39591443 a Case Study on Chronic Kidney Disease

CRITERIA

Intro & Objective Pt’s Data & Hx History Definition of Diagnosis Developmental Data Physical As Assessment Anatomy & Physiology Pathophysiology Diagnostic exams Drug Studies Nsg Care Plans Discharge Planning Prognosis Bibliography Promptness

5% 5% 5% 5% 10% 5% 10% 5% 5% 20% 5% 5% 5% 10%

TOTAL

100%

A Nursing Case Study

In Partial Fulfillment of the Requirements in NCM 103- RLE Oxygenation

Submitted to: Ms. Paula Gene Maniago, ST.N Mr. Nikko Jay Sulpot, ST.N Practicing Clinical Instructor   And  Mrs. Marilou Dela Cruz-Sawan, RN, MN Clinical Instructor  Submitted by: Flauta, Reina Alyannah Jimena, Phil Anthony Lego, Roselle Carmi Loquias, Mariel Anne Mamaluba, Desiree May Saballo, Kevin Van Erick

July 12, 2010

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Table of Contents

Rationale Goal and Objectives Data Base Biographical Data Clinical Data Family Health History  Past Health History  History of Present Illness Definition of Diagnosis Developmental Tasks Physical & Neuro Assessment Anatomy & Physiology Pathophysiology Medical Management Diagnostic Exams Management  Drug Studies Nursing Care Nursing Care Plans Discharge Plan Prognosis References

1 5 7 8 9 11 11 12 18 21 24 38 45 53 55 74 86 92

Rationale Oxygen is one of the main needs for the body’s life-supporting functions. No one can live without sufficient quantities of food, water, and oxygen. Of the three, oxygen is by far the most urgently needed. If necessary, a well-nourished person can go without food for many days or weeks, living on what are stored in the body. The need for water  is more immediate but still will not become critical for several days. The supply of 

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Table of Contents

Rationale Goal and Objectives Data Base Biographical Data Clinical Data Family Health History  Past Health History  History of Present Illness Definition of Diagnosis Developmental Tasks Physical & Neuro Assessment Anatomy & Physiology Pathophysiology Medical Management Diagnostic Exams Management  Drug Studies Nursing Care Nursing Care Plans Discharge Plan Prognosis References

1 5 7 8 9 11 11 12 18 21 24 38 45 53 55 74 86 92

Rationale Oxygen is one of the main needs for the body’s life-supporting functions. No one can live without sufficient quantities of food, water, and oxygen. Of the three, oxygen is by far the most urgently needed. If necessary, a well-nourished person can go without food for many days or weeks, living on what are stored in the body. The need for water  is more immediate but still will not become critical for several days. The supply of 

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oxygen in the body is limited to a few minutes. When that supply is exhausted, death is inevitable. Oxygenation is a dynamic interaction involved in the transportation of oxygen to all body parts and the removal of carbon dioxide. In this rotation we had our duty in Sta. Rosa ward at San Pedro Hospital and we conducted a study on our patient’s patient’s case which has UTI, CKD secondary to diabetes and hypertensive, Pleural effusion and ascites secondary to hypoalbumin secondary to CKD/liver pathology and DM type II uncontrolled. Through this, we can determine the interrelationship of kidney to other  complications such as diabetes and diabetes. Chroni Chronic c kidney kidney disea disease se (CKD (CKD), ), also also known known as chron chronic ic rena renall dise diseas ase, e, is a progressive loss of renal of  renal function over a period of months or years. The symptoms of  worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. appetite. Often, chronic kidney disease is diagnosed as a result of screening of  screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes or  diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, disease, anemia or pericarditis or pericarditis.. Recent professional professional guidelines guidelines classify classify the severity severity of chronic kidney disease in five stages, with stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF). Kidney diseases rank as the number 10 killer in the Philippines causing death to about 7,000 Filipinos every year, DOH reported. The DOH stepped up the advocacy on kidney disease prevention in observance of the 25th year of Kidney month with theme "25 Taong Pangunguna sa Serbisyo para sa Kalusugan ng Bato ng Sambayanang Pilipino". The population population of Filipinos Filipinos aged 20 years 46,627,172. A years and and above in 2005 was 46,627,172. prevalence of 2.6% means that 1,212,306 adult Filipinos have CKD. Philippines have a total of 254 dialysis centers where most of the dialysis machines are located in the

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National Capital Region with 41 % while Region 6 has only 5%. Iloilo and Negros Occidental provinces have the most number of dialysis machines while the provinces of  Antique and Guimaras have none. Chronic kidney disease is a worldwide public health problem. In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. There is an even higher prevalence of earlier stages of chronic kidney disease. Recent reports from the United States estimate that nearly half a million patients in the United States were treated for end-stage renal disease (ESRD) in 2004 and by 2010 this figure is expected to increase by approximately 40%. The number of people with renal replacement therapy has increased from 426,000 in 1990 to 1.5 million in 2000 and is expected to rise to 2.5 million by 2010. An Estimated 26 Million Adults in the United States have Chronic Kidney Disease (CKD). In 2006, CKD was responsible for the death of nearly 45,000 people, ranking as the ninth leading cause of death in the United States. A population survey in 1999-2000 found that 1 in 7 (13.4%) Australians adults over 25 years of age have some degree of CKD. In year 1999–2004 an estimated 11.5 percent of adults ages 20 or older (23 million adults) have physiological evidence of chronic kidney disease determined from data collected through the National Health and Nutrition Examination Survey. The frequency of CKD continues to increase worldwide as does the prevalence of end-stage renal disease (ESRD). Consequently, the identification and reduction of CKD has become a vital public health priority. The reported prevalence of CKD stages 1-4 in the most recent NHANES (national health and nutrition examination survey) between 1999 and 2006 was 26 million (13%) out of approximately 200 million United States residents aged 20 and older. Of these, 65.3% had CKD stage 3 or 4. The most recent report of the United States Renal Data System estimates that nearly one-half million patients in the United States were treated for ESRD in the year 2004, and by 2010 this figure is expected to increase by approximately 40%. The elderly are a growing segment of the population and at increased risk for renal disease. Additionally, males and African-Americans with

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pre-existing hypertension or diabetes and CKD are also at much higher risk for ESRD. These observations have also been confirmed throughout the developed world: Europe, Asia, Australia as well as in developing regions such as China, India and Africa. Recent reports from the United States estimate that nearly half a million patients in the United States were treated for end-stage renal disease (ESRD) in 2004 and by 2010 this figure is expected to increase by approximately 40%. The economic burden for developing countries is particularly severe, partly because CKD generally occurs at a younger age. For example, in Guatemala, 40% of  patients receiving RRT are under 40. In China, the economy will lose US$558 billion over the next decade due to effects on death and disability attributable to chronic cardiovascular and renal disease. More than 80% of individuals receiving renal replacement therapy (RRT) live in the developed world because in developing countries it is largely unaffordable. In countries such as India and Pakistan, less than 10% of all patients who need it receive any kind of renal replacement therapy. In many African countries there is little or no access to RRT, meaning many people simply die. Through this we have come up with ideas that this kind of disease are increasing now a days. In line with nursing implications and research, we as a student nurse should know the disease process and the possible complication that may occur if not treated; the therapies that could help lessen the disease and the medication appropriate for our client. By this we are conducting this case study so that we can upgrade our  knowledge and skills on how we could render our care appropriately. It will serve as a research material in which the case is thoroughly studied. It will give the future researcher a background on the disease and a literature on this disease and basis for  future studies. In Nursing Education the group will learn firsthand about the client case. The group will be the one who will learn themselves. Education and learning is not limited to the confines of a classroom but it is also achieved through effort and exposure to actual cases like in the clinical area To conclude, this case study will serve as a learning tool for nursing student and will give experiences that will broaden the groups’ skill in handling this condition, use of 

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interpersonal skills, acquire knowledge, and stimulate critical thinking.

Goal and Objective We, the BSN 3K, Group 3 Subgroup 1, formulated the following goals that will serve as our guide towards the completion of this nursing case study. Our group aims to achieve the objectives below and come up with a well-organized and comprehensive and detailed output. General Objectives: That within 32 intermittent hours of rotation oxygenation, we, the group 3 subgroup 1 of BSN 3K would be able to do a systematic way of research about Chronic Kidney Disease with regards to our patients condition and we will be able to present this case study to our Clinical Instructor and Practicing Clinical Instructor for further  discussion to be utilized by future researchers and aid in understanding the disease mentioned. Specific Objectives: At the end of our rotation at Sta. Rosa ward, the group will be able to specifically: a. Select a subject for our case study; b. establish a nurse-client relationship to the client, as well as to the family by rendering a therapeutic nurse-patient relationship; 6

c. gather adequate information to be used in the development of the study d. make a specific, measurable, attainable, realistic and time bounded objectives that will serve as a guide to have a good nursing management; e. present the clients personal data; f. illustrate the patient’s family tree and trace significant diseases which may be of relevance to the study; g. trace the health history of the client and the family by collecting information

both of the past and present illnesses; h. identify the client’s developmental data basing on Erik Erikson and Robert Havighurst’s theories; i. have a

cephalocaudal assessment of the client providing relevance to

changes both physically and physiologically because of the disease;  j. tackle the systems involved in the development of the disease in the human anatomy and physiology; k. provide a schematic and narrative explanation of the pathophysiology in a comprehensive manner; l.

present the predisposing factors, precipitating factors and symptomatology of the disease process and each of its rationales;

m. explain and interpret the diagnostic studies including the indication, result and their implications; n. discuss the medications given to our client which includes the classification, suggested and ordered dose, action, indication, contraindication, side effects, drug interactions and nursing responsibilities; o. formulate nursing care plans that is applicable to our patient’s condition; p. give health teachings to the client and to his family in relation to their needs in response to the disease process and therapy; q. evaluate the outcome of the disease and therapy whether there is good, fair  or poor prognosis; and r. present and defend comprehensively our case study to the group.

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Personal Data Name: Pt. S Gender: M Age: 76 yrs old Birthday: August 27, 1933 Birthplace: Panabo City Nationality: Filipino Address: 7091 Liceralde Subdivision, Panabo City Religion: Jehova’s Witnesses Education Level: High School Graduate Occupation: Farmer and Photographer  No. of Dependents and Siblings: Seven siblings Marital Status: Married

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Clinical Data

Chief Complaint: Body Malaise Date of Admission: June 27, 2010 Admitting Diagnosis:

UTI CKD secondary to diabetes and hypertensive Pleural effusion and ascites secondary to hypoalbumin secondary to CKD/liverpathology DM type II uncontrolled Ward: Sta. Rosa Attending Physician: Dr. Maria Clara Teresa, M.D. Date of Discharge: Final Diagnosis:

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Family Health History (Genogram) Apolonia

Benjamin Ø

Aniano

Becaya

ɷ

Teodoro Raquel Ø

ɤ

Ø

ɸ

? ?

David Sr. ¢ ɷ

Susana Ø

ɸ Rebeca Estrelieta ɷ

David Jr. ɷ ɸ Levi

Legend:

?

ɷ ɤ ɸ ¢ Narrative:

Male Female Unknown Hypertension Asthma Diabetes Client Ø Deceased

Denis

Danny Susaneth

 Norodine

Juceth

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We don’t have gathered data about the grandparents of our client because he cannot remember it anymore. Both parents of our client had already passed away due to old age and they had seven children named Benjamin as the eldest had experienced hypertension, Raquel as the second child experience asthma, Theodoro was the third, next to him were two siblings whom are unknown and next to them was our client David who had a diabetes and hypertension hypertension and lastly was Becaya as the youngest. Only two of them are living, David and Becaya. Our client marry Susana which they had nine offsprings. Their eldest was Rebeca, second is Estrelieta who had a hypertension, third was David Jr. who also had hypertension and diabetes, fourth was Levi, next is Denis, then Danny, then Susaneth, and then Norodine, and lastly the youngest was Juceth.

We don’t have gathered data about the grandparents of our client because he cannot remember it anymore. Both parents of our client had already passed away due to old age and they had seven children named Benjamin as the eldest had experienced hypertension, Raquel as the second child experience asthma, Theodoro was the third, next to him were two siblings whom are unknown and next to them was our client David who had a diabetes and hypertension hypertension and lastly was Becaya as the youngest. Only two of them are living, David and Becaya. Our client marry Susana which they had nine offsprings. Their eldest was Rebeca, second is Estrelieta who had a hypertension, third was David Jr. who also had hypertension and diabetes, fourth was Levi, next is Denis, then Danny, then Susaneth, and then Norodine, and lastly the youngest was Juceth.

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Past History

According to our patient, in year 1996 he experienced gangrenous at the right leg which causes amputation of his right big toe. He was diagnosed to have diabetes mellitus, twenty years ago and diagnosed as hypertensive, ten years ago. Present History

Eight days prior to admission, the patient had onset of body malaise and numbness numbness of lower extremities extremities which resulted to difficulty difficulty in walking, walking, chills were noted and also colds and dyspnea. Consultation was done and also laboratory tests which had a result of decrease in K, which mange by giving Kalium Dumule and Insulin injection.

Past History

According to our patient, in year 1996 he experienced gangrenous at the right leg which causes amputation of his right big toe. He was diagnosed to have diabetes mellitus, twenty years ago and diagnosed as hypertensive, ten years ago. Present History

Eight days prior to admission, the patient had onset of body malaise and numbness numbness of lower extremities extremities which resulted to difficulty difficulty in walking, walking, chills were noted and also colds and dyspnea. Consultation was done and also laboratory tests which had a result of decrease in K, which mange by giving Kalium Dumule and Insulin injection. Six days prior to admission there is a presence of symptoms of CKD which he was admitted in Panabo Polymedic Hospital. There were episodes of  fever, chills, and constipation.

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Definition of Diagnosis 1. Chronic Kidney Disease (CKD) Secondary to Diabetes & Hypertensive Nephropathy

DIAGNOSIS Chronic Kidney Disease (CKD)

RATIONALE

1. CKD is a progressive, irreversible loss of  Swearingen, Pamela L., RN (2008).All-in-One Care kidney function that develops over days to Planning Resource. years. Aggressive management of  Westline Industrial Drive St. Louise, hypertension and diabetes mellitus and Missouri. Mosby, Inc. avoidance of nephrotoxic agents may 2nd Ed. p.217. slow progression of CKD; however loss of  glomerular filtration is irreversible and can lead to end-stage renal disease (ESDR). 2. CKD is a term that describes kidney damage or a decrease in glomerular  filtration rate for 3 or more months. Untreated CKD can result in end-stage renal disease (ESRD) and necessitate renal replacement therapy.

3.

Chronic renal failure represents progressive and irreversible destruction of kidney structures. It results in loss of  renal cells with progressive deterioration of glomerular filtration, tubular  reabsorptive capacity, and endocrine functions of the kidney.

4. Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of  renal function over a period of months or years. Chronic kidney disease is identified by a blood test for creatinine. Higher levels of   creatinine indicate a falling glomerular  filtration rate and as a result a decreased capability of the kidneys to excrete waste products.

Diabetes

BIBLIOGRAPHY

Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). Medical- Surgical Nursing. 530 Walnut Street, Philadelphia. Wolters Kluwer Health & Lippincott Williams & Wilkins. 12th Ed. p.1313. Porth, Carol Mattson. (2005). Pathophysiology: Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincott Williams & Wilkins. 7th Ed. Pg. 837

http://en.wikipedia.org/wiiki/ Chronic_kidney_disease

1. DM is a group of metabolic disease Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). characterized by increased level of  Medical- Surgical glucose in the blood (hyperglycemia) Nursing. 530 Walnut Street, Philadelphia. resulting from defects in insulin secretion, Wolters Kluwer health insulin action, or both. The major source & Lippincott Williams &

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Wilkins. 12th Ed. p. 1196. of glucose is absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food McCann, Judith A. Schilling, substances. RN, MSN (2005).

2. DM is a chronic disease of absolute or  relative insulin deficiency or resistance characterized by disturbances in carbohydrate, protein, and fat metabolism.

3. DM is a chronic, progressive disease characterized by the body’s inability to metabolized carbohydrates, fats, and proteins, leading to hyperglycemia (high blood glucose level).

4. DM is a disorder of carbohydrate, fat, and protein metabolism brought about by impaired beta cell synthesis or  release of insulin, or the inability of  tissues to use glucose. Type 1: results from loss of beta cell function and absolute insulin deficiency. Type 2: results from impaired ability of the tissues to use insulin (insulin resistance) accompanied by a relative lack of insulin or impaired release of  insulin in relation to blood glucose levels. Hypertensive 1. It is a persistently high blood pressure. In

adults, this means a systolic pressure that is equal to or greater than 140 mmHg & a diastolic pressure that is equal to or  greater than 90 mmHg.

Professional Guide to Diseases. 323 Norristown Road, Suite 200, Ambler. Lippincott Williams & Wilkins. 8th Ed. p.865. Black, Joyce M., PhD, RN, CPSN, CWCN, FAPWCA & Jane Hokanson Hoaks, DNSc, RN, BC (2009). Medical- Surgical Nursing: Clinical Management for  Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p.1062. Porth, Carol Mattson. (2005). Pathophysiology: Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincott Williams & Wilkins. 7th Ed. pg. 995

deWit, Susan C., MSN, RNCs (1998). Essentials of  Medical- Surgial Nursing. Independence Square West Philadelphia, Pennsylvania. W.B. Saunders Company. 4th Ed. p. Black, Joyce M., PhD, RN, CPSN, CWCN, FAPWCA

2. Persistent elevation of the systolic blood pressure (SBP) at a level of 140 mmHg or  & higher & diastolip blood pressure (DBP) at

Jane Hokanson Hoaks, DNSc, RN, BC (2009).

