Bka Case Final

7/30/2019 Bka Case Final

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I. INTRODUCTION

Diabetes mellitus or simply Diabetes, is a group of metabolic diseases in which a person

has high blood sugar, either because the body does not produce enough insulin, or because

cells do not respond to the insulin that is produced. This high blood sugar produces the classical

symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia

(increased hunger).

There are three main types of diabetes mellitus (DM). Type 1 DM results from thebody's failure to produce insulin, and presently requires the person to inject insulin or wear an

insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus"

(IDDM) or "juvenile diabetes". Type 2 DM results from insulin resistance, a condition in which

cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This

form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-

onset diabetes". The third main form, gestational diabetes occurs when pregnant women

without a previous diagnosis of diabetes develop a high blood glucose level. It may precede

development of type 2 DM.

Other forms of diabetes mellitus include congenital diabetes, which is due to genetic

defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high

doses of glucocorticoids, and several forms ofmonogenic diabetes.
http://en.wikipedia.org/wiki/Blood_sugarhttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Polydipsiahttp://en.wikipedia.org/wiki/Polyphagiahttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2http://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Gestational_diabeteshttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/MODYhttp://en.wikipedia.org/wiki/MODYhttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/Gestational_diabeteshttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_2http://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Polyphagiahttp://en.wikipedia.org/wiki/Polydipsiahttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Blood_sugar


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carbohydrates), and endocrinopathies (e.g., Addison's disease). These phenomena are believed

to occur no more frequently than in 1% to 2% of persons with type 1 Diabetes.

Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with

relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is

believed to involve the insulin receptor. However, the specific defects are not known. Diabetes

mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most

common type. The most common form of diabetes is Type II, It is sometimes called age-onset

or adult-onset diabetes, and this form of diabetes occurs most often in people who are

overweight and who do not exercise

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

are obese (more than 20% above their ideal body weight) have a relative with diabetes mellitus belong to a high-risk ethnic population (African-American, Native American, Hispanic, or

Native Hawaiian)

have been diagnosed with gestational diabetes or have delivered a baby weighing morethan 9 lbs (4 kg)

have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a

triglyceride level greater than or equal to 250 mg/dL

have had impaired glucose tolerance or impaired fasting glucose on previous testing
http://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Insulin_receptorhttp://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/gestational-diabetes/http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/gestational-diabetes/http://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Insulin_resistance


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Diagnostic Tests:

1. Fasting Plasma Glucose Test- this test is to measure bloods plasma-glucose after fastingfor at least 8 hours, thus the name fasting plasma glucose test. This test is useful to

detect all types of diabetes.

2. Oral Glucose Tolerance Test- which measures blood glucose after 8 hours of fasting and2 hours after the person drinks a glucose-containing beverage. This test is effective to

diagnose all types of diabetes.

3. Random Plasma Glucose Test- also called a casual plasma glucose test, because there isno fasting required or worry about what we have eaten. This test, along with anassessment of symptoms, is used to diagnose diabetes but not pre-diabetes. However,

once random plasma glucose test confirms diabetes needs to be reconfirming by FPG or

OGTT

Causes:

The cause of diabetes depends on the type:

Type 1 diabetes is partly inherited, and then triggered by certain infections, with someevidence pointing at Coxsackie B4 virus. A genetic element in individual susceptibility tosome of these triggers has been traced to particular HLAgenotypes (i.e., the genetic

"self" identifiers relied upon by the immune system). However, even in those who have

inherited the susceptibility, type 1 DM seems to require an environmental trigger. The

onset of type 1 diabetes is unrelated to lifestyle.

Type 2 diabetes is due primarily to lifestyle factors and genetics.
http://en.wikipedia.org/wiki/Coxsackie_B4_virushttp://en.wikipedia.org/wiki/Human_leukocyte_antigenhttp://en.wikipedia.org/wiki/Human_leukocyte_antigenhttp://en.wikipedia.org/wiki/Human_leukocyte_antigenhttp://en.wikipedia.org/wiki/Coxsackie_B4_virus


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Urinary incontinence, over active bladder, bladder problems are all cause by nervedamage due to prolonged high blood-glucose.

