  %
  ² the posterior surface is in relation with the inferior vena
cava, the common bile duct, the renal veins, the right crus of the diaphragm, and
the aorta.

The  6 springs from the right upper portion of the front of the head. It is about
2.5 cm. long, and is directed at first upward and forward, and then upward and to
the left to join the body; it is somewhat flattened from above downward and
backward. Its antero-superior surface supports the pylorus; its postero-inferior
surface is in relation with the commencement of the portal vein; on the right it is
grooved by the gastroduodenal artery.

The & (a
   a  ) is somewhat prismatic in shape, and has three
surfaces:    and  

The   
  ( a  
) is somewhat concave; and is directed
forward and upward: it is covered by the postero-inferior surface of the stomach
which rests upon it, the two organs being separated by the omental bursa. Where
it joins the neck there is a well-marked prominence, the
- " which
abuts against the posterior surface of the lesser omentum.

The   


  ( a  

) is devoid of peritoneum, and is in
contact with the aorta, the lienal vein, the left kidney and its vessels, the left
suprarenal gland, the origin of the superior mesenteric artery, and the crura of
the diaphragm.

The   
  ( a  
) is narrow on the right but broader on the
left, and is covered by peritoneum; it lies upon the duodenojejunal flexure and on
some coils of the jejunum; its left extremity rests on the left colic flexure.

The 
  (r 
 
) is blunt and flat to the right; narrow and
sharp to the left, near the tail. It commences on the right in the omental
tuberosity, and is in relation with the celiac artery, from which the hepatic artery
courses to the right just above the gland, while the lienal artery runs toward the
left in a groove along this border.

The    (r 


 
) separates the anterior from the inferior
surface, and along this border the two layers of the transverse mesocolon
diverge from one another; one passing upward over the anterior surface, the
other backward over the inferior surface.

The    (r 


 
) separates the posterior from the inferior
surface; the superior mesenteric vessels emerge under its right extremity.

The " (a    a  ) is narrow; it extends to the left as far as the lower
part of the gastric surface of the spleen, lying in the phrenicolienal ligament, and
it is in contact with the left colic flexure.

Birmingham described the body of the pancreas as projecting forward as a


prominent ridge into the abdominal cavity and forming part of a shelf on which the
stomach lies. ³The portion of the pancreas to the left of the middle line has a very
considerable antero-posterior thickness; as a result the anterior surface is of
considerable extent; it looks strongly upward, and forms a large and important part of
the shelf. As the pancreas extends to the left toward the spleen it crosses the upper part
of the kidney, and is so moulded on to it that the top of the kidney forms an extension
inward and backward of the upper surface of the pancreas and extends the bed in this
direction. On the other hand, the extremity of the pancreas comes in contact with the
spleen in such a way that the plane of its upper surface runs with little interruption
upward and backward into the concave gastric surface of the spleen, which completes
the bed behind and to the left, and, running upward, forms a partial cap for the wide end
of the stomach.
The    
( a  a a [   ]; a
   ) extends
transversely from left to right through the substance of the pancreas (Fig. 1100). It
commences by the junction of the small ducts of the lobules situated in the tail of the
pancreas, and, running from left to right through the body, it receives the ducts of the
various lobules composing the gland. Considerably augmented in size, it reaches the
neck, and turning downward, backward, and to the right, it comes into relation with the
common bile duct, which lies to its right side; leaving the head of the gland, it passes
very obliquely through the mucous and muscular coats of the duodenum, and ends by
an orifice common to it and the common bile duct upon the summit of the duodenal
papilla, situated at the medial side of the descending portion of the duodenum, 7.5 to 10
cm. below the pylorus. The pancreatic duct, near the duodenum, is about the size of an
ordinary quill. Sometimes the pancreatic duct and the common bile duct open
separately into the duodenum. Frequently there is an additional duct, which is given off
from the pancreatic duct in the neck of the pancreas and opens into the duodenum
about 2.5 cm. above the duodenal papilla. It receives the ducts from the lower part of
the head, and is known as the     
( a
 
).

The pancreas is developed in two parts, a dorsal and a ventral. The former arises
as a diverticulum from the dorsal aspect of the duodenum a short distance above the
hepatic diverticulum, and, growing upward and backward into the dorsal mesogastrium,
forms a part of the head and uncinate process and the whole of the body and tail of the
pancreas. The ventral part appears in the form of a diverticulum from the primitive bile-
duct and forms the remainder of the head and uncinate process of the pancreas. The
duct of the dorsal part (    
) therefore opens independently into
the duodenum, while that of the ventral part (   
) opens with the common
bile-duct. About the sixth week the two parts of the pancreas meet and fuse and a
communication is established between their ducts. After this has occurred the terminal
part of the accessory duct,   the part between the duodenum and the point of
meeting of the two ducts, undergoes little or no enlargement, while the pancreatic duct
increases in size and forms the main duct of the gland. The opening of the accessory
duct into the duodenum is sometimes obliterated, and even when it remains patent it is
probable that the whole of the pancreatic secretion is conveyed through the pancreatic
duct.