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a level of 90 mmHg or above.

3. A persistently high blood pressure. It is known as “silent killer” bcause it can cause considerable damage to the blood vessels, heart, brain, and kidneys before it causes pain or other noticeable symptoms. This damages the kidney arterioles, causing them to thicken, which narrow the lumen; because the blood supply to the kidney is thereby reduced, the kidney secrete more renin, which elevates the blood pressure even more. 4.

Nephropathy 1. Diabetic Nephropathy is the result of an

alteration in glomerular function. There is thickening of the basement membranes of  the glomerular capillaries, leading to the development of glomerular sclerosis. These changes in the glomeruli are accompanied by a small urinary loss of  albumin.

2.

Medical- Surgical Nursing: Clinical Management for  Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p. Tortora, Gerald J. & Bryan Derrickson (2007). Principles of Anatomy and Physiology. 111 River  Street, Hoboken, USA. John Wiley & Sons, Inc. 11th ed. p. 798.

Bullock, Barbara L., RN, MSN & Reet L. Henze, DSN, RN (2000). Pathophysiology. Philadelphia. Lippincott Williams & Wilkins. p. 703.

Joyce M., PhD, RN, Diabetic Nephropathy is the most Black, CPSN, CWCN, FAPWCA common cause of stage 5 chronic kidney & disease, formerly known as end-stage Jane Hokanson Hoaks, DNSc, RN, BC (2009). renal disease. Nephropathy involves Medical- Surgical Nursing: damage to and obliteration of the Clinical Management for  capillaries that supply the glomeruli of the Positive Outcomes. 3 kidney. Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p.1103. Tortora, Gerald J. & Bryan Derrickson (2007). Principles of Anatomy and Physiology. 111 River  Street, Hoboken, USA. John Wiley & Sons, Inc. 11th ed. p. 1030.

3. Any disease of the kidney. Nephrotic syndrome is a condition characterized by proteinuria (protein in urine) and hyperlipidemia (high blood levels of  cholesterol, phospholipids, and triglycerides). Proteinuria is due to an increased permeability of the filtration membrane, which permits proteins, Porth, Carol Mattson. (2005). Pathophysiology: especially albumin, to escape from blood

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into urine. 4. Diabetic nephropathies is used to describe the combination of lesions that often occur concurrently in diabetic kidney. The most kidney lesions in diabetic people are those that affect the glomeruli. It is the leading cause of end-stage renal failure (ESRD).

Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincott Williams & Wilkins. 7th Ed. pg. 1010

2. Pleural Effusion & Ascites Secondary to Hypoalbuminemia Secondary to CKD/ Liver Pathology

DIAGNOSIS Pleural Effusion

RATIONALE

1. Pleural effusion is a collection of fluid in the pleural Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). space, is rarely a disease process; it is usually Medical- Surgical secondary to other diseases. Normally, the pleural Nursing. 530 Walnut Street, Philadelphia. space must contain only a small amount of fluid Wolters Kluwer health which acts as a lubricant that allows the pleural & Lippincott Williams & surfaces to move without friction. Wilkins. 12th Ed. p.574. 2. It is an abnormal collection of fluid or exudate in the pleural cavity. The fluid maybe a transudate, exudate, purulent drainage, chyle, or blood. I

Ascites

BIBLIOGRAPHY

Porth, Carol Mattson. (2005). Pathophysiology: Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincot Williams & Wilkins. 7th Ed. pg. 690

1. Accumulation of fluid in the peritoneal cavity that Black, Joyce M., PhD, RN, CPSN, CWCN, results from the interaction of several FAPWCA& pthophysologic changes. Portal hypertension, Jane Hokanson Hoaks, DNSc, RN, BC (2009). lowered plasma colloidal osmotic pressure, & Medical- Surgical Nursing: sodium retention all contribute to this condition. Clinical Management for  Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier.

2. Accumulation of serous fluid in the peritoneal cavity.

Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). Medical- Surgical Nursing. 530 Walnut Street, Philadelphia. Wolters Kluwer health & Lippincott Williams & Wilkins. 12th Ed. p.1196.

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Hypoalbumin 1. Hypoalbuminemia (low blood albumin level) Tortora, Gerald J. & Bryan Derrickson (2007). emia happens once liver production of albumin fails to Principles of Anatomy and meet increased urinary losses. Physiology. 111 River  Street, Hoboken, USA. John Wiley & Sons, Inc. 11th ed. p. 1030.

Liver

1. A large, highly vascular organ located behind the Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). ribs in the upper right portion of the abdominal Medical- Surgical cavity. It is considered as a chemical factory that Nursing. 530 Walnut Street, Philadelphia. manufactures, stores, alters, and excretes large Wolters Kluwer health number of substances involved in metabolism. It & Lippincott Williams & receives nutrient-rich blood directly from the Wilkins. 12th Ed. p.1117. gastrointestinal tract (GI) and then either stores or  transforms these nutrients into chemicals that are Microsoft® Student 2008 [DVD]. Redmond, WA: Microsoft used elsewhere in the body for metabolic needs. Corporation, 2007. 2. Largest internal organ of the human body. Its essential functions include helping the body to digest fats, storing reserves of nutrients, filtering poisons and wastes from the blood, synthesizing a variety of proteins, and regulating the levels of  many chemicals found in the bloodstream.

Pathology

1. Study of disease: the scientific study of the nature, origin, progress and cause of disease.

Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation. All rights reserved.

Microsoft® Student 2008 [DVD]. Redmond, WA: Microsoft Corporation, 2007. Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation. All rights reserved.

3. Diabetes mellitus (DM) Type 2 Uncontrolled DIAGNOSIS DM Type 2

RATIONALE

BIBLIOGRAPHY

Bullock, Barbara L., RN, 1. Type 2 DM range from mostly insulin MSN resistance with relative insulin deficiency to & Reet L. Henze, DSN, predominantly secretory defect with insulin RN (2000). Pathophysiology. resistance. It is a nonketotic form of DM and Philadelphia. Lippincott there is no autoimmune destruction of the Williams & Wilkins. pancreatic islet b cells. P.696

2. Type 2 DM is previously called adult-onset  diabetes mellitus, is a disorder involving both genetic and environmental factors. This Black, Joyce M., PhD, RN, CPSN, CWCN, type of DM has limited beta-cell response to FAPWCA

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& Jane Hokanson hyperglycemia. As the beta-cells are Hoaks, exposed to high levels of glucose, they DNSc, RN, BC (2009). become progressively less efficient. Medical- Surgical Nursing: Clinical Management for  Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p.1063.

3. Type 2 DM has 2 main problems and these are insulin resistance and impaired insulin secretion. Insulin resistance refers to decreased tissue sensitivity to insulin. Smeltzer, Suzanne C., EdD, Normally, insulin binds to special receptors RN, FAAN, et.al on cell surfaces and initiates a series of  (2010). Medical- Surgical reactions involved in glucose metabolism. Nursing. 530 Walnut But, in type 2 DM, these intracellular  Street, Philadelphia. reactions are diminished, making insulin less Wolters Kluwer health effective at stimulating glucose uptake by & Lippincott Williams & the tissues and at regulating glucose release Wilkins. 12th Ed. p.1199. by the liver. 4. Urinary Tract Infection DIAGNOSIS

MEANING

BIBLIOGRAPHY

Urinary Tract 1. Used to describe either an infection of a part Tortora, Gerald J. & Bryan Derrickson (2007). Infection of the urinary system of the presence of  Principles of Anatomy (UTI) large numbers of microbes in urine. and Physiology. 111 River  Symptoms include painful or burning Street, Hoboken, USA. urination, urgent and frequent urination, low John Wiley & Sons, Inc. back pain, and bed wetting. 11th ed. p. 1030. 2. UTI’s are caused by pathogenic Smeltzer, Suzanne C., EdD, RN, FAAN, et.al microorganisms in the urinary tract. They (2010). are generally classified as infections Medical- Surgical involving the upper and lower urinary tract Nursing. 530 Walnut Street, Philadelphia. and further classified as uncomplicated or  Wolters Kluwer health complicated, depending on other patient& Lippincott Williams & related conditions. Wilkins. 12th Ed. p.1359.

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Developmental Tasks of Later Maturity Robert Havighurst’s Developmental Tasks Developmental Tasks

Description

Passed or   Failed

Justification

1. Adjusting to decreasing physical strength and health

Older adults also have to adjust to decreasing physical strength and health. The prevalence of  chronic and acute diseases increase in old age. Thus, older  adults may be confronted with life situations that are characterized by not being in perfect health,serious illness and dependency on people.

Passed

Our patient is aware about his health and is very cooperative on the student nurses who provide care to him. He is cooperative in a way that he follows the student nurses in procedures like removing the catheter. Also, when giving meds, he does not refuse in taking the due meds given to him.

2. Adjusting to retirement and reduced income

A central developmental task that characterized the transition into old age is adjustment to retirement. The period after retirement has to be filled with new projects, but is characterized by few valid cultural guidelines. The achievement of this task may be obstructed by the management of  another task, living in a reduced income after retirement.

Passed

Our patient is not receiving pension but gets his income from his farm (banana plantation) and his photo studio. He is a photographer by experience according to his grandchildren. His annual income at his photo studio is 200,000 pesos.

Passed

When asked, the patient

3. Adjusting to death Older adults may

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of a spouse

become caregivers to their spouses. Some older adults have to adjust to the death of  their spouses. After  they have lived with a spouse for many decades, widowhood may force older  people to adjust to loneliness, moving to a smaller place,and learning about business matters.

stated that his wife is already dead. He accepts that he is now a widow. His deceased wife's name is Susanna. She died on November 7, 2005 due to cancer (not specified). They had 9 children.

4. Establishing an The development of a explicit affiliation with large part of the one's aged group population into old age is historically recent phenomenon to modern cities. Thus, advancements understanding of the aging process may lead to identifying further developmental tasks associated with gains and purposeful lives for adults.

Passed

Our patient is a member of  PHIC and a congregation of  Jehovah's witnesses in Panabo City. According to him, they have 7 congregations in Panabo and it is composed of 100 members per congregation. In their congregation, their  focus is on teaching the good news of Jehovah. He also mentioned that he has friends of the same age group namely Helson Daclan who delivers meds and Oscar Emier.

5. Meeting social and Older people might civil obligations accumulate knowledge about life, and thus may contribute to the development of  younger people and the society.

Passed

Our patient tells stories about his childhood life to his grandchildren. He shares experiences to them which served as a guide and lesson.

6. Establishing satisfactory physical living arrangements

Passed

Our patient lives in a subdivision in a Panabo City together with his daughter. According to him, his daughter is the only one who is not married among his children. All eight had their own families nonetheless he sometimes would visit them.

Oder adults are generally challenged to create positive sense of their lives as a whole. The feeling that life has order and meaning results in happiness.

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Eric Erikson’s Developmental Task Integrity vs. Despair 

Erikson felt that much of life is preparing for the middle adulthood stage and the last stage recovering from it. Perhaps that is because as older adults we can often look back on our lives with happiness and are contented, feeling fulfilled with a deep sense that life has meaning and we've made contribution to life, a feeling Erikson called integrity. On the other hand, some adults may reach this stage and despair at their  experiences and perceived failure. Our patient achieved happiness and contentment in his life based on his actions and speeches. He is faithful and devoted to his religion. When asked what his principle in life he said is, “Mamatay man kun buhi, mapabilin kay Jehovah”. He is ready to accept death completely and he has shared his experiences to his beloved grandchildren. Even though he accepted death fully but his faith and love for his worshipped God never changed.

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Physical Assessment Name: Mrs. J Bed: 304-6 Age: 56 Status: Married

Ward: San Lorenzo Ward Sex: Female

Civil

Vital Signs

Axillary T= 37.3 C, PR= 77 bpm, RR= 22, CR= 79 bpm, BP= 110/70 mmHg. General survey

Height= 5 ft and 3 inches, weight=46 kilos, head circumference=21cm, abdominal circumference= 28 inches. Mesomorph. No signs of distress noted upon assessment, able to smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show calmness during the examination. She has no IVF infused, and was asleep at initial assessment. Skin

Skin is brown in color, rough, dry and warm. She has good skin turgor. Brownish discolorations that resemble freckles are observed on arms and face. Head

Skull is round in shape, symmetrical (normocephalic). No masses noted. Facial movement is symmetrical. Hair is dry in texture; its color is black with mimimal streaks of  gray. Scalp is clear from dandruff and lice. No scars and wounds noted. Eyes

Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils constricted to light (2mm), round in shape, isocoric, shows uniform convergence. She is able to rotate eyes and has coordinated eye movements. Ears

Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye. Pinnas are symmetrical, mobile, and able to recoil, with no lesions noted. She has wet cerumen noted on both ears when pulled down and back for 

23

better visualization. She is able to hear on both ears. Her ears’ lobules have holes for   jewelry. Nose

Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when light is flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration. Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses noted. Mouth

Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in color with thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft palate is light pink in color while hard palate is lighter in color. Gums are pinkish in color. Her first and second right molars of the lower teeth, and her first left molar of the upper teeth are missing. Her teeth are a little yellow in color with few plaques usually found on her remaining molars. Pharynx

Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils are not inflamed. Neck

Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted. She is able to flex and extend neck and move it laterally (L and R). Chest and Lungs

Breathing pattern is regular (eupnea). Anteroposterior diameter to transverse diameter is in 1:2. Respiratory excursion is symmetrical (thumb separates to 2-3cm). Vocal tactile fremitus is bilaterally equal. She refused to have her breasts examined. Heart and Central Vessels

Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more audible in apical area upon auscultation. Back and Extremities

Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color, and have a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were noted. Calluses were observed at the tip of her fingers and toes. Her  hands are a little rough. Muscle strength is equal on both sides of the upper and lower  extremities. Spine is a little deviated to the left as seen when client was asked to bend

24

over. She is able to stand and walk on both feet independently, and her movements are well coordinated. Toes point straight ahead. And she is able to sit up straight. Abdomen

Her abdomen’s color is same with the rest of the part of the body. Her umbilicus is coated with blackish dirt. She has globular abdomen and dullness was noted upon percussion. Neurologic Assessment

Cranial Nerves: (CN1) able to identify aromas by smelling with eyes closed; (CN2) able to see objects; (CN3) pupil constricted to light sensation; (CN4&6) able to move eyeball downward and laterally; (CN5) able to blink eyes; (CN7) able to smile, raise eyebrows, puff cheeks and close eyes; (CN8) able to respond to questions being heard; (CN10) has rough and vibrating sound; (CN11) able to shrug shoulders, elevate and flex arms and legs against resistance; (CN12) able to protrude tongue and move it side to side.

25

Anatomy and Physiology

Function of the Urinary System:

The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism and because of this, it is sometimes referred to as the excretory system. Although the urinary system has a major role in excretion, other organs contribute to the excretory function. The lungs in the respiratory system excrete some waste products, such as carbon dioxide and water. The skin is another excretory organ that rids the body of wastes through the sweat glands. The liver and intestines excrete bile pigments that result from the destruction of hemoglobin. The major task of excretion still belongs to the urinary system. If it fails the other organs cannot take over and compensate adequately.

26

The urinary system maintains an appropriate fluid volume by regulating the amount of water that is excreted in the urine. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. In addition to maintaining fluid homeostasis in the body, the urinary system controls red blood cell production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. Components

of

the

Urinary 

System:

The

urinary

system

consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside. KIDNEYS

The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine. They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body. The paired kidneys are located between the twelfth thoracic and third lumbar  vertebrae, one on each side of the vertebral column. The right kidney usually is slightly

27

lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a thick layer of  adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside. In the adult, each kidney is approximately 3 cm thick, 6 cm wide and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at the hilum. The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists of a series of renal pyramids, which appear striated because they contain straight tubular  structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of  the kidney. The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a renal tubule. The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular  capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole

28

leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop. Parts of the Kidney:

Renal Vein -This has a large diameter and a thin wall. It carries blood away from the kidney and back to the right hand side of the heart. Blood in the kidney has had all its urea removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the renal vein also has exactly the right amount of water and salts. This is because the kidney gets rid of excess water and salts. The kidney is controlled by the brain. A hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control exactly how much water is excreted. Renal Artery - This blood vessel supplies blood to the kidney from the left hand side of  the heart. This blood must contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal artery must have sufficient pressure or the kidney will not be able to filter the blood. Medulla - The medulla is the inside part of the kidney. This is where the amount of salt and water in your urine is controlled. It consists of billions of loops of Henlé. These work very hard pumping sodium ions. ADH makes the loops work harder to pump more sodium ions. The result of this is that very concentrated urine is produced. Cortex - The cortex is the outer part of the kidney. This is where blood is filtered. We call this process "ultra-filtration" or "high pressure filtration" because it only works if the blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of  capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak.