Urinary tract infection is also due to nerve damage, but it is not directly relating with anerve cause. Due to Diabetic Gastroparesis, there is a delay in the food emptying, which

in-turn starts bacterial growth, and causes urinary tract infection. Furthermore, due to

long term of diabetes, immune system losses it capacity thereby it is not able to fight

the infection.

Diabetes Management:

1. Food - What you eat directly influences your blood-glucose levels. Follow the foodpyramid for effective diabetes control or management. Take food at the same time also

the same volume and never skip your food or even snack.

2. Physically active try to make your busy in your daily life routine or spent some timefor physical exercises such as walking, swimming, exercising and playing. It produces

positive results in blood-glucose control as well as a drop in medicine (pills or insulin)

requirements.

3. Lose weight if you are obese or overweight, try to reduce weight by following foodpyramid and increasing physical activity or exercising. Losing weight has a direct positive

impact in your blood-glucose control.

4. Monitor glucose level closely monitor your blood-glucose, check your blood-glucoseusing home glucose monitor, and make a record. If you maintain your blood-glucose

l h id di b i li i


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Nursing Responsibilities:

Advice patient about the importance of an individualized meal plan in meeting weeklyweight loss goals and assist with compliance.

Assess patients for cognitive or sensory impairments, which may interfere with theability to accurately administer insulin.

Demonstrate and explain thoroughly the procedure for insulin self-injection. Helppatient to achieve mastery of technique by taking step by step approach.

Review dosage and time of injections in relation to meals, activity, and bedtime basedon patients individualized insulin regimen.

Instruct patient in the importance of accuracy of insulin preparation and meal timing toavoid hypoglycemia.

Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to eat

carbohydrate snack before exercising to avoid hypoglycemia.

Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses,dryness, hair distribution, pulses and deep tendon reflexes.

Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce

vasoconstriction and enhance peripheral flow.

II. NURSING HISTORY


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PRESENT HISTORY:

Patient BKA never knew that her condition will lead her to amputation. She vieweddiabetes as a simple disease that can be treated by simple medications. Because of her

oblivious attitude regarding her condition, it complicates until she begun to have non-healing

wounds which causes her to undergone debridement on her left foot then followed by her

right. When her right foot doesnt heal on debridement, she undergone below the knee

amputation.

FAMILY HISTORY:

According to patient BKA, her family has history of diabetes which caused her mothers

death. She is aware that she inherits her condition from her mother which was inherited by her

daughter to her.

GORDONS 11 FUNTIONAL PATTERN

HEALTH PERCEPTION

BEFORE: patient BKA considered diabetes as a simple disease only. She ignored the fact

that it may result into many complications. She seldom goes to hospital for check-up until one

day she collapsed following body malaise and dizziness that makes her family to rush her to the

hospital only to find out that her diabetes was being triggered. When she was diagnosed with

diabetes the doctor recommended her to take medications such as insulin and placil. She also


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COGNITIVE AND PERCEPTUAL PATTERN

BEFORE: patient BKA decides in her own as she told us and goes for check-up all byherself. She only consulted her family if it requires family decision. Patient BKA experienced

blurring of vision only when looking from distant places.

PRESENT: she has still sharp memory that she can still able to manage in decision

making and remembered past events. Her vision remains the same, experiencing blurring of

vision form a distant area.

SLEEP-REST PATTERN

BEFORE: patient BKA sleeps 5 hours per day starting 10pm-3am. She seldom had rest

due to her occupation being a vendor working whole day in the market. She only rested when

she sold all her manufactured goods already or if theres no customer. She is aware of her

sleeping pattern and considered it normal rationalizing that its a part of aging and she need to

do that for her work.

PRESENT: when she was diagnosed of diabetes and had undergone debridement, shetried to cope up in her sleeping pattern. She told us that she sleep earlier compared before.

Aside from that, she also tried to look for time to give herself a rest even when she is at work.

ROLE RELATIONSHIP PATTERN

BEFORE: patient BKAs husband is a farmer though her husband earned enough money


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DATE: 08-01-12; TIME: 2:45pm

GENERAL APPEARANCE: the patient looks weak, feels dizzy, irritable with the IFC, andcomplains that she still doesnt feel her left leg, the patient still smiles while she talks to

her relative but hardly to cooperate due to weakness and under the presence of

anesthesia.