FIG. 1101± Pancreas of a human embryo of five (left) and six (right) weeks. (Kollmann.)

FIG. 1103± Schematic and


enlarged cross-section through the body
of a human embryo in the region of the
mesogastrium. Beginning of third month.
(Toldt.)

At first the pancreas is directed upward and backward between the two layers of
the dorsal mesogastrium, which give to it a complete peritoneal investment, and its
surfaces look to the right and left. With the change in the position of the stomach the
dorsal mesogastrium is drawn downward and to the left, and the right side of the
pancreas is directed backward and the left forward (Fig. 1103). The right surface
becomes applied to the posterior abdominal wall, and the peritoneum which covered it
undergoes absorption (Fig. 1104); and thus, in the adult, the gland appears to lie behind
the peritoneal cavity.

In structure, the pancreas resembles the salivary glands. It differs from them,
however, in certain particulars, and is looser and softer in its texture. It is not enclosed
in a distinct capsule, but is surrounded by areolar tissue, which dips into its interior, and
connects together the various lobules of which it is composed. Each lobule, like the
lobules of the salivary glands, consists of one of the ultimate ramifications of the main
duct, ending in a number of cecal pouches or alveoli, which are tubular and somewhat
convoluted. The minute ducts connected with the alveoli are narrow and lined with
flattened cells. The alveoli are almost completely filled with secreting cells, so that
scarcely any lumen is visible. In some animals spindle-shaped cells occupy the center
of the alveolus and are known as the     ""  $   These are
prolongations of the terminal ducts. The true secreting cells which line the wall of the
alveolus are very characteristic. They are columnar in shape and present two zones: an
outer one, clear and finely striated next the basement membrane, and an inner granular
one next the lumen. In hardened specimens the outer zone stains deeply with various
dyes, whereas the inner zone stains slightly. During activity the granular zone gradually
diminishes in size, and when exhausted is only seen as a small area next to the lumen.
During the resting stages it gradually increases until it forms nearly three-fourths of the
cell. In some of the secreting cells of the pancreas is a spherical mass, staining more
easily than the rest of the cell; this is termed the 
"
 and is believed to be an
extension from the nucleus. The connective tissue between the alveoli presents in
certain parts collections of cells, which are termed  "2" """  (   

    ). The cells of these stain lightly with hematoxylin or carmine, and are more
or less polyhedral in shape, forming a net-work in which ramify many capillaries. There
are two main types of cell in the islets, distinguished as A-cells and B-cells according to
the special staining reactions of the granules they contain. The cell islets have been
supposed to produce the internal secretion of the pancreas which is necessary for
carbohydrate metabolism, but numerous researches have so far failed to elucidate their
real function.

FIG. 1105± Section of pancreas of dog.


X 250.
The walls of the pancreatic duct are thin, consisting of two coats, an external
fibrous and an internal mucous; the latter is smooth, and furnished near its termination
with a few scattered follicles.

The   of the pancreas are derived from the lienal, and the pancreaticoduodenal
branches of the hepatic and superior mesenteric. Its 2  open into the lienal and
superior mesenteric veins. Its "-   are described on page 711. Its 2 are
filaments from the lienal plexus.


Predisposing factors:

  
)  #. .8%c$!8


 
  
Precipitating factors:
 þ 


 

 
 HGT level of 321 mg/dL

 
Glucose level in the blood stream

Insulin insufficiency



Glucose are not taken within the cells

 Blood viscosity Hypokalemia (3.0meq/L)



  


 ! 


Tissue perfusion



Peripheral: Renal: Eyes:

   



 "      


 $ 


 Punctured at the right foot 


with an unknown object serum creatinine Retention of water
(1.27)


 #
   !
 



!  
 Pitting edema of 4mm (upper and lower
 
   extremities)
c: c%.#!( $#c!5.(#$.(#.c!%

-edication to take
Instruct and explain to the patient and/or to the significant others that the medication is
very important to continue depending on the duration that the doctor ordered for the
total recovery of the patient, otherwise the disease condition will occur again and to
prevent further complications. Relapses can be far more serious than the first attack.

Review dosage and time of injections in relation to meals, activity, and bedtime
based on patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation and meal
timing to avoid hypoglycemia.
Emphasize to the patient the importance of obediently taking the prescribed
medications and the disadvantages or complications that may arise if these are
not taken properly.