29

Things like red blood cells, white blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours. Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into the blood. Blood supplied to the kidney contains a toxic product called urea which must be removed from the blood. It may have too much salt and too much water. The kidney removes these excess materials. Glomerulus and Bowman's Capsule - This is where ultra-filtration takes place. Blood from the renal artery is forced into the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's capsule which surrounds it. Proximal Convoluted Tubules - Proximal means "near to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's capsule. This is the place where all that useful glucose is re-absorbed from the ultra-filtrate and put back into the blood. If  the glucose was not absorbed it would end up in your urine. This happens in people who are suffering from diabetes. Loop of Henlé - This part of the nephron is where water is reabsorbed. Kidney cells in this region spend all their time pumping sodium ions. This makes the medulla very salty; you could say that this is a region of very low water concentration. If you remember the definition of osmosis, you will realize that water will pass from a region of high water  concentration (the ultra-filtrate and urine) into a region of low water concentration (the medulla) through cell membranes which are semi-permeable. Distal Convoluted Tubules - Distal means "distant" so it is at the other end of the nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate are re-absorbed. Collecting Duct - Collecting ducts run through the medulla and are surrounded by loops of Henlé. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are removed from it. Although our kidneys make about 160 litres of urine every 24

30

hours, we only produce about ½ litre of urine. It is called a collecting duct because it collects the liquid produced by lots of nephrons.

URETERS

Each ureter is a small tube, about 25 cm long that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface.

31

The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells.

URINARY BLADDER

The urinary bladder is a temporary storage reservoir for  urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers. The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other  regions, the outer layer is fibrous connective tissue.

32

There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter. URETHRA

The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control the flow of urine through the urethra. In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina. In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the

33

urethra extends the entire length of the penis, and the external urethral orifice opens to the outside at the tip of the penis.

LIVER

The liver is the largest internal organ in the body, and weighs about 3 pounds in an adult. The liver is located in the right upper quadrant of the abdomen, just below the diaphragm. A thick capsule of connective tissue called Glisson's capsule covers the entire surface of the liver. The liver is divided into a large right lobe and a smaller left lobe. The falciform ligament divides the two lobes of the liver. Each lobe is further divided into lobules that are approximately 2 mm high and 1 mm in circumference.

34

These hepatic lobules are the functioning units of the liver. Each of the approximately 1 million lobules consists of a hexagonal row of hepatic cells called hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a variety of metabolic functions. Between each row of hepatocytes are small cavities called sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove amino acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that flows through the sinusoids. The main functions of the sinusoids are to destroy old or  defective red blood cells, to remove bacteria and foreign particles from the blood, and to detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the liver each minute, making it one of the most vascular organs in the body. Seventy-five percent of the blood flowing to the liver comes through the portal vein; the remaining 25% is oxygenated blood that is carried by the hepatic artery. Central Role of Liver in Metabolism

The liver is vitally important in helping to maintain blood glucose levels within normal range. After a carbohydrate-rich meal, thousands of glucose molecules are removed from the blood and combined to form the large polysaccharide molecules called glycogen, which are then stored in the liver. This process is glycogenesis, literally, “glycogen formation”. Later, as body cells continue to remove glucose from the blood to meet their needs, blood glucose levels begin to drop. At this time, liver cells break down the stored glycogen, by a process called glycogenolysis, which means “glycogen splitting.” The liver cells then release glucose bit by bit t the blood to maintain homeostasis of blood glucose levels. If necessary, the liver can also make glucose from noncarbohydrate

substances

such

as

fats

and

proteins.

This

process

is

gluconeogenesis, which means “formation of new sugar”. Some of the fats and fatty acids picked up by the liver cells are oxidized for  energy to make ATP for use by the liver cells themselves. The rest are broken down to simpler substances such as acetic acid and acetoacetic acid (two acetic acids linked together) and released into the blood, or stored as fat reserves in the liver. The liver also makes cholesterol and secretes cholesterol’s breakdown products in bile. All blood proteins made by the liver are built from the amino acids its cells pick up from the blood. The completed proteins are then released back into the blood to travel

35

throughout the circulation. Albumin, the most abundant protein in blood, holds fluid in the bloodstream. When insufficient albumin is present in blood, fluid leaves the bloodstream and accumulates in the tissue spaces, causing edema. The liver cells also synthesize nonessential amino acids and detoxify ammonia (produced when amino acids are oxidized for energy) by converting into urea. The liver is responsible for important functions, including: •

Bile production and excretion

•

Excretion of bilirubin, cholesterol, hormones, and drugs

•

Metabolism of fats, proteins, and carbohydrates

•

Enzyme activation

•

Storage of glycogen, vitamins, and minerals

•

Synthesis of plasma proteins, such as albumin and globulin, and clotting factors

•

Blood detoxification and purification The liver synthesizes and transports bile pigments and bile salts that are needed

for fat digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol, bilirubin, phospholipids, potassium, sodium, and chloride. Primary bile acids are produced from cholesterol. When bile acids are converted or "conjugated" in the liver, they become bile salts. Bilirubin is the main bile pigment that is formed from the breakdown of heme in red blood cells. The broken-down heme travels to the liver, where is it secreted into the bile by the liver. Bilirubin production and excretion follow a specific pathway. When the reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble to a water-soluble form. The liver also plays a major role in excreting cholesterol, hormones, and drugs from the body. The liver plays an important role in metabolizing nutrients such as carbohydrates, proteins, and fats. The liver helps metabolize carbohydrates in three ways: •

Through the process of glycogenesis, glucose, fructose, and galactose

are converted to glycogen and stored in the liver. 36

•

Through the process of glycogenolysis, the liver breaks down stored

glycogen to maintain blood glucose levels when there is a decrease in carbohydrate intake. •

Through the process of gluconeogenesis, the liver synthesizes glucose

from proteins or fats to maintain blood glucose levels. The liver synthesizes about 50 grams of protein each day, primarily in the form of  albumin. Liver cells also chemically convert amino acids to produce ketoacids and ammonia, from which urea is formed and excreted in the urine. Digested fat is converted in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins. These substances are converted in the liver into glycerol and fatty acids, through a process known as ketogenesis. Prothrombin and fibrinogen, substances needed to help blood coagulate, are both produced by the liver. The liver also produces the anticoagulant heparin and releases vasopressor substances after hemorrhage. Liver cells protect the body from toxic injury by detoxifying potentially harmful substances. By making toxic substances more water soluble, they can be excreted from the body in the urine. The liver also has an important role in vitamin storage. High concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's vitamin A stores are concentrated in the liver. The liver also contains small amounts of  Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.

PANCREAS

The hormones administered by the pancreas are responsible for controlling and manipulating blood glucose levels. The pancreas houses islets responsible for  production and secretion of the hormones, glucagon and insulin. Because of this, the pancreas falls under both the endocrine glandular system as well as the exocrine glandular system. The islets which produce these hormones are semi scattered throughout the pancreas and are known as the islets of Langerhans. These particular  endocrine functioning structures are typically able to be located in the body and along the tail of the pancreas. Alpha cells and Beta cells are the cells that are known to secrete 37

the hormones within the islets. Glucagon is administered from the Alpha cells and insulin comes from the Beta cells. Gulcagon has an affect on insulin by providing the appropriate stimulus for the liver to convert glycogen into glucose. The Alpha cells are able to respond appropriately to the feedback provided and thus are able to self monitor. High blood sugar, which is also known as hypoglycemia, can be the result of continuous output of glucagon. Insulin’s function on the human physiology is opposite of its counterpart, glucagon. Insulin is designed to lower the blood sugar in the body. Insulin is the initiating factor that allows blood glucose to the necessary movement through the cell membranes. Muscular cells and adipose cells rely on this movement of glucose for their  ability to function. The glucose level within the cell drops as the glucose moves throughout the cell membrane. Insulin is also an initiating factor in the conversion of  glucose to glycogen by the cells of the muscles and liver. This action actually assists amino acids into the cells and provides the foundation for the creation of fats and proteins. When Beta cells are incapable of producing the appropriate amount of insulin, diseases

such

as

diabetes

occur.

The pancreas is rather soft, created from lobes, Measures about 6 inches long and 1 inch thick, and performs the functions of a mixed gland. Serving both endocrine functions and exocrine functions, the pancreas is serving dual systems. The islets of  Langerhans, or pancreatic islets, are the cell clusters responsible for the pancreas’ endocrine functions. Insulin and glucagon are required hormones of the bloodstream to maintain optimal homeostasis. Performing the exocrine functions requires the proper  ability to secrete pancreatic juices which aid in digestion. The pancreatic juice is created within the pancreas and immediately released into the pancreatic duct which empties into

the duodenum. The pancreas is positioned snugly up against the greater curvature of 

the stomach, which runs along the posterior wall of the abdominal cavity. It head is located close to the duodenum, which is expanded over the central body. The tail tapers off

near

the

location

of

the

spleen.

The exocrine secretion units are tucked inside the pancreatic lobules. These

38

secretion units are technically referred to as the pancreatic acini. The endocrine secretion units are found right next to the exocrine secretion units, these are referred to as pancreatic islet cells however. The pancreatic juice is secreted from the acini, and each individual acinus has only one mere layer of epithelial acinar cells which encompass

a

lumen.

Branches from the celiac plexus are responsible for the innervation of the pancreas. The innervation of the pancreas is segregated by function; the glandular  functional portion innervation

is

receives the parasympathetic innervation held

for

the

blood

vessels of

while

sympathetic

the

pancreas.

The splenic artery branches off into the pancreatic branch in order to deliver the appropriate blood supply. The splenic artery is a branch from the celiac artery. The pancreatoduodenal artery is a branch derived from the superior mesenteric artery, which also serves the pancreas; blood flow demands. Venous return is naturally through the splenic and superior mesenteric veins. These veins drain into the hepatic portal vein.

Pathophysiology Diabetes Mellitus a. Etiology: Predisposing Factors Factors

Genetic

Presence

(+)

Mechanism/Justification

Initial decrease in beta cell mass related to genetic factors responsible for beta cell differentiation or   presence of diabetogenic gene. Pancreas, similar to several

39

Age >40

Precipitating Factors Factors Over weight/Obesity

(+)

other components of the body, does not function well due to old age.

Presence

Mechanism/Justification

BMI – 21.0 (Normal) (-)

Environment stage)

(intrapartal

(-)

Virus Infection

(-)

Presence of Toxin

(-)

Decrease potassium level

serum (-)

Obese people have increased resistance to the action of insulin and impaired suppression of glucose by liver, resulting both hyperglycemia and hyperinsulinemia. 85% of all people with diabetes are obese. Initial decrease in beta cell mass related to presence of  Maternal Diabetes Mellitus during pregnancy or in uterine factors such as intrauterine growth restriction. Mumps, coxsackeivirus Nitrosamines that are found in smoked and cured meats, are related to streptozoin that is used to induce DM in experimental animals, rat poison named Vacor that induces DM when ingested by Human Low potassium level impairs release of insulin

b. Symptomatology Symptoms Polyuria urination)

Presence (excessive (+)

Polydipsia thirst)

(excessive

(+)

Polyphagia hunger)

(excessive

(+)

Blurred Vision

(+)

Mechanism/Justification Glucose exceeds the amount that can be reabsorbed by renal tubules this results glycosuria. Excess glucose in the blood pulls water out of the cell causing intracellular   dehydration, including those in thirst center. Results from depleation of  cellular reserves of   carbohydrates, fats and proteins. Lens and retina are exposed

40

to hyperosmolar fluids (+) Lowered plasma volume (+) Temporary dysfunction of   peripheral sensory nerves (-) Hypergycemia and glycosuria favors growth of  yeast organisms. Decrease insulin (-) Initial loss due to depleation production/sensitivity of water, glycogen, and triglyceride store; chronic loss secondary to decrease muscle mass as amino acid are diverted to form glucose and ketone bodies. Elevated Serum The body is able to adopt ta Glucose a slow rise of blood glucose level to a greater extent than it can to a rapid rise.

Weakness and fatigue Predisposing Factors Paresthesias

Genetics Age >40 Pruritus, vaginitis, chronic

skin infections Weight loss Precipitating Environment(intrapartal)  Toxin/Virus Obesity Decrease Serum Potasium

Increased Osmolarity Often Asymptomatic due to Glucose

Polydipsia

Polyuria

Chronic elevation of  Serum Glucose

Polyphagia

Weight loss

Diabetic neuropathy

Small vessel disease

Accelerated atherosclerosis

Diabetic retinopathy

Impaired immune function

Hypertension

Symmetrical loss of sensation

Diabetic nephropathy  Numbness and  paresthesia

c. Schematic Tracing Wasting of  End-stage intrinsic muscles renal failure

Infection

Coronary artery disease

Loss of vision Increase LDL levels

Delayed wound healing

Autonomic neuropathy Impotence Diabetic foot ulceration

Dry, cracked skin

41 Charcot changes in joints

Gastroparesis

 Neurogenic  bladder 

d. Narrative Type two Diabetes Mellitus is a heterogeneous condition that describes the presence of excess serum glucose level in association with relative insulin deficiency. Type 2 Diabetes is associated with high, normal, low insulin levels. However there is a presence of insulin resistance thus the insulin cannot function effectively and hyperglycemia will occur. Most people with this type of diabetes are older and obese, but type 2 Diabetes is becoming a more common occurrence in obese adolescent. The metabolic abnormalities that contribute in hyperglycemia in people with type 2 diabetes are

42

impaired beta cell function and insulin production, peripheral insulin resistance, and increase hepatic glucose production. Insulin is a anabolic hormone. Without insulin three major metabolic problem occur: decrease glucose uptake and utilization, increase fat and lipid mobilization and increased protein and amino acid utilization. Beta cells chronically exposed to high blood levels of glucose become progressively less efficient when responding to further glucose elevation. Insulin resistance initially produces an increase beta cell secretion of insulin as body attempt to maintain normoglycemic state. In time, however the insulin response declines because of  increasing beta cell dysfunction. This results to postprandial hyperglycemia. Eventually fasting blood glucose level also rise until frank type 2 Diabetes occurs. Cells that require insulin as carrier of glucose can take only 25% of glucose they require for fuel, but nerve tissues, erythrocytes, and cells of intestine, liver, kidney tubules do not require insulin for glucose transport. However, adipose tissue, along with skeletal and cardiac muscle requires insulin for glucose transport. During severe stress such as hospitalization, the body of a type 2 diabetes patient will turn fat reserves into glucose for energy production when glucose is not available. Fat and lipid metabolism cause breakdown products called ketones to form. Ketones accumulate in the blood and excreted through kidneys and lungs. Ketones interfere with the body’s acid base balance by producing Hydrogen ions. The pH can decrease, and metabolic acidosis can result. In addition when ketone is excreted in urine, sodium is also eliminated, causing sodium depletion and further acidosis. The excretion of ketone also increases osmotic pressure, leading to increase fluid loss. In this type of Diabetes Mellitus the onset of clinical manifestation may develop gradually that clients may notice a few or no clinical manifestations for a number of year. Some of the manifestations are frequency in urination, increase thirst or fluid intake, and as the disease progresses, weight loss despite hunger and increased food intake. Clients with diabetes mellitus are living longer, with an increased risk for  development of chronic complications. Chronic complication are the major cause of  morbidity and mortality in client with diabetes mellitus. Diabetes mellitus-related complications are classified into two types: macrovascular, including coronary artery diseases, cerebrovascular disease, hypertension, peripheral vascular disease and infection; and microvascular, including retinopathy, nephropathy, and neuropathy.

43

The very-low density lipoprotein and low density lipoprotein level are increased and high density lipoproteins are decreased, and the most characteristic of lipid abnormality in diabetes mellitus is an increase triglyceride level. Therefore the influence of diabetes in these disease are not additive, it is multiplicative. Macrovascular disease tends to occur year before the onset of clinical diabetes mellitus. Clients with DM are two to four times more likely to have coronary artery disease than those who do not have DM. In many clients with DM, often presents atypical or  silent CAD, that often presents as indgestion, or unexplained heart failure, dyspnea or  excretions, or epigastric pain. CAD is common in clients younger than 40 years old, of  diabetes mellitus is of long duration. DM patients with history of myocardial infarction have higher chance of having second infarct than the patient who does not have DM. The incidence of cerebrovascular disease is two to three times greater in diabetic client, and is more severe. Atherothromboembolic infarction manifested by transient ischemic attracts and cerebrovascular accidents are the most commont incidence of CVD that are the complication of DM. Hypertension has increased of 40% occurrence in diabetic population. Hypertension is a major risk factor for stroke and nephropathy. Diabetis mellitus augments the process of atherosclerosclerosis by variety of  mechanism thus causing peripheral vascular disease. Hyperglycemia and insulin resistance contribute to endothelial dysfunction by decreasing available nitric oxide bioavailability and altering the function of various cell mediators. Clients with diabetes are susceptible to different type of infection. Three factors may contribute to the development of infection are impaired polymorphonuclear-leukocyte function, diabetic nephropathies and vascular insufficiencies. Damaged area heals slowly because the damaged vascular system cannot carry sufficient amount of oxygen, white blood cells, nutrients and antibodies to the injured site. Infection increases the need for insulin and enhances the possibility of ketoacidosis. Urinary tract infection is the most

common

infection

especially

in

women.