PHYSICAL ASSESSMENT:

T: 36.9o

C RR: 20 cpm

PR: 96 bpm BP: 110/80 mmhg

IFC: 100cc

PARTS TECHNIQUE USE ABNORMAL FINDINGS ANALYSIS

HAIR Inspection White strands Dry

Due to aging

HEAD Inspection OilyPalpation Round, symmetry; no mass

or nodules

NormalFACE Inspection Facial grimace, irritable Due to post-operative

Palpation Cold to touch Due to


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TEETH Inspection Incomplete Due to aging

VAGINA Inspection Presence of polyps Due to complication of

diabetesUPPER EXTREMITIES

NAILS Inspection Dirty fingernails Due to poor hygieneSKIN Inspection

Palpation

Dry skin Pale nail bed

Due to increaseurination

Due to poor bloodcirculation or

anemiaPALM Inspection Pale Due to anemia or

poor blood

circulation

LOWER EXTREMITIES

SKIN Inspection

Inspection

Dry skin BKA right leg

Debridement left leg

Due to poor hygiene Due to unhealing

wound and impaired

skin integrity

Due to impaired skinintegrity


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Endocrine- The endocrine gland, which consists of the islets of Langerhans, secretes hormones

into the bloodstream.

Functions of the Pancreas:

The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine gland in the pancreas help break downcarbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down

the pancreatic duct into the bile duct in an inactive form. When they enter the

duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to

neutralize stomach acid in the duodenum. The hormones secreted by the endocrine gland in the pancreas are insulin and glucagon

(which regulate the level of glucose in the blood), and somatostatin (which prevents the

release of the other two hormones).


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Pathophysiology:

Precipitating factor:

Eating sweets and fatty

foods

Decrease insulin production of pancreas

Diabetes mellitus Type II

Predisposing factor:

Genetics

Age45 years old

Gender: female

Accumulation of glucose in the blood

stream

Glucose is not metabolize by the body

Fat is broken down in

adipose tissue

Releases fatty acid

in the blood

stream.

Fatty acids

convert into

ketones by


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Gestational

diabetes

Body malaise,

nausea and

vomiting,

pale.

Non healing

wound

Debridement

on the left

and right foot

BKA on the

right foot

Infectious

vaginitis

Peripheral

neuropathy

Diabetic

retinopath

Deteriorationsmall blood

vessels that

nourish retin

Opacity in thelens

Blurred visionosteomyelitis


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IV. LABORATORY RESULTS

August 01 2012

Tests Normal Values Results Interpretation

Hemoglobin F (12-18 g/dl) 10.2 Due to anemia

Monocyte F (37-47%) 30.0 Due to bacteria

White blood

cell

4.0-10.0 18.4 Due to infection

Granulocyte 44.2-80.2% 76 Normal

Lymphocyte 28.0-48.0% 24 Due to the presence of

wound


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VI. COURSE IN THE WARD

August 01,2012

POST-OP ORDERED

DATE TIME DOCTORS ORDER RATIONALE NURSING RESPONSIBILITIES

8/1/12 11:45am To ward/ status post BKA rightunder SAB

For the patient recovery Endorse to ward. Diabetic diet, if with full motor

and sensory

To prevent aspiration Check for the full motor and sensory VS q 15mins. until stable To monitor baseline V/S and any

changes after operation

Monitored V?S q15min For Hgb- now, then q 8 hours

thereafter

To prevent blood loss Request for laboratory IVF:PNSS 1Lx8 hours x 3 cycles

Meds:

1. Ketorolac2. Tramadol3. Metoclopromide

To maintain fluid and electrolyteimbalances

To alleviate sign and symptoms IV hooked and regulated and meds

administered and recorded

Start- diabetic meds andantibiotic once on DAT

To prevent the occurrence of infectionand for maintenance

Give diabetic meds and antibiotic once onDAT

Elevate with one pillow operativesite

To prevent for bleeding Elevate with one pillow atoperative site Watch out for bleeding on

operative site

To check for infection Watch out for bleeding on operative sitethen report.