Inform and discuss the possible side effects and reactions that these drugs might
produce and seek medical attention immediately is these arise.

Never missed any medications that were ordered to take to avoid reoccurrence
of the condition. Instruct significant others to be reminded of the proper intake of
the medication because the patient might forget to take those medication due to
his oldness.

c 
" can¶t be taken in pill form because enzymes in your
stomach break it down so that it becomes ineffective. For that reason,
many people inject themselves with insulin using a syringe or an insulin
pen injector,a device that looks like a pen, except the cartridge is filled
with insulin. Others may use an insulin pump, which provides a continuous
supply of insulin, eliminating the need for daily shots.

%
" "
 
 These medications stimulate your pancreas
to produce and release more insulin. For them to be effective, your
pancreas must produce some insulin on its own. Second-generation
sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide
(DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are
prescribed most often. The most common side effect of sulfonylureas is
low blood sugar, especially during the first four months of therapy. You¶re
at much greater risk of low blood sugar if you have impaired liver or kidney
function.
"   These medications, such as repaglinide (Prandin),
have effects similar to sulfonylureas, but you¶re not as likely to develop low
blood sugar. Meglitinides work quickly, and the results fade rapidly.
&
  Metformin (Glucophage, Glucophage XR) is the only
drug in this class available in the United States. It works by inhibiting the
production and release of glucose from your liver, which means you need
less insulin to transport blood sugar into your cells. One advantage of
metformin is that is tends to cause less weight gain than do other diabetes
medications. Possible side effects include a metallic taste in your mouth,
loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and
diarrhea. These effects usually decrease over time and are less likely to
occur if you take the medication with food. A rare but serious side effect is
lactic acidosis, which results when lactic acid builds up in your body.
Symptoms include tiredness, weakness, muscle aches, dizziness and
drowsiness. Lactic acidosis is especially likely to occur if you mix this
medication with alcohol or have impaired kidney function.
#""
    These drugs block the action of
enzymes in your digestive tract that break down carbohydrates. That
means sugar is absorbed into your bloodstream more slowly, which helps
prevent the rapid rise in blood sugar that usually occurs right after a meal.
Drugs in this class include acarbose (Precose) and miglitol (Glyset).
Although safe and effective, alpha-glucosidase inhibitors can cause
abdominal bloating, gas and diarrhea. If taken in high doses, they may
also cause reversible liver damage.
0"   These drugs make your body tissues more
sensitive to insulin and keep your liver from overproducing glucose. Side
effects of thiazolidinediones, such as rosiglitazone (Avandia) and
pioglitazone hydrochloride (Actos), include swelling, weight gain and
fatigue. A far more serious potential side effect is liver damage. The
thiazolidinedione troglitzeone (Rezulin) was taken off the market in March
2000 because it caused liver failure. If your doctor prescribes these drugs,
it¶s important to have your liver checked every two months during the first
year of therapy. Contact your doctor immediately if you experience any of
the signs and symptoms of liver damage, such as nausea and vomiting,
abdominal pain, loss of appetite, dark urine, or yellowing of your skin and
the whites of your eyes (jaundice). These may not always be related to
diabetes medications, but your doctor will need to investigate all possible
causes.
 - may be given, it has the same mechanism of actions of
most of the oral antidiabetic drugs. Side effects must cautiously observed
to promote awareness and prevention of re-existence of the illness.

(-xercise

Instruct patient to start a healthy lifestyle through adequate exercise like walking
or it may be incorporated in the activities of daily living.

Install to the minds of the patient as well to his significant others the avoidance of
sedentary lifestyle to prvent from obesity and other interrelated illnesses.
-reatment

Your doctor will help you learn how to keep Diabetic Mellitus Type II under
control and will prescribe insulin and oral antidiabetic drugs.

For the wound, it should be cleaned always for fast healing of the wound.

.-ygiene

Encourage and explain to the patient and /or significant others that it is
important to maintain proper hygiene to prevent further infection. Instruct
the patient to take a bath every day.

Encourage the guardians and the client to wash hands frequently. The
hands come in daily contact with germs that can cause infection that may
lead to further complications. These germs enter one's body when he
touches his wounds at the right foot. Washing hands thoroughly and often
can help reduce and often can help reduce the risk.

Advise patient to wash his wound with soap and water and apply
³betadine´ daily to prevent from any forms of complications. It¶s helpful to
tell patient to expose wound when he is in the house only to dry it directly
because wet wounds are at risk in developing infection and cover it with
clean gauze when going out.

-ut patient follow up

Regular consultation to the physician can be a factor for recovery and to assess
and monitor the patient's condition.

Even though the patient has escaped to the distinct danger, explain that the
condition has a greater chance occur again. If that happens, advise patient to
consult the doctor directly.