Factors

that

impairs

the

polymorphonuclear-leukocyte is the presence of glycosuria and the development of  neurogenic bladder, which results in incomplete emptying and or urinary stasis. About 80% of clients with DM have some form of retinopathy, the exact cause of  retinopathy is not understood but it is probably a multifactorial and associated with protein glycosylation, ischemia, and hemodynamics mechanism that increases the permeability and decreases the elasticity of capillaries.

44

About 20% of diagnosed DM type 2 patients have nephropathy 5 to 10 years after  diagnosis. A consequence of microangiopathy, nephropathy involves damage to and eventual obliteration of the capillaries that supply the glomeruli of the kidney. This damage leads to complex pathologic changes and manifestations such as intercapillary glomerolonecrosis, nephrosis, gross albuminuria and hypertension. Unsuccessful treatment of nephropathy will lead to stage 5 chronic kidney disease. Like retinopathy, diabetic nephropathy is irreversible. Neuropathy, the most common chronic complication of diabetes mellitus. Nearly 60% of diabetic patients experience it. Because nerve fibers do not have their own blood supply, they depend on diffusion of nutriens, and oxygen across membrane. When axon and dendrites do not receive nourishment their transmission of impulses becomes slow. Both temporary and permanent neurologic problem may develop. The neuropathy might be mild that causing minor inconveniences or severe that quality of life is affected. Clients might present mononeuropathy or polyneuropathy and may have motor or  sensory impairment, depending on which nerve that are involved. Mononeuropathy usually involves single or group nerves. It produces sharp, stabbing pain and is usually caused by an infarction of blood supply. Polyneuropathy also known as diffuse neuropathy, which involves both sensory and autonomic nerves. Sensory neuropathy is most common type. It is commonly assed as bilateral, symmetrical and is affecting the lower extremity. Client may describe tingling, numbness, burning, and mild to severe sensory loss, a major factor in injuries to the legs. Autonomic neuropathy affects the nerves that regulate vital functions, including the heart muscle and smooth muscles. Autonomic neuropathy involves damage to the nerves that run through a part of the peripheral nervous system. The peripheral nervous system includes the nerves used for communication to and from the brain and spinal cord (central nervous system) and all other parts of the body, including the internal organs, muscles, skin, and blood vessels. Damage to the autonomic nerves affects the function of areas connected to the problem nerve. Some of the autonomic neuropathy are: autonomic neuropathy of the pupil which interferes with pupils ability to adapt to dark because pupils dilation is inadequate; autonomic neuropathy of the cardiovascular  system is evidence by abnormal response to exercise, fixed heart maybe noted; autonomic neuropathy of gastrointestinal, client may have dysphagia, abdominal pain, nausea, vomiting, diarrhea malabsorption, post prandial hypoglycemia, constipation, or  fecal incontinence and gastroparesis. Bladder hypotonisity of neurogenic bladder is

45

common manifestation of autonomic neuropathy of genitourinary organs. In male client it can contribute to erectile dysfunction and retrograde ejaculation. Women may experience painful coitus. All of these complication can be prevented by good control of blood sugar level, exercise and diet modification.

Medical Management Legend: Red – HIGH Green - LOW

1.1 ACTUAL Date 06/26/10

Definition and Normal Range

Test Chest

X-

The chest x-ray is the

Result -The lungs show no

Interpretation and Significance Left Pleural Effusion

46

Ray

most commonly performed diagnostic xray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of  the body. X-rays are the oldest and most frequently used form of medical imaging.

definite recent evidence of active pulmonary infiltrates. -Heart is magnified. -Aortic knob is calcified. -Left costrophenic sulcu is blusted. Diaphragm and right costrophenic sulcus are intact. -Old healed fracture is appreciated in the 5th right posterior rib. -The rest of the included structure are unremarkable.

- may compress the lungs and cause collapse of the alveoli; impairing gas exchange and result to respiratory distress Atherosclerotic Aorta

- the thrombus that formed in the intimal layer of the aorta may dislodge and become an emboli and travels to the pulmonary circulation, causing pulmonary embolism and later on would result to CHF, or  travel to the systemic circulation obstructing blood flow to the peripheries causing hypotension or worse tissue necrosis. Old healed fracture left 5th posterior rib

-may become brittle as client aged. It might break again and cause injury to the underlying organs. 06/26/10

Complete Blood Count

The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of  the cellular (formed elements) of blood.

Normal Values: Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils

140-180 4.5-5.0 27-33 80-96 32-36 5-10 0.55-0.65 0.25 -0.40 0.02-0.06 0.01-0.05

Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

121 3.88

31.1 95.0 12.1 0.70 0.17 0.08

0.05 0.00 0.37

278

Decreased hemoglobin and erythrocyte

-indicates anemia. If  RBC is decreased, the hemoglobin decreases also. This means that exchange of gases between the alveoli, and the capillary beds are affected, and there will be less oxygenated blood circulating the body, and hypoxia results. This is caused by impaired production of  erythropoietin by the kidney. Eythropoietin stimulates the bone marrow to produce blood products especially RBC. Increased Leukocytes

47

Basophils Hematocrit Platelelt

-Increase in number  indicates infection or  damage caused by bacteria, viruses, etc. The patient is diagnosed to have UTI, specifically cystitis.

0.000-0..005 0.40-0.48 150-300

Increased Neutrophils

-Also indicates infection. Neutrophils are avid phagocytes at sites of  acute infection. Decreased Lymphocytes

-Patient is prone to immunosupression since his lymphocytes are small in number. Lymphocytes play an important role in immune response (B and T lymphocytes). Increased Monocytes

-Indicates chronic infection. Monocytes are active phagocytes that become macrophages in the tissues. They are called the long-term clean-up team. Decreased Hematocrit

-Hemodilution or there is decreased concentration of RBC in the blood. Plasma volume is increased because of  fluid shifting. For 06/28/10:

06/28/10

Same results + Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

107 3.46

31.0 94.7 32.8 15.5 0.70 0.16 0.08

High Platelet -Risk for 

coagulation/clotting, and may lead to arteriosclerosis due to thrombus formation.

0.05 0.01 0.37 322

For 07/02/10:

48

07/02/10 Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

06/26/10

06/26/10

07/01/10

Urine Culture and Sensitivity

A urine specimen is collected tested for growth of microorganisms. Antibiotics are also tested if the discovered microbe is sensitive to the drug.

Serum Electrolytes

Tests that measure the concentration of  electrolytes are needed for both the diagnosis and management of renal, endocrine, acid-base, water balance, and many other conditions. Their  importance lies in part with the serious consequences that follow from the relatively small changes that diseases or  abnormal conditions may cause.

07/02/10 Normal: Creatinine Albumin Sodium Potassium Calcium Magnesium Alanine Aminotransfe rase

53-115 34-50 136-145 3.5-5.1 2.12-2.52 0.79-0.99 30-65

94 3.10

30.4 91.8 33.1

-Number of monocytes normalized.

12.6 0.78 0.13

0.05 0.04 0.00 0.28 466

Multiple Growth of  Microorganisms

Creatinine Albumin Sodium Potassium Calcium Magnesium Alanine Aminotransfe rase

Same results with the first two tests except:

272.8 17 126

4.7 1.81

0.87 37

Creatinine Albumin Sodium Potassium Calcium

359.6 25 131

Creatinine Sodium Potassium

389.0 131

4.0 2.06

4.2

-Result proves infection

of the urinary tract (cystitis).

-Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. Creatinine reflects glomeruli filtration rate. Some signs and symptoms of kidney dysfunction include: Fatigue, lack of  • concentration, poor  appetite, or trouble sleeping Swelling or  • puffiness, particularly around the eyes or in the face, wrists, abdomen, thighs or  ankles Urine that is • foamy, bloody, or  coffee-colored A decrease in the • amount of urine Problems • urinating, such as a burning feeling or  abnormal discharge during urination, or a change in the frequency of urination, especially at night Mid-back pain • (flank), below the ribs, near where the kidneys are located High blood • pressure

49

-Low sodium affects the neuromuscular function and water-electrolyte balance in the body. - On the cellular level,

calcium is used to regulate the permeability and electrical properties of  biological membranes (such as cell walls), which in turn control muscle and nerve functions, glandular  secretions, and blood vessel dilation and contraction. Ca deficiency can make the muscles or tissues spastic, therefore contractility is impaired. -Renal kidney dysfunction can cause hypoalbuminemia, since more albumin is excreted in the urine. Ascites, muscle weakness, and fatigue can be brought about by low albumin in the blood. 06/27/10

Urinalysis

Tests for specific gravity (urine concentration or the amount of solutes present in the urine), and presence of abnormal constituents such as pus cells, glucose, protein, and RBC. Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine. Normal: Color Appearance Reaction Specific gravity

Straw, amber  Transpare nt 4.5 - 8 1.0101.025

Color Appearance Reaction Specific gravity Chemical Characteristics Pus Cells RBC

Yellow Cloudy 6.0 1.00 Alb- trace Sugar-+++ 20-30 1-2

-Urine is not concentrated since color  is not dark. Cloudy urine indicates presence of  WBC, bacteria, pus, contaminants, or  prostatic fluid. Glycosuria indicates high blood glucose levels and maybe indicative of  uncontrolled DM. Hematuria can be caused by irritation or  injury to endothelial wall of the ureters Proteinuria indicates kidney damage. There is an increased pus cells which means infection is present.

50

Chemical Characterist ics Pus Cells RBC

06/26/10

ABG Test

Alb- absent Sugarabsent 1-5 hpf   none

The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level.

pH PCO2 PO2 HCO3 TCO2 BE O2 Sat

7.37 67 acidosis

83 15 acidosis 16 -8.3

96%

Normal Values: pH PCO2 PO2 HCO3 TCO2 BE O2 Sat

7.35-7.45 35-45 80-100 22-26 25-30 +/-1 95-100%

pH PCO2 PO2 HCO3 TCO2 BE O2 Sat

06/27/10

06/28/10

Lipoprotein Profile with Glucose and Uric Acid

The lipid profile is a group of  tests that are often ordered together to determine risk of coronary heart disease. They are tests that have been shown to be good indicators of whether  someone is likely to have a heart attack or stroke caused by blockage of blood vessels or  hardening of the arteries

Cholesterol LDL TGL HDL Glucose Uric Acid

7.385 27.9 alkalosis

-A high PaCO2 (respiratory acidosis) indicates underventilation. Carbon dioxide is produced constantly as the body burns energy, and this CO2 will accumulate rapidly if the lungs do not adequately dispel it through alveolar ventilati on. Alveolar  hypoventilation thus leads to an increased PaCO2 (called hypercapnia). The increase in PaCO2in turn decreases the HCO3−/PaCO2 ratio and decreases pH. -A low HCO2 indicates metabolic acidosis which is a condition that occurs when the body produces too much acid or when the kidneys are not removing enough acid from the body. Fully Compensated Metabolic Acidosis

79.8 16.3 acidosis 17.2 -6.8

95.6% 4.0 3.0 1.35 0.40 6.7

0.31

-There is very little high density lipoprotein or  good cholesterol which implies that there is lesser chance for the remaining HDL to remove more cholesterol from atheromas within the arteris and transport it back to the liver for  excretion or re-utilization.

51

(atherosclerois). Normal Values: Cholesterol LDL TGL HDL Glucose Uric Acid

06/28/10

Ferritin Test

0.0-5.2 0.0-3.4 0.00-1.70 0.90-1.55 3.9-6.1 0.16-0.43

The ferritin test is ordered to assess a person's iron stores in the body. The test is sometimes ordered along with an iron test and a TIBC to detect the presence and evaluate the severity of an iron deficiency or overload. Ferritin is a protein that releases iron in a controlled fashion.

Ferritin = 1021.71 ng/mL

If there is damage in the liver (where ferritin is stored), ferritin levels can become elevated because liver’s function is affected. Also, low iron or hemoglobin coupled with increase ferritin production is a sign of a chronic illness.

Left Kidney Right Kidney 11.3 11.1 Length 4.0 4.7 Width

-No significant disparity in size, shape and location of the kidneys and both show intact central echocomplexes of both renal corticomedullary differentiation. -There is an increase in the echogenecity of both renal cortices relative to the liver and spleen. -No focal lesions. -Ureters are not dilated. -Urinary bladder distends adequately. -Has smooth thickened walls with trabeculations. -Prostate gland measures: 40mm x 47 mm x 26 mm, 26 grams. -Pre void urine volume is about 437 cc. -Post void scan shows 76% (333 cc) residual urine.

Normal Values: Men: 68-236 ng/mL Women: 9.3-58 ng/mL

06/28/10

KUB/Prost ate USD

It is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. Normal Size in cm: Left Kidney Right 10.8 +- Length 0.8 4.2 + Width -0.5 4.8 +Thick 0.5 1.5 C. Thick

Kidney 9.7 +0.7 4.3 +0.5 3.9 +0.5 1.5

4.6 1.8

Thick C. Thick

4.9 1.6

Impression: -Diffuse Bilateral Renal

Parenchymal Disease -Cystitis

52

-Grade 1 Prostatic Enlargement -Ultrasonographically normal ureters -Significant urinary bladder retention 07/2/10

Arterial Duplex Scan

Arterial duplex scan is a painless exam that uses high-frequency sound waves (ultrasound) to capture internal images of  the major arteries in the arms, legs and neck.

-Intimal irregularities with occasional type III and V plaques in the bilateral popliteal arteries with normal triphasic waveform pattern with full color except the bilateral posterior tibialis arteries and bilateral dorsalis pedis arteries with monophasic waveform patterns. -No focal increase in flow velocities noted.

Peripheral Arterial Disease >50% stenosis bilateral posterior tibilais arteries & bilateral dorsalis pedis arteries. Peripheral arterial disease <50% stenosis bilateral common femoral arteries, bilateral superficial femoral arteries, bilateral popliteal arteries. Incomprehensive arteries bilaterally

07/02/10

Creatinine Clearance Test

07/04/10

A creatinine clearance test Crea: 1.53 q/24 hr  measures how well creatinine is removed from your blood by your  kidneys. A creatinine clearance test gives better  Crea: 14.1 mg/dL information than a blood creatinine test on how well your kidneys are working. A creatinine clearance test is done on both a blood sample and on a sample of urine collected over 24 hours (24-hour urine sample).

Creatinine in the 24 hr  urine sample falls between the normal range. Due to impaired kidney function, creatinine in the blood elevates.

Normal Values: 24 hr urine: 0.6-1.6 q/24 h Blood: 0.8-1.4 mg/dL

1.2 POSSIBLE

Test

Rationale

Uric Acid Test

The patient has been complaining of  pain in the pelvic area. Since he has

Result (Normal Values)

Interpretation and Significance

Male: mg/dL

High uric acid level indicates impaired GFR and destruction of RBC

2.1-8.5

Female: 2.0-7.0

Nursing Responsibilities Evaluate or  continuously monitor  degree of joint •

53

CKD, his kidneys might have broken down purine (protein) rather very fast causing accumulation to the  joints. It has to be checked to know if  the patient is suffering from gout, Some patients with high levels of uric acid have a disease called gout, which is an inherited disorder  that affects purine breakdown. Patients with gout suffer from  joint pain, most often in their toes but in other joints as well.

mg/dL

to purine.

inflammation or pain. ® Level of activity  or exercise depends on  progression and  resolution of  inflammatory process.

Maintain bed rest or chair rest when indicated. Schedule activities providing frequent rest periods and uninterrupted night time sleep. ® Systemic rest during  •

acute attacks and  important throughout all   phases of disease to reduce fatigue and  improve strength.

Encourage adequate fluid intake. ® To assist with •

excretion of uric acid  and  decrease likelihood of  stone formation.

Assist with active or  passive range of motion. ® Maintains or improves •

 joint function, muscle strength, and general  stamina.

Encourage patient to maintain upright and erect posture when sitting, standing, or  walking. ® Maximizes joint  •

function, maintains mobility.

Encourage the patient to avoid alcohol. ® Alcohol precipitates •

acute attacks.

Review foods that are rich in purines like sardines, anchovies, shell fish and organ meats. ® These foods are rich •

in purine. Uric acid is by   product of purine metabolism in the liver.

Provide safety needs. ® Prevents injuries and  •

54

falls.

Administer antiinflammatory drugs and also colchicines as prescribed. ® These medications •

relieve pain and  swelling during acute attacks.

Management Therapuetics Date

Order

Rationale

06/27/10

Venoclysis of PNSS1L to run at KVO rate.

NSS is a solution of common salt in distilled water, of strength of 0.9%. It is called normal saline because the percentage of salt resembles that of the crystalloids in the blood plasma. It is an isotonic solution. It is less irritating for  the body cells. It is used to patients with salt and water deprivation. KVO rate is ordered for prophylactic access.

06/27/10

I & O q shift and VS q 4

This measures how much fluids are taken and how much has been excreted. This also indicates any problem in the kidneys. Vital signs are done every 4 hours to monitor the client’s well being such as temperature which is indicative of hyperthermia.

O6/27/10

Calibrated diabetic diet

Diet for diabetic patients must be accurately weighed or gauged. Too many carbohydrates mean too much glucose; too much protein and fats may overwork the liver and kidneys.

06/27/10

Increase oral fluid intake

To minimize formation of crystals in the urine.

06/27/10

Lipid profile, CBC, serum uric acid, KOH and urine culture

These laboratory tests measures the body chemistry such lipoproteins, blood products, nitrogenous wastes, and presence of infection in the urinary system.