I & O q 1 hour and record For urine elimination monitoring I and O monitored q1hr Refer as needed To inform ROD Referred


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VIII. NURSING CARE PLAN

August 01, 2012

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

hindi mabilis

gumaling ang sugat

ko. As verbalized

by the patient.

Objective:

Alteredsensation

Delayedwound

healing

Ineffective peripheral

tissue perfusion related

to decreased blood flow

to the area of non

healing wound due to

obstruction of blood

vessels

After 3o

minutes of

nursing

interventions

the patient will

be able to

verbalize

understanding

of condition,therapy

regimen, side

effects of

medications

and when to

conduct health

care provider.

Get vital signsand record.

Establish rapport. Educate client in

active range of

motion exercise.

Elevate head ofbed at night.

Discouragewearing

constrictive

clothing, crossing

legs.

Provide otherpost-op teaching

appropriate for

the situation.

For base line data. To gain the patient

trust.

To promote circulationof blood.

To increasegravitational blood

flow.

To promote bloodcirculation.

Goal met.

After 3o minutes of nursing

interventions the patient was

able to verbalize

understanding of condition,

therapy regimen, side effects

of medications and when to

conduct health care provider.


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Encourage earlyambulation when

possible.

Discuss care offoot care as

appropriate.

To promote peripheralcirculation and limit

mplication associated

with poor perfusion.

When circulation isimpaired, changes in

sensation place client

at risk for

development of lesions

or ulcerations that are

often slow to heal.


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August 01, 2012


Subjective:ang alam ko

noon sa diabetes

simpleng sakit lang,

pero hindi pala as

verbalized by the

patient.

Deficient knowledgeabout the disease

process, diet, care

and treatment

related to lack of

information.

After 3 hours of nursinginterventions the patient

will be able to verbalized

importance of having

healthy lifestyle and

correctly perform

prescribed health

behaviors.

Get vital signs andrecord. Establish rapport. Provide information

to support self-

efficacy, self

regulation and self

management by

focusing on problem

solving and decision

making.

Tailor the delivery ofinstructions to the

clients cognitive level

by accessible words.

Provide healthteaching related to

disease condition.

Evaluate learningoutcomes using

verbalizations.

For base linedata. To gain the

patient trust.

Evaluationserves as an

assessment.

After 3 hours of nursinginterventions the patient

was able to verbalized

importance of having

healthy lifestyle and

correctly performs

prescribed health behaviors.


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August 01, 2012


OBJECTIVE:

Increase WBC Presence ofwound due to

operation

Risk for Infection

related to post

operative surgery

After 8 hours of

implementing the

nursing intervention thepatient will be able to

manifest the decrease

of infection.

Check vital signs q15

Observe forlocalized signs of

infection at

insertion site of

wound

Stress proper handhygiene by all

caregivers between

therapies and

clients before

cleaning the wound

Change surgicalwound dressing, as

indicated, using

proper technique

for changing/

disposing of

contaminated

materials.

For baseline data

To prevent crosscontamination of

the infection

To reduce infection

To reduce infectionAnd prevent

contamination

After 8 hours of nursing

intervention the patient was able

to reduce/lessen the infection


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Encourage theclient to increase

protein intake

Administerceftriaxone as

prescribe

To promote woundhealing

To reduceinfection


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VIII. DRUGS STUDY

DRUG NAME INDICATION ACTION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

KETORALAC

Classification:

Nonsteroidal anti-

inflammatory and

non opioid

analgesic

Route: IV every 6

hours

Dosage: 30 mg- 4

doses

Short term

management of

pain.

Inhibits prostaglandin

synthesis, producing

peripherally mediated

analgesia. Also have

antipyretic and anti-

inflammatory

properties.

Therapeutic effects:

decrease pain.

Hypersensitivity; cross

sensitivity with other

NSAIDs may exist.

CNS: drowsiness, dizziness,

headache

Respiratory: dyspnea

CV: edema, pallor,

vasodilation

GI: oliguria

1. Assess for rhinitisincreased risk for

developing

hypersensitivity reactions.

2. Assess pain (note type,location and intensity)

prior to 1-2 hours

following administration.


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TRAMADOL

Classification:

Analgesic

Route: slow IV

push

Dosage: 50 mg- 4

doses

Moderate to

severe pain

Binds to mu-opioid

receptors. Inhibits

reuptake of

serotonin and

norepinephrine in

the CNS.