Advise patient to always wear slippers to avoid puncture due to decrease


sensation of his lower extremities.

-iet
Diet should be advised to strictly follow the modified Diet he¶s up to---Diabetic
Diet for faster recovery from the disease condition. Patient is advised not to eat
too much to avoid increase blood glucose level and to avoid obesity.

#  "."   ;

The best way to control is prevention. Truly, prevention is better than cure.

Teach the family about the management required for the disorder.

Keep your environment clear of potential microorganisms.

Be smart about exercise.

Encourage significant others to help in maintaining good

Instruct to give medications at the right route, dose, and time.

Remind significant others to always assess to patient needs.

Instruct significant others to keep the patient¶s wound always clean and dry.

Advise to go to the physician if signs and symptoms of pneumonia and bronchial


asthma are observed.

Teach the folks the importance of monitoring the progress and compliance with
the treatment regimen.

Patient needs health promotions activities and health screening.

Emphasize to the significant others the importance of having regular check-up to


know her present condition.

Advice patient about the importance of an individualized meal plan in meeting


weekly weight loss goals and assist with compliance.
Assess patients for cognitive or sensory impairments, which may interfere with
the ability to accurately administer insulin.
Demonstrate and explain thoroughly the procedure for insulin self-injection. Help
patient to achieve mastery of technique by taking step by step approach.
Review dosage and time of injections in relation to meals, activity, and bedtime
based on patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation and meal
timing to avoid hypoglycemia.
Explain the importance of exercise in maintaining or reducing weight.
Advise patient to assess blood glucose level before strenuous activity and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns,
calluses, dryness, hair distribution, pulses and deep tendon reflexes.
Maintain skin integrity by protecting feet from breakdown.
Advice patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral flow.



































: $(#c!(: (c((

In my duty experience in A3F2 Medical Ward at Northern Mindanao Medical


Center (NMMC) we¶ve encounter so many kind of things, which are often unexpected
and were full of lessons that must be inculcated in our hearts and minds like giving
medication to our patients, having a bedside care, regulating the IVF every 1 hour,
monitoring the patients vital signs, and so many more.

In my first duty in the said ward I personally committed so many kinds of errors
and I¶m guilty for that but for those errors I¶ve learned a lot and gradually I am learning
to improve our work in order to follow the mission of the nursing profession, which is to
give care to the patient. I¶ve learned that not at all the times I will be perfect on what we
will be doing yet I need to be specific in my nursing management to particular diseases
because I am dealing with the lives of the patient, thus, Life is precious.

In my skills, I¶ve improve and I¶ve got a new knowledge for what we are doing like
NGT feeding, HGT monitoring, Termination of catheter, Cheat thoracostomy tube
monitoring, importance of suctioning and improve all the basic procedures that we all
learned from previous duty experiences like vital signs taking and monitoring intake and
output.

I would also like to extend my deepest gratitude to our PCI, Maam Chriselle Ma
ALavanza, who were patient enough to tolerate our mistakes and good enough to
correct those mistakes. She was the perfect PCI for us, that help us in transforming
ourselves into total person. We can¶t forget also our Clinical Instructor, Mrs. Karen
Callangan, RN who was our chief nurse that taught us the necessary procedures in
promoting proper nursing care towards our ever beloved patients. Friendships also
made together with my group mates, the nurses in Ward as well as to the patients and
for that, I greatly treasure every moment I had during the medical rotation.

And last I learned the real value of being a student nurse that I should control my
temper, my emotion while we are on our patient¶s side. I have to adjust in the
environment where I belong to consider the feelings of the watchers. As I¶ll always say.
It has been very productive learning experience during my first ever junior rotation. I¶m
glad I was able to enhance my skills together with this influential people. Because
through this, I¶ll be an effective nurse in the near future
:c %(%*

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http://chinese-school.netfirms.com/diabetes-types.html

www.caninsulin.com/Pathophysiology-algorithm.htm

http://www.medhelp.org/posts/Heart-Disease/Retro-Cardio-Density/show/869680

http://www.mghradrounds.org/index.php?src=gendocs&link=2006_may

http://www.labtestsonline.org/understanding/analytes/electrolytes/test.html

http://answers.yahoo.com/question/index?qid=20060825191958AAsQ7vn

http://www.drugs.com/arcoxia.html

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=Kalium+durule%3Creg%3E&
CTRY=PH

http://www.uptodate.com/patients/content/topic.do?topicKey=~X0jjLnBn4._kohttp://www
.uptodate.com/patients/content/topic.do?topicKey=~X0jjLnBn4._ko

http://www.medicinenet.com/insulin_resistance/page2.htm

http://www.virtualmedicalcentre.com/diseases.asp?did=826&page=1#Risk_Factors

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