55

06/27/10

Doppler scan the left extremity

To determine adequate blood flow in the extremities and to rule out any obstruction.

06/27/10

Weighing once a day

To monitor any weight gain due to edema or increased extra-cellular fluid.

06/27/10

Nebulization q 6 with Berodual

Berodual is a bronchodilating and anticholinergic agent which gives of  parasympatholytic effects. It relieves bronchospasms.

06/27/10

Hgt q 6

To monitor any fluctuations in the blood glucose levels and evaluate effectiveness of insulin taking.

06/28/10

IVF rate to 60 cc/hr

06/30/10

Moderate high back rest

06/30/10

Abdominal girth measurement

07/04/10

Physical therapy session 3x

07/05/10

Insertion of foley catheter

To relieve urinary retention

07/07/10

Removal of foley catheter

For discharge

To combat dehydration. Promotes thoracic facilities breathing.

expansion

and

Measures extent of ascites Promotes well being of an elderly client; facilitates fast recovery

Drug Study

Domperidone

Motilium (1 tab, 100 mg) Classification: Anti-emetic and anti-vertigo

56

Desired Dosage and Directions for use: Acute conditions (mainly nausea, vomiting, hiccup)  Adults: Two tablets (20 mg) 3 to 4 times per day, 15 to 30 minutes before meals and, if 

necessary, before retiring. Chronic conditions (mainly dyspepsia) Adults: One tablet (10 mg) taken 3 times per day,

15 to 30 minutes before meals and, if necessary, before retiring. The dosage may be doubled. Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the dopamine-receptors in the chemo-emetic trigger zone produces an anti-emetic effect. Interactions: •

Concomitant administration of anti-cholinergic drugs may inhibit the antidyspeptic effects of MOTILIUM.

•

Anti-muscarinic agents and opioid analgesics may antagonize the effect of  MOTILIUM

•

MOTILIUM suppresses the peripheral effects (digestive disorders, nausea and vomiting) of dopaminergic agonists.

•

Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of  concomitant orally administered medicines, particularly those with sustained release or enteric coated formulations.

•

As MOTILIUM interferes with serum prolactin levels, it may interfere with other  hypoprolactinaemic agents and with some diagnostic tests.

•

Antacids and anti-secretory agents lower the oral bioavailability of domperidone. They should be taken after meals and not before meals, i.e. they should not be taken simultaneously with MOTILIUM.

•

Reduced

gastric

acidity

impairs

the

absorption

of

domperidone.

Oral bioavailability is decreased by prior administration of cimetidine or sodium bicarbonate Side Effects: •

Allergic reactions, such as rash or urticaria, have been reported.

•

Abdominal cramps have been reported.

•

Dystonic reactions (extrapyramidal phenomena) may occur.

•

Reversible raised serum prolactin levels have been observed which may lead to galactorrhoea and gynaecomastia.

57

•

Hypertensive crises in patients with phaeochromocytoma may occur with administration of domperidone.

•

Where the blood brain barrier is not fully developed (mainly in young babies) or is impaired, the possible occurrence of neurological side-effects cannot be totally excluded

Nursing Responsibilities: 1. Assess for extra-pyramidal effects such as jerking and tongue pr otrusion. 2. Check for hypotension. Imdur 

Durule (60 mg ½ tab OD @ HS) Classification: Anti-anginal Desired Dosage: 60 mg once daily in the morning, may be increased

to

120

mg

daily

in

the

morning.

If headache occurs, the dose may initially be reduced to 30 mg daily for the 1st 2-4 days. Mode of Action: The principal pharmacological action of isosorbide-5-mononitrate, an active metabolite of isosorbide dinitrate, is relaxation of the vascular smooth muscle, producing vasodilatation of both arteries and veins, with the latter effect predominating. The effect of the treatment is dependent of the dose. Low plasma concentrations lead to venous dilatation, resulting in peripheral pooling of blood, decreased venous return and reduction in left ventricular end-diastolic pressure (preload). High plasma concentrations also dilate the arteries reducing systemic vascular resistance and arterial pressure leading to a reduction in cardiac afterload. Isosorbide-5-mononitrate may also have a direct dilating effect on the coronary arteries. By reducing the end-diastolic pressure and volume, the preparation lowers the intramural pressure, thereby leading to an improvement in the sub-endocardial blood flow. The net effect when administering isosorbide-5-mononitrate is therefore a reduced workload of the heart and an improved oxygen supply/demand balance in the myocardium. Interactions: Concomitant administration of Imdur and phosphodiesterase type 5 inhibitors can potentiate the vasodilatory effect of Imdur with the potential results of  serious side effects as syncope or myocardial infarction. Side Effects:

58

•

Most of the adverse reactions are pharmacodynamically mediated and dose dependent. Headache may occur when treatment is initiated, but usually disappears during continued treatment.

•

Hypotension with symptoms eg, dizziness and nausea with syncope in isolated cases, has occasionally been reported. These symptoms generally disappear  during continued treatment.

•

Cardiovascular System: Common: Hypotension, tachycardia

•

Central Nervous System: Common: Headache, dizziness. Rare: Fainting.

•

Gastrointestinal: Common: Nausea. Uncommon: Vomiting, diarrhea.

•

Musculoskeletal: Very Rare: Myalgia.

•

Skin: Rare: Rash, pruritus.

Nursing Responsibilities: 1. Check for hypotension. 2. Put patient on bed rest because of fainting. Provide supervision when ambulating. 3. Perform nonpharmacologic measures for nausea and vomiting such as letting client to drink weak tea, Gatorade, carbonated beverages, pedialyte and eat gelatin, crackers and dry toast. Calcium Carbonate

(1 tab tid) Classification: Electrolyte replacement or  supplements. Antacid Desired Dosage: 500 mg (200 mg Ca), 600 mg (240 mg Ca), 650 mg (260 mg Ca), 667 mg (266.8 mg Ca), 1 g (400 mg Ca), 1.25 mg (500 mg Ca), 1.5 mg (600 mg Ca) Mode of Action: Essential for nervous, muscular, and skeletal systems. Maintain cell membrane and capillary permeability. Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscles. It is essential for  bone formation and blood coagulation. It is also used a replacement of calcium in deficiency states. It controls of hyperphosphatemia in end-stage renal disease without promoting aluminum absorption.

59

Interactions: Hypercalcemia increases the risk of digoxin toxicity. Chronic use with antacids in renal insufficiency may lead to milk-alkali syndrome. Ingestion by mouth may decrease the absorption of orally administered tetracyclines, fluoroquinolones, phenytoin, and iron salts. Excessive amounts may decrease the effects of calcium channel blockers, atenolol. Concurrent use with diuretics may result in hypercalcemia. Side Effects: •

CNS: syncope, tingling

•

CV: cardiac arrest, arrythmias, bradycardia

•

GI: constipation, nausea, vomting

•

GU: calculi, hypercalciuruia

•

Local: phlebitis (IV only)

Nursing Responsibilities: 1. Monitor VS especially BP and PR. 2. Obtain ECG result. 3. Asses for heartburn, indigestion, abdominal pain. 4. Monitor serum calcium before treatment. 5. Assess for nausea and vomiting, anorexia, thirst, severe constipation.

Metoprolol

Beloc, Betaloc Durules, Lopresor, Metoprol (100 mg 1 tab q 12 hrs) Classification: Anti-anginal and Anti-hypertensive: Beta-blockers

Desired Dosage: (PO) 25-100 mg/day as a single dose initially divided or 2 divided doses; maybe increased q 7 days as needed up to 450 mg/day. Mode of Action: Blocks stimulation of beta1 (myocardial)-adrenergic receptors. It does not usually affect beta2 (pulmonary, vascular, uterine)-adrenergic receptor sites. It also decreases blood pressure and heart rate. It decreases frequency of attacks of angina

60

pectoris, and decreases rate of cardiovascular mortality and hospitalization in patients with heart failure. Interaction: •

Additive effect with catecholamine-depleting drugs e.g. reserpine and MAOIs.

•

May antagonise β1-adrenergic stimulating effects of sympathomimetics.

•

Additive negative effects on SA or AV nodal conduction with cardiac glycosides, nondihydropyridine calcium-channel blockers.

•

Increased oral bioavailability with aluminium/magnesium-containing antacids.

•

Paradoxical

response

concentrations

to

epinephrine

may

with

occur.

Increased

CYP2D6

plasma inhibitors

(e.g. bupropion, cimetidine,diphenhydramine, fluoxetine, hydroxycholoquine, paroxetine, propafenone, quinidine,ritonavir , terbinafine, thioridazine). •

Increased risk of hypotension and heart failure with myocardial depressant general anaesthetics (e.g. diethyl ether).

•

Risk of pulmonary hypertension with vasodilators e.g. hydralazine in uraemic patients.

•

Reduced plasma levels with rifampicin.

•

May increase negative inotropic and negative dromotropic effect of antiarrhythmic drugs e.g. quinidine and amiodarone.

•

Propafenone may increase serum levels of metoprolol.

•

Concurrent use with indomethacin may reduce the antihypertensive efficacy of βblocker.

•

May reduce clearance of lidocaine.

•

May increase effects of hypoglycemics.

•

Efficacy may be reduced by isoprenaline.

•

Concurrent use with digoxin may lead to additive bradycardia.

Nursing Responsibilities: 1. Monitor blood pressure, and pulse frequently.

61

2. Monitor intake and output ratios and daily weight. 3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight gain, peripheral edema, jugular venous distention) 4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold medication and notify health care professional. 5. Administer metoprolol with meals or directly after eating. 6. Caution patient minimize activities that require alertness because metoprolol can cause dizziness. 7. Caution patient that this medication can increase sensitivity to cold. 8. Instruct to avoid caffeinated drinks like teas and colas. 9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue occurs. 10. Reinforce the need to continue additional therapies for hypertension such as sodium restriction, stress reduction, regular exercise) 11. Emphasize compliance to the medication.

Prednisone

Sterapred (5000 u 2x/week SC) Classification:

Systemic

corticosteroids,

anti-

asthmatics Desired Dosage: (PO) 5-60 mg/day as single dose or in divided doses. Mode of Action: It suppresses inflammation and the normal immune response. Prednisone is biologically inert and converted to the predominantly prednisolone in the

62

liver. It decreases inflammation by suppression of migration of polymorphonuclear  leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and vol of the lymphatic system; suppresses adrenal function at high doses. Interaction: •

Increase risk of hypokalemia with thiazide and loop diuretics, or amphotericin B.

•

May increase requirement for insulin or oral hypoglycemic agents.

•

Pheytoin, Phenobarbital, and rifampin increase metabolism; may decrease effectiveness.

•

At chronic cases, may decrease antibody response to and increase risk of  adverse reactions from live-virus vaccines.

•

Antacids decrease absorption of it.

•

Increase risk of GI ulceration with NSAIDs.

Side Effects: •

Insomnia,

nervousness,

increased

appetite,

indigestion,

dizziness/lightheadedness, headache, hirsutism, hypopigmentation, diabetes mellitus, glucose intolerance, hyperglycaemia, arthralgia, cataracts, glaucoma, epistaxis, diaphoresis, Cushing's syndrome, edema, fractures, hallucinations, hypertension, muscle-wasting, osteoporosis, pancreatitis, pituitary-adrenal axis suppression, seizures Nursing Responsibilities. 1. Assess for adverse effects 2. Implement safety measures to prevent falls and fractures. 3. Monitor clients with diabetes for hyperglycemia. 4. Assess for fluid and electrolyte imbalance. 5. Assess stools for melena. 6. Administer with food to minimize gastric irritation.

63

7. Instruct to avoid people with active infection because resistance is low. 8. Instruct to avoid activities that could cause bone fracture. 9. Not to take NSAIDs unless directed. 10. Increase intake of protein, calcium, and potassium.

Albumin 25%

Albuminar, Albutein, Buminate, Normal Human Serum Albumin, Plasbumin (50cc + Furosemide 20 mg x 4 to OD) Classification: Volume expanders, blood products, colloids Desired Dosage: (IV) 12.5-50 g/day in 3-4 divided doses. (Availability Injection: 250 mg/mL) Mode of Action: It provides colloidal oncotic pressure, which serves to mobilize fluid from extravascular tissues back into intravascular space. It increases intravascular fluid volume. Interactions: Do not mix with protein hydrolysates, amino acid solution and alcohol. Side Effects: •

CNS: Headache

•

CV: Pulmonary edema, fluid overload, hypertension, hypotension, tachycardia

•

GI: Vomiting, increased salivation, nausea

•

Derm: Rash, urticaria

•

MS: Back pain

•

Chills, fever, flushing

Nursing Responsibilities: 1. Monitor vital signs, and intake and output.

64

2. Assess for signs of vascular overload such as elevated CVD, rales/crackles, dyspnea, hypertension, jugular venous distention) during and after administration. 3. Monitor serum sodium levels because it may cause increase concentrations. 4. Solution should be clear amber, and do not administer solutions that are discolored or  contain particulate matter.

Sodium Bicarbonate

Baking Soda, Bell-Ans, Citrocarbonate, Neut, Soda Mint (650 mg 1 tab tid) Classification: Anti-ulcer agent and alkalinizing agent Desired Dosage: Alkalinization of urine: (PO) 48 mEq or 4 g initially. Then 1-2 g q4 hr or  1 tsp of powder q4 hr as needed. Metabolic acidosis: >4.8 g/day as needed. Mode of Action: Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to alkalinize urine and promote excretion of certain drugs in overdosage situations. Interactions: Increase toxicity of amphetamins, ephedrine, pseudoephedrine, flecainide, quinidine and quinine. It decreases effects of lithium, chlorpropamide and salicylates due to increased clearance. It may affect the absorption of certain drugs due to raised intragastric pH. Side Effects: Metabolic alkalosis; mood changes, tiredness, shortness of breath, muscle weakness, irregular heartbeat; muscle hypertonicity, twitching, tetany; hypernatraemia, hyperosmolality, hypocalcaemia, hypokalaemia; stomach cramps, flatulence. Nursing Responsibilities: 1. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea, hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered breathing pattern), hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed

65

skin, mental irritability), or hypokalemia (weakness, fatigue, arrhythmias, polyuria, polydypsia) 2. Assess fluid balance (intake and output, daily weight, edema, lung sounds) 3. Take med with full glass of water. 4. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance, and renal function prior to and periodically through out the therapy.

Clonazepam

Rivotril (1/4 tab daily) Classification: Anticonvulsant Desired Dosage: 0.5 mg 3x daily Mode of Action: It produces sedative effects in the CNS, probably by stimulating inhibitory GABA receptors. It prevents seizures and decreases manifestations of panic disorder. Interactions: •

CNS

depression

with

alcohol,

antidepressants,

antihistamines,

other 

benzodiazepines, and opioid analgesics. •

Cimetidine,

hormonal

contraceptives,

disulfiram,

fluoxetine,

isoniazid,

ketoconazole, metoprolol, propoxyphene, propanolol, or valproic acid may decrease metabolism of clonazepam. •

Sedative effects with theophylline.

Side Effects: Fatigue, somnolence, muscular hypotonia, coordination disturbances, aggressiveness, irritability or agitation. Nursing Responsibilities:

66

1. Assess for drowsiness, unsteadiness, and clumsiness. These symptoms are dose related and most sever during initial therapy. 2. Administer with food to minimize gastric irritation. 3. Have CBC and liver function test results evaluated periodically because it may cause increase in serum bilirubin, AST and ALT.

Epoetin B

Recormon (5000 u SC) Classification: Hematopoeitic Agent Desired Dosage: 50-100 u/kg 3x weekly initially, then adjust dose base on Hct.

 Anemia w/ CRF: Correction phase SC inj Initially, 3 x 20 iu/kg/wk, may be increased every 4 wk by 3 x 20 iu/kg/wk if the increase of packed cell vol (PCV) is inadequate (< 0.5% per wk). Wkly dose can be divided into daily doses or administered as a single dose. Max: 720 iu/kg/wk. IV inj Initially, 3 x 40 iu/kg/wk. Dose may be increased after 4 wk to 3 x 80 iu/kg/wk. If further increments are needed, increase at 20 iu/kg 3 times wkly at mthly intervals. Max: 720 iu/kg/wk.

Maintenance phase In SC inj, to maintain a PCV of 30-35%, initially reduce to ½ of the previously administered amount. Subsequently, adjust dose at 1-2 wk intervals individually for the patient. Patient stable on a once-wkly dosing regimen may be switched to once every 2 wk administration.

Prevention of anaemia of prematurity SC inj 3 x 250 iu/kg/wk for 6 wk. Increasing the amount of autologous blood SC or IV inj Twice wkly over 4 wk. Max IV Dose: 1,600 iu/kg/wk. Max SC Dose: 1,200 iu/kg/wk.