Therapeutic

effects: decrease

pain

Hypersensitivity; cross

sensitivity with opioids

may exist.

CNS: dizziness, headache

GI: constipation, nausea

1. Assess type, pain location,intensity of pain and 2-3

(peak) after administration.

2. Assess BP and respiratoryrate before and periodically

during administration.

3. Prolonged use may lead to,physical and psychological

dependence and tolerance.

If tolerance develops,

changing to an opiod may be

required to relieve pain.


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METOCLOPROMI

DE

Classification:

antiemetics

Route: IV

Dosage: 10 mg

PRN

-Treatment pi post

surgical and diabetic

gastric stasis.

-Treatment and

prevention post

operative nausea and

vomiting.

Block dopaminre

receptors in

chemoreceptor trigger

zone of the CNS.

Motilates motility of the

ipper G.I. tract and

accelerates gastric

emptying.

Therapeutic effects:

decrease nausea and

vomiting and decrease

symptoms of gastric

stasis.

Hypersensitivity; possible

G.I. obstruction/

hemorrhage.

CNS: drowsiness,

extrapyramidal

reactions,

restlessness.

GI: constipation,

nausea

1. Assess patient for nauseavomiting, abdomina

distention, and bowe

sounds before and afte

administration.

2. Assess for extrapyramidareactions.

3. Monitor for tardivedyskinesia.

4. Assess patient for signs odepression periodically

throughout therapy.


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DRUGS INDICATION ACTION CONTRAINDICATION SIDE EFFECT NURSING RESPONSIBILITIES

Drug name:

Metformin

Classification:

Anti

diabetic

ROUTE:

P.O

DOSAGE:

500mg x a

day with meal

l

Managementof type 2

diabetesmellitus; may

be used with

diet,insulin, or

sulfonylurea

oral

hypoglycemic.

Decreasehepatic

glucose

production

THERAPEUTICEFFECTS:

Maintenance

of blood

glucose

Hypersensitivity; metabolic

acidosis;

dehydration,sepses,hypoxemia, hepatic

impairment.

1. Nausea and vomiting,hypoglycemia

2. Decrease vitamin B121. Obtain baseline and periodic

kidney and liver function tests;

drug contraindicated in the

presence of renal or hepatic

insufficiency. Monitor blood

glucose and HbA1C, and lipid

profile periodically.

2. Assess renal function beforeinitiating.

3. monitor serum folic acid andvitamin B12.

4. Encourage patient to followprescribed diet, medication,

and exercise regimen to

prevent hyperglycemic or

hypoglycemic.


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DRUGS INDICATION ACTION CONTRAINDICATION SIDE EFFECT NURSING RESPONSIBILITIES

Drug name:

INSULIN

Classification:

Anti

diabetics

Route:

sub cut

Dosage:

0.5 to 1 unit/

kg per day

Control ofhyperglyce

mia in

patients

with type

1 or type 2

diabetes

mellitus

lower bloodglucose uptake in

skeletal muscle

and fat,

inhibiting hepatic

glucose

production.

THERAPEUTICEFFECTS: Control

of hyperglycemia

in diabetic

effects.

hyperglycemia, allergy or

hypersensitivity to a

particular type of insulin.

erythema, lipodystrophy,

prurutis, swelling

1. Monitor body weightperiodically. Changes in

weight may necessities

changes in insulin dose.

2. Monitor blood glucose every6 hours during therapy, more

frequently in times of stress.

3. Notify physician promptly forpresence of acetone with

sugar in the urine; may

indicate onset of ketoacidosis.

Acetone without sugar in the

urine usually signifies

insufficient carbohydrate

intake.4. Monitor for hypoglycemia

(see Appendix F) at time of

peak action of insulin. Onset

of hypoglycemia (blood sugar:

5040 mg/dL) may be rapid

and sudden.

5. Check BP, I&O ratio, andblood glucose and ketones

every hour during treatment

for ketoacidosis with IV

insulin.6. .Emphasize the importance of

compliance with nutritional


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guidelines and regular

exercise as directed by health

care professional.

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Bka Case Final