67

Symptomatic anaemia in cancer SC inj 1 inj/wk or 3-7 divided doses/wk. Recommended Dose: Initially, 30,000 iu/wk (approx 450 iu/kg body wt/wk based on ave wt). Treatment is indicated if haemoglobin value is ≤11 g/dL (6.83 mmol/L), should not exceed 13 g/dL (8.07 mmol/L). After 4 wk therapy, if haemoglobin value increased by at least 1 g/dL (0.62 mmol/L), continue therapy; if not, double the wkly dose. After 8 wk, if  value has not increased by at least 1 g/dL, discontinue therapy. After the end of  chemotherapy, continue therapy up to 4 wk. Max: ≤60,000 iu/wk. When therapeutic objective has been achieved, reduce dose by 25-50% to maintain haemoglobin at that level, may reduce further to ensure haemoglobin level does not exceed 13 g/dL. If >2 g/dL (1.3 mmol/L) haemoglobin rise in 4 wk, reduce dose by 25-50%. Mode of Action: Epoetin beta is identical in its amino acid and carbohydrate composition to erythropoietin that has been isolated from the urine of anemic patients. Erythropoietin is a glycoprotein that stimulates the formation of erythrocytes from precursors of the stem cell compartment. It acts as a mitosis-stimulating factor and differentiation hormone. After administration of epoetin beta, the number of erythrocytes, the Hb values and reticulocyte counts increase as well as the

59

Fe-incorporation rate. An increased 3H-

thymidine incorporation in the erythroid-nucleated spleen cells has been found in vitro (mouse spleen cell culture) after incubation with epoetin beta.

Interaction: The clinical results obtained so far do not indicate any interaction of  Recormon with other substances. Incompatibilities: To avoid incompatibility or loss of  activity, do not mix with other drugs or infusion solutions. Side Effects: •

CNS: Seizures, headache

•

CV: Hypertension, thrombotic events such as MI or stroke

•

Derm: Transient rashes

Nursing Responsibilities: 1. Monitor blood pressure before and after therapy. Additional antihypertensive drug maybe required during initiation of therapy.

68

2. Monitor Hct and other hematopoietic parameters (CBC with differential and platelet count) 3. Monitor renal function studies and electrolytes closely. Increase in BUN, creatinine, uric acid, phosphorus, and potassium may occur. 4. Do not shake vial because inactivation of medication may occur. 5. Discard vial immediately after withdrawing dose from single-use 1-ml vial. Refrigerate multi-dose 2-ml vial; stable for 21 days after initial entry. 6. Stress importance of compliance with dietary restrictions, medications, and dialysis. Foods high in iron and low in potassium include liver, pork, veal, beef, mustard and turnip greens, etc…

Gabapentin

Neurontin (300 mg 1 tab @ night) Classification: Analgesic adjuncts, anticonvulsants, mood stabilizers Desired Dosage: CCr 30-60 mL/min—300 mg 2x daily; 1530 mL/min—300 mg 1x daily. Mode of Action: Mechanism of action is not known. It may affect transport of amino acids across and stabilize neuronal membranes. It can decrease incidence of seizures. Gabapentin is structurally related to the neurotransmitter GABA but is neither a GABA agonist nor antagonist. Gabapentin-binding sites have been identified throughout the brain tissues e.g. neocortex and hippocampus. However, the exact mechanism of action is still unknown. Interactions: •

Antacids may decrease absorption of gabapentin.

69

•

Increase risk of CNS depression with other CNS depressants like alcohol, antihistamines, opioids, and sedatives.

•

Morphine may increase level of gabapentin and increase risk of toxicity.

Side Effects: Somnolence, dizziness, ataxia, weakness, paraesthesia, fatigue, headache; nystagmus, diplopia; nausea, vomiting, wt gain, dyspepsia; rhinitis; tremor; leucopenia; altered LFTs; Stevens-Johnson syndrome Nursing Responsibilities: 1. Caution patient to avoid activities that require alertness to prevent injury d/t dizziness. 2. Provide supervision when patient is ambulating. 3. Monitor for side effects and instruct patient to refer if adverse effects are felt.

Sennosides

Senokot Classification: Laxative Desired Dosage: 12-50 mg 1-2x daily Mode of Action: Active components of senna (sennosides) alter water and electrolyte transport in the large intestine, resulting in accumulation of water and increased peristalsis. Interactions: May decrease absorption of other orally administered drugs because of  decreased transit time. Side Effects: •

GI: cramping, diarrhea, nausea

•

GU: pink-red or brown-black discoloration of urine

70

•

F & E: electrolyte abnormalities

•

Misc: laxative dependence

Nursing Responsibilities: 1. Asses patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. 2. Assess for color, consistency, and amount of stool produced. 3. Take with full glass of water. Ideally, administer at bedtime for evacuation 6-12 hours later. Administer on an empty stomach for a rapid result. 4. Advise patient that laxatives should be used only for short-term therapy. Long-term therapy may cause electrolyte imbalance and dependence, 5. Encourage patient to use other forms of bowel regulation such as increasing bulk in the diet, increasing fluid intake, and increasing mobility. 6. Inform that medication may cause change in his urine’s color to pink, red, violet, yellow or brown.

Berodual (neb)

Ipratropnium Br, Fenoterol HBr  Classification: Anticholinergic Indication: Acute prevention and treatment of symptoms of chronic obstructive airway disorders with

reversible

bronchospasm

(e.g.bronchial asthma schronic bronchitis with or without emphysema) Contraindication:

Hypertrophic

obstructive

cardiomayopathy,

tachyarrhythmia. Precaution: Diabetic patient with unstable metabolism, recent myocardial infarction, severe organic heart or vascular disorder; transient dose dependent doer in serum K+; hyperthyroidism; narrow-angle glaucoma; urinary outflow obstruction d/t prostatic hypertrophy.

71

Side effects: Tremor, restlessness, palpitation, tachycardia, dizziness, head ache, potentially serious hypokalemia, dryness of mouth, throat irritation, allrergic reactions, cough. Interactions: B2 adrenergics, systematically absorbed anticholinergics, xanthine derivatives and corticosteroids may increase in effect and may occur on concurrent administration of B2 blocker. Availability & Prize: UDV solution for inhalation 4ml (₱58.85) Inhalation solution 20 ml (₱932.00) Metered aerosol 10ml (₱1,253.00)

Norgesic Forte

Per norgesic tab- Ophenadrine citrate 35 mg + Paracetamol 450mg.

Per norgesic forte tab- Ophenadrine

citrate 50 mg + Paracetamol 659mg. Indication: For the relief of painful skeletal muscle spasm associated with chronic low back pain, spasms and strains, prolapsed intervertebral disc, muscle injury, non-articular  rheumatism (fibrisitis, myositis, & myalgia) whiplash injuries, tension head ache, dysmenorrhea, and other acute or chronic painful muscular condition. Dosage: Norgesic tab 1-2 tab TID. Contraindications: Glaucoma; prostatic hypertrophy or bladder neck obstruction. Precaution: Cardiac arrhythmias, tachycardia, cardiac decompensation, coronary insuffiency, pregnancy. Side effects: Nausea, dry mouth, blurred vision, rarely rash, drowsiness, dizziness, and restlessness. Prize: Norgesic Forte tab (₱21.00); Norgesic tab (₱14.00)

Cilostazol

Pletal

72

Classification: Antiplatelet Action:

Inhibits

the

enzyme

cyclic

adenosine

monophosphate

(cAMP)

phosphodiesterase III, which results in increased cAMP in platelets and blood vessels, producing inhibition of platelet aggregation and vasodilation. Indication: Reduction of symptoms of intermittent claudication allowing increased walking distance. Contraindications: Hypersensitivity, heart failure, active bleeding, hemostatic disorders. Use cautiously with renal dysfunction. Availability: 50,100 mg tablets Dosage: 100 mg po BID @ least 30 minute before or 2 hours post breakfast and dinner. Adverse effects: CNS – dizziness, head ache CV – heart failure, tachycardia, palpitations GI – diarrhea, nausea, flatulence, dyspepsia Respiratory – cough, pharyngitis, rhinitis Others – peripheral edema, infection, back pain Nursing Responsibilities: 1. Assess patient for intermittent claudication 2. Administer on an n empty stomach, 1 hour before of 2 hours post meal. 3. Do not administer with grapefruit juice. May increase cilostazol levels. 4. Caution patient to avoid driving or other activities requiring alertness. 5. Advise patient to avoid smoking; nicotine constricts blood vessels. 6. Prevent injury which may cause bleeding. - use soft bristled toothbrush. - avoid sharp objects. - instruct patient not to strain too much while defecating to avoid perforating the rectal muscle. Humulin 70/30

Insulin (mixtures) Classification: Antidiabetics, hormones Action: Lowers blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Contraindications: Hypoglycemia; allergy or hypersensitivy.

73

Precautions: In patient with real/hepatic impairment (may decrease insulin requirements) Adverse effects: Endo – Hypoglycemia Local – Erythema, lipodystrophy, pruritus, swelling Misc – Allergic reactions including anaphylaxis Drug-Drug interactions: B-blockers, clonidine and reserpine – may mask some of the signs andsymptoms of hypoglycemia. Corticosteroids, thyroid supplements, estrogens, isoniazid,niacin, phenothiazines and rifampin – increase insulin requirements. Alcohol, ACE inhibitors, MAO inhibitors, oral hypoglycemic agents and salicylates – decrease insulin requirements Availability: (100 units/ml total) in 10 ml vials and 3 ml disposable delivery devices. Nursing Interventions: 1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling in hands, feet, lips or tongue, chills, cold sweat, confusion, pale skin, difficulty in concentration, drowsiness, excessive hunger, head ache, irritability, nightmares or trouble sleeping, nausea, tachycardia, tremor, weakness, unsteady gait. 2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and dry skin, rapid deep breathing, polyuria, loss of appetite, nausea & vomiting, unusual thirst. 3. Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose. 4. Monitor blood glucose every 6 hours during therapy. 5. Note for toxicity and overdose: HYPOGLYCEMIA - let patient ingest oral glucose - if severe hypoglycemia: administer IV glucose, glucagon or epinephrine. 6.

Store insulin in refrigerator. Do not use if cloudy, discolored or unusually

viscous. 7.

Rotate site of infection.

8.

Instruct patient on proper techniques for administration.

9.

Explain to the patient that this medication controls hyperglycemia but does

not cure diabetes. 10. Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed.

74

Loperamide

Diar-aid caplets, Imodium, Imodium A-D, Kaopectate II caplets, Maalox antidiarrheal caplets, Neo-Diaral, Pepto Diarrhea control Classification: Antidiarrheals Indications: Adjunctive therapy of acute diarrhea. Chronic diarrhea associated with inflammatory bowel disease decrease the volume of ileostomy drainage. Action: Inhibits peristalsis and prolongs transit time by a direct effect on nerves in the intestinal muscle wall. Reduces fecal volume, increases fecal viscosity and bulk while diminishing loss of fluid and electrolytes. Therapeutic effects: Relief of diarrhea. Contraindications: Hypersensitivity; patients in whom constipation must be avoided; abdominal pain of unknown cause, especially if associated with fever; alcohol intolerance(liquid only). Precautions: Hepatic dysfunction Side effects: CNS – drowsiness , dizziness GI – constipation, abdominal pain/distention/discomfort, dry mouth, nausea and vomiting. Misc – allergic reactions Drug-Drug interactions: Increase CNS depression with other CNS depressants including alcohol, antihistamines, opioid analgesics, and sedatives. Increase anticholinergic properties

with

the

other

drugs

having

anticholinergic

properties

including

antidepressants and antihistamines. Nursing Management: 1. Assess frequency and consistency of stools and bowel sounds prior to and during therapy. 2. Assess skin turgor for dehydration. 3. Administer with clear fluids to help prevent dehydration which may accompany diarrhea. 4. Instruct patient to take medication as directed. In acute diarrhea, medication may be ordered after each unformed stool.

75

5. Advise patient that frequent mouth rinses and good oral hygiene may relieve dry mouth. 6. Instruct patient to notify health care professional if diarrhea persist or if fever, abdominal pain, or distention occurs. Furosemide

Novosimide; PMS-Furosimide Classification: Loop diuretics Indications:

Edema

d/t

heart

failure,

hepatic

impairment or renal disease. Hypertension. Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in impaired renal function. Decreased blood pressure. Dosage: 1 tablet, 200 mg Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur; Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol intolerance. Precautions: Severe liver disease; electrolyte depression Side effects: CNS – blurred vision, dizziness, head ache, vertigo EENT – hearing loss, tinnitus CV – hypotension GI – anorexia, constipation, diarrhea, dry mouth, nausea, vomiting GU – excessive urination Derm – photosensitivity, rash F and E – dehydration Nursing Responsibilities: 1. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth, hypotension, or oliguria occurs. 2. Monitor blood pressure and pulse before and during administration. 3. Monitor blood glucose closely; may cause increased blood glucose level. 4. Caution patient to change positions slowly to minimize orthostatic hypotension.

76

5. Advi Advise se pati patien entt to cont contac actt heal health th care care prof profes essi sion onal al imme immedi diat atel ely y if musc muscle le weakness, cramps, nausea, dizziness and numbness occurs. 6. Caution Caution older patient patients s or their their caregivers caregivers about about increas increased ed risk for for falls. falls. Lactulose

Duphalac Classification: Laxatives Indica Indicatio tions: ns: Treatm Treatment ent of chroni chronic c consti constipat pation ion in adults adults and geriatric patients. Adjunct in the management or portal- systemic (hepatic) encephalopathy. Action: Action: Increases Increases water and softens softens the stool. stool. Lowers Lowers the pH of  the colon, which inhibits the diffusion diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia levels. Contraindication: Patients on low-galactose diets. Precautions: Diabetes mellitus; excessive use may lead to dependence. Side effects: GI – belching, cramps, distention, diarrhea Endo – hyperglycemia Drug-Drug interactions: should not be used with other laxatives in the treatment of  hepatic encephalopathy (leads to inability to determine optimal dose of lactulose). Antiinfectives may diminish effectiveness in treatment of hepatic encephalopathy. Dosage: 30 cc PO Nursing Interventions: 1. Asse Assess ss pati patien entt for for abdo abdomi mina nall dist disten enti tion on,, pres presen ence ce of bowe bowell soun sounds ds,, and and normal pattern of bowel function. 2. Assess Assess color, color, consist consistency, ency, and amount amount of stool produced. produced. 3. May cause cause increas increased ed blood blood glucose glucose levels levels in diabetic diabetic patients patients.. 4. Encourage Encourage patient patient to increas increased ed oral oral fluid fluid intake intake.. 5. Caut Cautio ion n pati patien ents ts that that this this medi medica cati tion on may may caus cause e belc belchi hing ng,, flat flatul ulen ence ce,, or  abdomi abdominal nal crampi cramping. ng. Health Health care care profes professio sional nal should should be notifi notified ed if this this becomes bothersome or if diarrhea occurs.

77

78

Date

07/0 5/10 @ 9:15 am

Cues

Subjective:

“Paminaw nako kay puno kaayo diri,” stated by Mr. S. Objective:

-with IVF of  PNSS1L @ 60 cc/hr  -abdominal girth: 90 cm -ascitis -bipedal edema -weak and sleepy -CXR shows pleural effusion -(+) crackles -decreased Hb (94) and Hct (0.28) -increase glucose in the blood. -Furosemide

Need

N U T R I T I O N A L M E T A B O L I C P A T T E R N

Nursing Diagnosis

Excess fluid volume related to compromised regulatory mechanism. ® Fluid volume excess or  hypervolemia occurs from an increase in total  body sodium content and an increase in total  body water. This fluid excess usually results from compromised  regulatory  mechanisms for  sodium and water  as seen in CHF, kidney failure, and  liver failure. Bibliography: Gulanick, Meg, PhD, RN, et.al (2003).Nursing Care Plan: Nursing Diagnosis &

Goal of Care

Intervention Plan

At the end of 5 hours of  nursing interventions, the patient will be able to stabilize fluid volume as evidenced by:

1. Assess Assess for presen presence ce of  of  edema by palpating over tibia, ankles, feet, and sacrum.

a. Bala Balanc nced ed inta intake ke and output; b. Vita Vitals ls sign signs s within normal limits and; c. Drai Drain n at at lea least st 1 liter of urine at foley catheter.

Evaluation

® Pitting edema is manifested  by a depression that remains after one’s finer is pressed  over an edematous area and  then removed.

2. Monito Monitorr daily daily weigh weightt of the the patient. ® Any change in weight is indicative of increase extracellular fluid volume.

3. Monitor VS of the patient. ® Tachycardia and increased  blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines, thus their  response to fluid overload  may be blunted, with less rise in heart rate.

4. Auscultate for a 3rd sound. ® S3 sound is an early sign of   pulmonary congestion.

79

Interpretation. Westline Dive St. Louise. Mosby Inc. 5th ed, p. 65

5. Monitor for distended neck veins and ascites. ® Distended neck veins mean increase pressure in the  jugular veins brought about  by increased circulating fluid.

6.

Monitor abdominal girth daily. 7. Monitor input an output ® Although overall fluid intake may be adequate, shifting of  fluid out of the intravascular  to extravascular spaces may  result in dehydration.

8. Evaluate urine output in response to diuretic therapy. ® Focus on monitoring the response to the diuretics, rather than the actual amount  voided. Fluid volume excess

Interpretation. Westline Dive St. Louise. Mosby Inc. 5th ed, p. 65

5. Monitor for distended neck veins and ascites. ® Distended neck veins mean increase pressure in the  jugular veins brought about  by increased circulating fluid.

6.

Monitor abdominal girth daily. 7. Monitor input an output ® Although overall fluid intake may be adequate, shifting of  fluid out of the intravascular  to extravascular spaces may  result in dehydration.

8. Evaluate urine output in response to diuretic therapy. ® Focus on monitoring the response to the diuretics, rather than the actual amount  voided. Fluid volume excess in the abdomen may interfere with the absorption of oral  diuretic medications.

9. Check urinary catheter for  presence of urine. ® Treatment focuses on diuresis of excess fluid 

80

10. Instruct patient regarding fluid restrictions as appropriate. ® Facilitates reduction of  extracellular volume.

11. Instruct patient to take diuretics as prescribed. ® Diuretic therapy may  include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem.

12. Note medications that may cause fluid retention, such as non-steroidal antiinflammatory agents, vasodilators, and steroids. 13. Instruct to avoid crossing of legs ® Reduce constriction of 

10. Instruct patient regarding fluid restrictions as appropriate. ® Facilitates reduction of  extracellular volume.

11. Instruct patient to take diuretics as prescribed. ® Diuretic therapy may  include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem.

12. Note medications that may cause fluid retention, such as non-steroidal antiinflammatory agents, vasodilators, and steroids. 13. Instruct to avoid crossing of legs ® Reduce constriction of  vessels thus preventing   pooling.

14. Assist patient in repositioning every 2 hours ® Prevent accumulation of  fluid in dependent areas.

81

Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

N U T R I T I O N A L

Fluid & electrolyte imbalance related to excessive urination

At the end of 5 hours of  nursing interventions, the patient will be able to show negative signs of dehydration as evidenced by:

1. Assess capillary refill time of  the patient regularly including the mucus membrane and skin turgor.

“GOAL PARTIALLY MET”

® These are indicators of 

07/06/20 2:15 PM

Subjective:

07/0 6/10 @ 9:15 AM

“Kapoy kaayo ang paminaw,” Mr. S said. “Daghan kaayo na siya’g ma-ihi”, as verbalized by the watcher. Objective:

-with IVF of PNSS 1L infusing well @ R metacarpal vein running @ 60cc/hr  @ 400 cc level. -with good skin turgor  -with capillary refill time of 2 seconds - VS taken result

M E T A B O L

® Excessive urination coupled  by impaired  glomerular  filtration rate can affect reabsorption of sodium in the distal renal tubule, excretion of  creatinine in the urine and wastage of calcium which will result to muscular spasms

d. Vital signs within normal range;

dehydration, adequacy of  circulating volume.

2. Monitor intake and output e. increase fluid intake to at least 850 ml; f.

consume whole meal served;

® Provide ongoing estimation of volume replacement  needs, kidney function, & effectiveness of therapy.

3. Instruct patient to increase oral fluid intake to at least 2.5 L/day or above depending on

@

After 5 hours of  nursing interventions, the patient showed no signs of  dehydration as evidence by: a. able to consume 950 mL of fluids; b. had good appetite

Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

N U T R I T I O N A L

Fluid & electrolyte imbalance related to excessive urination

At the end of 5 hours of  nursing interventions, the patient will be able to show negative signs of dehydration as evidenced by:

1. Assess capillary refill time of  the patient regularly including the mucus membrane and skin turgor.

“GOAL PARTIALLY MET”

® These are indicators of 

07/06/20 2:15 PM

Subjective:

07/0 6/10 @ 9:15 AM

“Kapoy kaayo ang paminaw,” Mr. S said. “Daghan kaayo na siya’g ma-ihi”, as verbalized by the watcher. Objective:

-with IVF of PNSS 1L infusing well @ R metacarpal vein running @ 60cc/hr  @ 400 cc level. -with good skin turgor  -with capillary refill time of 2 seconds - VS taken result of: T= PR= CR= RR= 17 BP= 130/80 -drowsy & weak -urine output of  approx. 4000 mL

M E T A B O L I C P A T T E R

® Excessive urination coupled  by impaired  glomerular  filtration rate can affect reabsorption of sodium in the distal renal tubule, excretion of  creatinine in the urine and wastage of calcium which will result to muscular spasms if not corrected.

d. Vital signs within normal range;

dehydration, adequacy of  circulating volume.

2. Monitor intake and output e. increase fluid intake to at least 850 ml; f.

consume whole meal served;

g. maintain good skin turgor and good capillary refill time and; h. exhibit alertness or intact level of  consciousness.

® Provide ongoing estimation of volume replacement  needs, kidney function, & effectiveness of therapy.

3. Instruct patient to increase oral fluid intake to at least 2.5 L/day or above depending on the amount determined by the health care provider. ® Maintains hydration and  circulatory volume.

4. Promote comfortable environment: cover patient with light sheets.

@

After 5 hours of  nursing interventions, the patient showed no signs of  dehydration as evidence by: a. able to consume 950 mL of fluids; b. had good appetite and consumed entire meal; c. maintained good skin turgor and capillary refill time of  less than 2 seconds and;

82

-abnormal serum electrolyte result of: Sodium=126 (low) Creatinine=272.8 (high) Calcium=1.81 (low) -with medications of: Furosemide NaHCO3 CaCO3 Lactulose

N ® Avoid overheating which could promote further fluid  loss.

5. Continue to administer fluids ® Type and amount of fluids depends on the degree of  deficit and individual patient  response

6. Instruct patient to take highwater content foods like watermelon and soup if not contraindicated. ® Replace fluid loss in the body due to excessive urination

7. Administer medications as ordered. 8. Monito

m electrolyt

d. alert and responsive to any stimuli

-abnormal serum electrolyte result of: Sodium=126 (low) Creatinine=272.8 (high) Calcium=1.81 (low) -with medications of: Furosemide NaHCO3 CaCO3 Lactulose

N ® Avoid overheating which could promote further fluid  loss.

d. alert and responsive to any stimuli

5. Continue to administer fluids ® Type and amount of fluids depends on the degree of  deficit and individual patient  response

6. Instruct patient to take highwater content foods like watermelon and soup if not contraindicated. ® Replace fluid loss in the body due to excessive urination

7. Administer medications as ordered. 8. Monitor serum electrolytes and urine osmolarity ® Elevated hemoglobin and  elevated blood urea nitrogen suggest fluid deficit. Urinespecific gravity is likewise increased.

9. Instruct to eat the whole meal

83

serve.

Date

07/0 5/10 @ 8 AM

Cues

Subjective:

“Kapoy ang paminaw!” answered by the client when asked about how he’s doing. Objective:

-always sleeping or  drowsy -(+) sleep disturbances such

Need

A C T I V I T Y E X E R C I

Nursing Diagnosis

Goal of Care

Intervention Plan

Fatigue r/t increase decrease insulin production

After 21 hours of care, Mr. S will be able to improve sense of  energy as evidenced by:

1. Assess vital signs.

® An imbalance in blood sugar is the main cause of  diabetes-related fatigue. Cells use glucose - sugar for fuel. The hormone insulin controls the distribution and

a. lessened or  diminished irritability;

2. Determine presence/degree of sleep disturbances.

® To evaluate fluid status and  cardiopulmonary response to activity.

Evaluation

“GOAL MET” @ 07/07/10

b. ability to answer  questions or  communicate with high spirits; c. ability to sit independently on chair 

® Fatigue can be a consequence of, and/or  exacerbated by, sleep deprivation.

3. Obtain client’s description of  fatigue (i.e. lacking energy or  strength, tiredness, weakness

12 nn After 21 hours of  care, Mr. S was able to improve sense of energy as evidenced by: a. welcomes visitors

serve.

Date

07/0 5/10 @ 8 AM

Cues

Subjective:

“Kapoy ang paminaw!” answered by the client when asked about how he’s doing. Objective:

-always sleeping or  drowsy -(+) sleep disturbances such as administration of  drugs during days and repeated medical procedures done early in the morning -irritable -answers questions crossly and

Need

A C T I V I T Y E X E R C I S E P A T T E R

Nursing Diagnosis

Goal of Care

Intervention Plan

Fatigue r/t increase decrease insulin production

After 21 hours of care, Mr. S will be able to improve sense of  energy as evidenced by:

1. Assess vital signs.

® An imbalance in blood sugar is the main cause of  diabetes-related fatigue. Cells use glucose - sugar for fuel. The hormone insulin controls the distribution and use of glucose in the body. In diabetics, due to poor production of  insulin, the glucose is not properly utilized by the cells; instead, it's floating around

a. lessened or  diminished irritability;

2. Determine presence/degree of sleep disturbances.

® To evaluate fluid status and  cardiopulmonary response to activity.

Evaluation

“GOAL MET” @ 07/07/10

b. ability to answer  questions or  communicate with high spirits; c. ability to sit independently on chair  and; d. having greater time being awake.

® Fatigue can be a consequence of, and/or  exacerbated by, sleep deprivation.

3. Obtain client’s description of  fatigue (i.e. lacking energy or  strength, tiredness, weakness over length of time) ® To assist in evaluating impact  on client’s life.

4. Ask client to rate fatigue (110 scale). ® To assess level of fatigue based on client’s perception.

12 nn After 21 hours of  care, Mr. S was able to improve sense of energy as evidenced by: a. welcomes visitors and gives jokes; b. open to questions and answers patiently, and initiates communication to student nurse;

84

impatiently -gives inadequate answers -needs supervision from watcher  -weak -in bed rest -blood glucose level of: 278 mg/dL -takes Humulin 70/30 SC

N

in the bloodstream, where it can't be used as energy. As a result, diabetic people will feel drained.

5. Encourage use of assistive devices (e.g. wheeled walker or  crutches). ® Conserves energy for other  tasks.

6. Assist with self-care need like ambulation, as indicated. 7. Avoid or limit exposure to temperature and humidity extremes. ® Temperature extremes can negatively impact energy level.

8. Provide diversional activities like open and jovial communication. ® Participating in pleasurable activities can refocus energy  and diminish feelings of  unhappiness, sluggishness, and worthlessness that can accompany fatigue.

c. able to sit on the chair without maximum supervision and; d. is awake most of  the time during the day.

impatiently -gives inadequate answers -needs supervision from watcher  -weak -in bed rest -blood glucose level of: 278 mg/dL -takes Humulin 70/30 SC

N

in the bloodstream, where it can't be used as energy. As a result, diabetic people will feel drained.

5. Encourage use of assistive devices (e.g. wheeled walker or  crutches). ® Conserves energy for other  tasks.

6. Assist with self-care need like ambulation, as indicated.

c. able to sit on the chair without maximum supervision and; d. is awake most of  the time during the day.

7. Avoid or limit exposure to temperature and humidity extremes. ® Temperature extremes can negatively impact energy level.

8. Provide diversional activities like open and jovial communication. ® Participating in pleasurable activities can refocus energy  and diminish feelings of  unhappiness, sluggishness, and worthlessness that can accompany fatigue.

9. Encourage to drink fluids. ® It is important to keep up fluid  intake as even mild dehydration can cause fatigue. Dehydration can also lead to an increase in blood sugar. Calming herbal  teas are more beneficial than caffeine based drinks.

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10. Avoid drinks containing caffeine. ® Small amounts may affect  our brain in such a way that we are not aware that we are fatigued and drinking too many  cups of tea, coffee or soft  drinks, leads to restlessness and interferes with sleep.

11. Instruct to breathe more evenly, deeply and slowly. ® Deep breathing exercises can help turn off the body's stress switch and reduce blood  sugar levels.

12. Provide a sound and comfortable environment conducive for resting. Limit noise and bring the curtains down to prevent light from getting inside. Provide adequate clothing. ® It is easier to false asleep if 

10. Avoid drinks containing caffeine. ® Small amounts may affect  our brain in such a way that we are not aware that we are fatigued and drinking too many  cups of tea, coffee or soft  drinks, leads to restlessness and interferes with sleep.

11. Instruct to breathe more evenly, deeply and slowly. ® Deep breathing exercises can help turn off the body's stress switch and reduce blood  sugar levels.

12. Provide a sound and comfortable environment conducive for resting. Limit noise and bring the curtains down to prevent light from getting inside. Provide adequate clothing. ® It is easier to false asleep if  the environment is dim and  cool. Enough clothing can  provide the body enough warmth.

13. Stress the importance of  sleep. ® A basic way to feel less stressed during the day is to get 

86

enough sleep at night. Research shows that not having enough sleep may contribute to insulin resistance. One reason is that   poor sleepers often experience sleep apnea; this is a condition that interferes with normal  breathing and has been linked to diabetes.

Date

07/0 6/10 @

Cues

Subjective:

“Dili nako makatindog ug ako ra,” stated by the client.

7:00

Objective:

AM

-creatinine levels of:

Need

Nursing Diagnosis

Goal of Care

A C T I V I T Y

Activity intolerance r/t muscular  weakness as evidenced by high serum creatinine level

At the end of 2 days of  care, Mr. S. will be able to demonstrate a decrease in physiological signs of  intolerance as evidenced by:

® Creatinine can cause dehydration

a) able t

rf

Intervention Plan

1. Establish guidelines and goals of activity with the patient and the caregiver  ® Motivation is enhanced  if the patient participates in goal setting.

Evaluation

“GOAL MET” @ 07/07/10 12:00 nn At the end of 2 days

enough sleep at night. Research shows that not having enough sleep may contribute to insulin resistance. One reason is that   poor sleepers often experience sleep apnea; this is a condition that interferes with normal  breathing and has been linked to diabetes.

Date

07/0 6/10 @

Cues

Subjective:

“Dili nako makatindog ug ako ra,” stated by the client.

7:00

Objective:

AM

-creatinine levels of: 272.8 (06/26/10) 359 • (07/01/10) • 389 (07/02/10) -needs assistance •

Need

Nursing Diagnosis

Goal of Care

A C T I V I T Y

Activity intolerance r/t muscular  weakness as evidenced by high serum creatinine level

At the end of 2 days of  care, Mr. S. will be able to demonstrate a decrease in physiological signs of  intolerance as evidenced by:

A N D E X E R C

® Creatinine can cause dehydration and fatigue. medicinenet.com

a) able to perform a specific task with improved strength; b) able to seek help in performing activities of daily living;

Intervention Plan

1. Establish guidelines and goals of activity with the patient and the caregiver  ® Motivation is enhanced  if the patient participates in goal setting.

2. Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation ® Rest between activities  provides time for energy 

Evaluation

“GOAL MET” @ 07/07/10 12:00 nn At the end of 2 days of care, Mr. S was able to demonstrate a decrease physiological signs of intolerance as evidenced by: a. had great strength on lower 

87

-PT 2 sessions -complained of pain in pelvic area

I S E P A T T E R N

conservation and recovery.

c) verbalize acceptance of  decreased activity level and; d) experience less discomfort when transferring, or  performing other  activities.

3. Refrain from performing nonessential procedures ® Patients with limited  activity tolerance need to  prioritize tasks.

4. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self  ® Assisting the patient  with ADLs allows for  conservation of energy. Caregivers need to balance providing  assistance with facilitating   progressive endurance

extremities; observed during draping for removal of catheter  b. asked help from student nurse or  watcher in changing positions; c. “Ana jud ng mutiguwang ka,” he  joked. d. “Nagasakit gihapon diri dapita (arthritis) pag mulihok, pero gamay gamay na lang.”

-PT 2 sessions -complained of pain in pelvic area

I S E

conservation and recovery.

c) verbalize acceptance of  decreased activity level and;

P A T T E R N

d) experience less discomfort when transferring, or  performing other  activities.

3. Refrain from performing nonessential procedures ® Patients with limited  activity tolerance need to  prioritize tasks.

4. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self  ® Assisting the patient  with ADLs allows for  conservation of energy. Caregivers need to balance providing  assistance with facilitating   progressive endurance that will ultimately enhance the patient’s activity  tolerance and self-esteem.

extremities; observed during draping for removal of catheter  b. asked help from student nurse or  watcher in changing positions; c. “Ana jud ng mutiguwang ka,” he  joked. d. “Nagasakit gihapon diri dapita (arthritis) pag mulihok, pero gamay gamay na lang.”

5. Assist patient to plan activities for times when he has the most energy

88

® Not all self-care and  hygiene activities need to be completed in the morning. Likewise, not all  housecleaning needs to be completed in 1 day.

6. Improvise in adapting environment ® Appropriate aids will  enable the patient to achieve optimal  independence for selfcare.

Date/ Time

Cues

Need

Nursing Diagnosis

Objective of  Care

Nursing Interventions

Evaluation

® Not all self-care and  hygiene activities need to be completed in the morning. Likewise, not all  housecleaning needs to be completed in 1 day.

6. Improvise in adapting environment ® Appropriate aids will  enable the patient to achieve optimal  independence for selfcare.

Date/ Time

Cues

Need

Nursing Diagnosis

Objective of  Care

Nursing Interventions

Evaluation

89

Subjective: 07/05/ - “Doc, kani dinhi 10 ba(holding the right leg, pelvic area) sakit man @ kaayo, kaning bukog-bukog”, 10 “maglisod ko ug AM lakaw, wala man gud koy kusog, naunsa naman ni?” “Dili man ko ing ani pag-abot diri”, as verbalized by the patient.

- rated the intensity of pain as 7 in the pain scale of: 1 - no pain 2 less

C O G N I T I V E P E R C P T U A L P A

Acute pain related to inflammation of  the joints ®Inflammation is a defensive reaction intended to neutralize, control, or eliminate the offending agent and  to prepare the site for repair. Regardless of the cause, a general  sequence of events occurs in the local  inflammatory  response. This sequence involves changes in the microcirculation, including  vasodilation, increased vascular 

That within the 2-hour span of  care, my patient’s comfort condition will improve as evidenced by: - decreased pain intensity as 1 in pain scale - no grimaced face noted - no withdrawal when there is physical contact with the  joint - verbalization of feeling of 

1. Assess pain characteristics. ®Assessment of the pain experience, is the first step in planning pain management strategies.

2. Accept client’s description of pain. ®Pain is subjective experience and cannot be felt by others.

3. Respond immediately to complaint of pain ®Prompt responses to complaints may result in decrease anxiety in the  patient. Demonstrated  concern for the patient’s welfare and comfort fosters the development of a trusting relationship.

4.

Inst ct th

atient to

“GOAL MET “ @ 07/05/10 12pm After 2-hour  span of care, the patient’s condition is improved as evidenced by: - pain scale of 1 - grimaced face not noted - no withdrawal when there is physical contact with the joint - “di naman sakit akong mga joints

Subjective: 07/05/ - “Doc, kani dinhi 10 ba(holding the right leg, pelvic area) sakit man @ kaayo, kaning bukog-bukog”, 10 “maglisod ko ug AM lakaw, wala man gud koy kusog, naunsa naman ni?” “Dili man ko ing ani pag-abot diri”, as verbalized by the patient.

- rated the intensity of pain as 7 in the pain scale of: 1 - no pain 2 less 3 pain 4 slightly moderate

5 pain 6 7 moderate pain 8 9 severe

C O G N I T I V E P E R C P T U A L P A T T E R N

Acute pain related to inflammation of  the joints ®Inflammation is a defensive reaction intended to neutralize, control, or eliminate the offending agent and  to prepare the site for repair. Regardless of the cause, a general  sequence of events occurs in the local  inflammatory  response. This sequence involves changes in the microcirculation, including  vasodilation, increased vascular   permeability, and  leukocytic cellular  infiltration. As these changes take place, five cardinal signs of inflammation are  produced: redness, heat swelling, pain, and loss of function.

1. Assess pain characteristics.

That within the 2-hour span of  care, my patient’s comfort condition will improve as evidenced by:

®Assessment of the pain experience, is the first step in planning pain management strategies.

2. Accept client’s description of pain. ®Pain is subjective experience and cannot be felt by others.

- decreased pain intensity as 1 in pain scale - no grimaced face noted - no withdrawal when there is physical contact with the  joint - verbalization of feeling of  comfort

3. Respond immediately to complaint of pain ®Prompt responses to complaints may result in decrease anxiety in the  patient. Demonstrated  concern for the patient’s welfare and comfort fosters the development of a trusting relationship.

4. Instruct the patient to report pain. ®Relief measures may be instituted  .

5. Position the patient comfortably on bed.

“GOAL MET “ @ 07/05/10 12pm After 2-hour  span of care, the patient’s condition is improved as evidenced by: - pain scale of 1 - grimaced face not noted - no withdrawal when there is physical contact with the joint - “di naman sakit akong mga joints karon(holding the right leg)”, as verbalized by the patient.

®Comfortable position will  aid in relaxing the muscle and it will help to lessen the  pain.

90

Discharge Planning

Categories •

Medication

Plan Instruct patient to take prescribed

Rationale -Compliance to appropriate

medications regularly and comply with

medication and treatment

the treatment regimen prescribed by the

prevents further complications

physician.

and resistance to antibiotics and promote continuous recovery of  optimal health. -The patient has the right to know

•

Teach patient regarding the names

of

the

drug

its

dosage

time

of 

his drug’s therapeutic effects as

Discharge Planning

Categories •

Medication

Plan Instruct patient to take prescribed

Rationale -Compliance to appropriate

medications regularly and comply with

medication and treatment

the treatment regimen prescribed by the

prevents further complications

physician.

and resistance to antibiotics and promote continuous recovery of  optimal health. -The patient has the right to know

•

Teach patient regarding the names

of

the

drug,

its

dosage,

time

of 

administration, its contraindication and side effects.

his drug’s therapeutic effects as well as its adverse effects. He also has the right to gain awareness about why is it given to him.

•

Inform patient and significant others

-Drug interactions may occur 

not to take drugs not prescribed by the

which may be fatal to patient’s

physician, especially OTC drugs.

current situation.

•

Instruct the patient to check for the

-Checking for the expiration date

expiration date of the drug before taking

of the drug before administering it

it.

ensures it potency and safety. It also prevents any unwanted reactions like hypersensitivity.

•

Do not administer any other drug

with same action without the physician’s prescription. •

Educate

the

patient

and

-Non-prescription drug may have antagonistic or synergistic effects if taken with other drugs.

the

significant others about the expected

-To be geared up of enough

responses of drug to the body, side

information that may lead to

effects,

immediate medical responses.

adverse

effects

that

may

possibly seen into the patient.

91

•

Exercise

•

Instruct the significant others to

-For immediate remedial action

report any remarkable adverse reactions

response and to prevent any

or any appearance of side effects noted.

complicated reactions.

Explain to patient the significance of  -Exercises promote proper blood and

circulation and prevent arterial and

stretching. If unable to mobilize alone,

venous stasis thus lessens platelet

instruct the watcher to give assistance

coagulation to aged people. Older 

all the time. Encourage to use crutches

people have weakened blood

or any device for support. Stretching

vessel walls which can cause any

upper extremities also promote healthy

alteration in blood flow.

living. Also instruct patient to perform

Also exercise prevents atrophy of 

passive range of motion.

the muscles.

regular

•

exercise

like

walking

Teach patient to wait for 1 to 2 hours

after

eating before performing any

physical activities.

-Older people has slower digestion rate, thus they need to conserve more oxygen which will be necessary for digestion of food. Activities must be limited to decrease oxygen demand by organs and tissues other than the digestive system.

If patient’s pleural effusion worsens,

-Deep breathing exercises promote

instruct the patient to practice deep

thoracic expansion which allows air 

breathing exercise.

to enter the respiratory tract and

•

provide oxygen to the alveoli to avoid atelectasis or lung collapse due to increase fluid pressure in Treatment

•

Instruct patient to comply with his

medication treatment like the continuous

the pleural space. -Maintenance meds should not be forgotten to achieve highest

use of beta blocker Metoprolol for  therapeutic effect. control of hypertension and Insulin for  diabetes mellitus. •

Instruct client to seek medical help if  -These unusualties may be

any unusualties are felt such as tingling

indicative of worsening condition.

92

sensation or paresthesia, fatigue and body malaise, dizziness, headaches, irritability, tremors, diaphoresis, etc. •

As part of long-time treatment,

-Medical alert bracelet provides

advise patient to wear medical alert

basic information about the client in

bracelet all the time and wherever he

case of accidents.

goes. It contains the patient’s name, disease condition, address and contact person. •

Advise to have a family member  -Monitor of blood pressure is

take your blood pressure to check if  significant for evaluating the you’re

maintaining

a

stable

blood

medication’s effectiveness. -Glucose monitoring is a big factor 

pressure.

in the management of diabetes •

Since the client has his own glucose

mellitus.

monitor, tell client to continue monitoring blood glucose level, and immediately seek Hygiene

for

medical help

if

level

is

abnormally high. Instruct patient to practice foot care •

-Proper foot care prevents injury to

to prevent ulceration and formation of  feet and toes. gangrenous

tissues

to

the

lower 

extremities. - Check and carefully wash your feet every day. -Do not wear shoes that are too small or  socks that do not fit right inside your  shoes. -Soak your feet in warm soapy water for  10 minutes before cutting your nails. Trim your toenails straight across to prevent ingrown toenails. You may also file down your toenails. Do not cut your  nails into the corners or close to the skin. You should not dig under or around the

93

nail. -Proper bathing eliminates •

Emphasize

the

importance

of 

bathing everyday. Wash genitals with mild soap.

proliferation of germs and bacteria in the body. Mild soap does not irritate the skin and the genitals. -Tooth brushing prevents build up

•

Instruct client to maintain good oral

hygiene. •

Instruct to wear clean clothes and

underwear.

of plaques and cavities. -Dirty or improperly washed underwear may become a sanctuary for microbial growth. Microbes may enter the genitals and might worsen the client’s

Out-Patient Referral

•

Encourage patient to undergo physical

UTI/Cystitis. -A Physical Therapist is a source of 

therapy sessions.

information to understand agerelated changes and offer  assistance for regaining lost abilities or develop new ones. Physical therapy can be applied to the client’s condition: arthritis, urinary and fecal incontinence, amputation, and cardiac and pulmonary disorders. It can : a). increase, restore or maintain range of motion, physical strength, flexibility, coordination, balance and endurance b.) aids adaptations to make the home accessible and safe teach positioning, transfers, and walking skills c.) promote maximum function and independence within an individual's capability d.) increase overall fitness through exercise programs

94

e.) prevent further decline in functional abilities through education, energy conservation techniques, joint protection, and use of assistive devices to promote independence f.) improve sensation, joint proprioception g.) reduce pain •

Advise to have check-ups after discharge.

-Serves as an evaluation process to note if condition has progressed to better or worse.

•

Advise to have regular laboratory exams

-To assess for renal function.

for creatinine, albumin, sodium, potassium and calcium.

Diet

•

Encourage to undergo ABG Test every

•

month or once every 2 months. Instruct client to avoid simple sugars.

-Simple sugars easily break down

Take energy from complex carbohydrates

and enter the blood stream.

like unpolished rice, bread and

Complex carbohydrates can

vegetables.

sustain the body’s energy requirement for a longer time because they are not broken down easily.

•

Encourage patient to eat fibrous foods

-A diet rich in fiber relieves

like fruits and vegetables. But do not eat

constipation. It adds bulk to the

too much as it can irritate the GI tract and

excreta and facilities expulsion.

causes bleeding. Other examples of  sources of fiber are: whole grains, cereals and legumes. •

Limit intake of purine rich foods such as

-Accumulation of uric acid in the

sardines, liver, beef kidneys, brains and

 joints causes arthritis. Uric acid is

meat extracts. Encourage to eat in

the by product of purine break

moderate amount: asparagus, cauliflower,

down in the liver. Because of renal

spinach, mushrooms, green peas, dried

malfunction, uric acid is retained in

peas and beans.

the blood stream and is shunted to connective tissues.

95

•

Instruct patient’s family to prepare foods

-Cholesterol build up can cause

low in fat and cholesterol. Also have

atherosclerosis. Since elder people

moderate amount of sodium in the diet.

have weakened blood vessel walls, cholesterol or atherosclerotic plaques (atheromas) can lodge in the blood vessels and obstruct blood flow. If the atheroma is dislodged, it might become an emboli and travel through the pulmonary circulation. -Since the patient is suffering from hyponatremia, do not deprive client of sodium but just limit his intake, because too much sodium can result to fluid shifting and edema. Hyponatremia stimulate  juxtaglomerular cells to activate RAAS, the precursor of  hypertension. Also hypontremia affects action-potential of the heart, affecting repolarization and depolarization. Low levels of  sodium can also result to neurologic problems.

•

Maintain good oral hydration.

-Water replenishes the cells and decreases the chance of  crystalluria.

96

Prognosis Diabetes needs to be considered a very serious condition. It is a chronic condition for which we have no cure. About 2/3 of people with diabetes die of heart disease. It is the leading cause of adult blindness, the leading cause of kidney failure, and the leading cause of lower extremity amputation. It is also the second most common chronic condition seen by American doctors. Although diabetes is a serious and chronic condition, early diagnosis and proper  patient self-management can reduce and possibly eliminate the majority of the chronic complications. Meticulous control of blood glucose (HbA1c below 7% which would correlate to an average blood glucose below 150 mg/dL), good blood pressure control (below 130/80), low LDL (low density lipoprotein) cholesterol levels (below 100 mg/dL), one daily aspirin (either adult or children's), and daily foot inspection can make a major  impact on improving one's risk for all diabetes-related problems. Pain

High blood glucose levels do not cause pain. However, having high glucose levels for many years can lead to nerve damage in the feet (called neuropathy), which can be painful. It is estimated that 25% of newly diagnosed patients with type 2 diabetes have pain or numbness in their feet from neuropathy. Client can take analgesics for pain. Debilitation

Diabetes can be debilitating, and there are many reasons for this. It is not uncommon for people with diabetes to experience advanced neuropathy to the point that he or she cannot walk. For Mrs. J’s case, she sometimes stoops while walking, but still does not need supervision. The good news is that debilitation can be prevented if treatment is started early and aggressively. This treatment includes meticulous control of blood glucose (average glucose below 150 mg/dL), blood pressure (below 130/80), LDL cholesterol (bad cholesterol below 100 mg/dL), daily aspirin, and smoking cessation. Research also has shown that one particular type of blood pressure medication, called ACE (angiotensin converting enzyme) inhibitors, has an additional protective effect on complications besides lowering blood pressure. ACE inhibitors appear to stabilize or even reverse

97

diabetic kidney disease if it is caught early enough. These drugs also have been found useful for people who have had heart attacks or have heart failure. One study even showed these drugs reduced the risk of heart attack or stroke by 25%. Finally, there is a growing body of research suggesting ACE inhibitors may protect against diabetic eye disease. Comfort

Diabetes usually does not cause discomfort. In fact, one of the biggest public health problems in America is that there are over 5 million Americans who have asymptomatic diabetes and do not know it. The most common reason for any discomfort is the neuropathy noted above. Another common reason people have discomfort is from the finger sticks to measure blood glucose. Fortunately, this technology is quickly improving so that discomfort is minimal. Curability

Diabetes is currently not curable. Type 1 diabetes is defined as no requirement for insulin with normal blood sugars. Scientists are working on this so that the cells that make insulin ("islets") may be able to be transplanted to result in a cure. To date these experiments are not quite ready and are still in the research phases. For type 2 diabetes, there is no "cure" but often it can be treated early in its course with a strict diet, exercise, and weight loss. However, it is rare for the diabetes to "disappear" even with these measures. The main focus of research now is to prevent both types of diabetes. Independence

In the vast majority of cases patients with diabetes should have no problems with independence. But for elderly, fatigue and neuropathies can occur, so strict supervision is needed. Family members should also make sure that their home environment is free from injury causing objects. Mrs. J still belongs in the middle adulthood, thus she can experience independence more than elders without causing harm to self. Mobility

Again, in the vast majority of cases, diabetes should have no impact on someone's ability to move about. The exceptions to this are those people who suffer  from advanced neuropathy or vascular disease. A complication involving the foot, such as a foot ulcer or amputation can impact one's ability to move around. Visual problems also will impact one's ability to move about. These are true to young diabetic patients.

98

Mrs. J has complained of blurry vision, thus her ability to move about is readily and always affected. But she said that she uses eye glasses which aids her sight. But complications brought about by aging should not be neglected. Senile people are mostly at risk for injury. Daily activities

For most people however, small amounts of time should be reserved for selfmanagement. This would include time for home blood glucose monitoring (although our  current meters take as little as 5 seconds) and extra time to ensure the proper  medication is received. Exercise is encouraged for people with diabetes, although for those over the age of 40 years old it is recommended a stress test is performed to rule out early heart disease (claudication). Rest is always a necessity. Energy

Extremes in blood glucose levels can cause fatigue. Although it is difficult to give exact levels since it differs with the person, many people note fatigue when the blood glucose exceeds 400 mg/dL. Although hypoglycemia often presents with a tremor, fast heart rate, a sweating, it may be noted only as fatigue. This often occurs when the blood glucose drops below 60 mg/dL. Mrs. J can have some time for rest. Though she has to baby sit for her grand son Benedict, and perform all the house chores, she can have a bit of time in the afternoon while her grandson is at school to rest and sleep. Diet

In general, it is recommended that one eats a low-fat diet with less than 10% of  the calories coming from saturated fat. For people with high levels of LDL-cholesterol (the "bad" cholesterol) the January 2002 guidelines from the ADA suggest only 7% of  total calories from saturated fat. The most confusion about diet for people with diabetes has to do with carbohydrates, which are the types of foods most quickly broken down to glucose (such as breads, potatoes, pasta, fruit, and simple sugar). Research has clearly shown that table sugar (sucrose) does not increase blood sugar any more than breads, pasta or  other carbohydrates AS LONG AS THE SAME NUMBER OF CALORIES ARE CONSUMED. For example, putting table sugar into coffee (about 15 grams of  carbohydrate) would not change blood glucose any more than 1 piece of bread (about

99

15 grams of carbohydrate). Therefore, simple sugars ("sweets") do not need to be restricted by people with diabetes, but rather need to be substituted for other  carbohydrate sources. For people using insulin, it is much easier since additional insulin can be administered to "cover" additional carbohydrate. Relationships

The

interactions

between

relationships

and

diabetes

are

greatly

underappreciated. Communication becomes particularly important for people in their early adult years, as issues pertaining to marriage and family planning are discussed. It is critical that concerns be discussed in the open with the assistance from a health care provider  with understanding about the disease. For older adults, the impact of both the daily living of diabetes and its complications becomes even more important. Again, one needs to talk to a healthcare provider knowledgeable about diabetes to explore its complications and how it affects everything from work performance to driving or sexual function. Everyone living with an individual who has diabetes needs to have some knowledge about how to treat emergencies (hypoglycemia). Finally, psychological support can be extremely effective for many individuals due to the extreme challenges this condition presents for many individuals.

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References

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