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A CASE STUDY OF A PATIENT WITH DIABETES
MELLITUS
Prepared by:Josmy Joseph
LTIM-Department
I. DEMOGRAPHIC DATA
Name: Patient X
Age: 56 yrs.old
Nationality: Saudi
Date of Admission: July 9,2012
II. PHYSICAL ASSESSMENTSKIN - warm, slightly moist,
smooth, hair evenly distributed
HEAD -symmetric, no flaking of scalp, no lesions, no tenderness
EYES - no redness, no discharges, sclera white and clear, pupils
reactive to light and accommodation
NOSE & SINUSES – nasal septum straight, not perforated
no discharge, naso-gastric tube present
MOUTH - no gum bleeding, tongue and uvula in midline position, oral cavity is pinkish in color, buccal
mucosa smooth and moist, no ulcers, no swelling, no palpable
massesNECK - no palpable lymph nodes,
trachea on midlineposition, Trache. Tube present
BREASTS - nipples at same level and protrude slightly, no palapable masses, no nipple discharges
THORAX AND LUNGS – thorax is symmetric, no retraction of
the intercostal spaces, notenderness, back areaslightly reddened
UPPER EXTREMITIES – decorticate position arms are unable to extend, abduct and adduct
NAILS - convex curvature, smooth texture
good capillary refill
ABDOMEN – slight abdominal distention(+) bowel sounds
LOWER EXTREMITIES – unable to flex,abduct and adduct
GENITALIA - skin of the glans penis is smooth, no ulceration, urethral meatus ventrally located on the end of
the penis, no discharge, no palpable masses
III. PATIENT HISTORY
III. A Past HistoryPatient X – with Hypertension, Diabetes Mellitus
controlled by long term use of insulin
- brought to Prince Sultan Cardiac Center due to Cardiogenic shock and Ventricular
febrillation, resuscitated for 30 mins.
- considered stable from cardiac point of view
but he was admitted repeatedly due to
recurrent infections - Echocardiography done and
revealed impaired left ventricular function
- no valvular lesion noted
III. B Present History Patient X is now admitted in Dr. Ahmed Abanamy
Hospital since July 09, 2012 after he was transferred by Prince Sultan Cardiac Center for continuous long term nursing care and management. He is currently in tracheostomy tube supported by humidified oxygen at 5LPM. He is nasogastric tube feeding. He is on long term use of foley catheter with no episodes of penile bleeding noted. Patient X is maintained with insulin NPH combined with regular insulin subcutaneously. He is also maintained with Amlodipine, Clopidogrel, Concor and Pantoprazole. He has stable vital signs with no recent episodes of desaturation noted.
IV. TOPIC PRESENTATION
DIABETES MELLITUS
Diabetes Mellitus or simply Diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin or because cell do not respond to the insulin that is produced. This high blood sugar produce the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger). There are three main types of Diabetes Mellitus: Type 1, Type 2 and Gestational Diabetics.
Type 1 is a result from the body’s failure to produce insulin and currently recurs the person to inject insulin or wear an insulin pump. This form was previously referred to as Insulin-dependent Diabetes Mellitus (IDDM) or childhood onset or Juvenile Diabetes.
Type 2 is a result from insulin resistance, a condition in which cells failed to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred o non- insulin dependent diabetes mellitus (NIDDM), obesity related diabetics or adult onset diabetics.
Gestational Diabetics occur when pregnant woman without the previous diagnosis of Diabetes developed a high blood glucose level, it disappears after delivery and it is treatable. (It may precede development of Type 2 Diabetes.
V. ANATOMY AND PHYSIOLOGY
Pancreas The pancreas is an elongated tapered organ located across
the back of the abdomen, behind the stomach. The right side of the organ called head and it is the widest part. It lies the curve of the duodenum. The left side ends near to spleen.The homone administered by the pancreas are responsible for controlling and manipulating blood glucose level. The pancreas houses islets responsible for production and secretion of the hormone glycogen and insulin.
Endocrine cells or the lslets of langerban make up 1% of the pancreatic cells.there are most numerous in the tail region of the pancreas.the major endocrine cells of the pancreas are alpha ,beta,and delta cells.Which secrete glucagons,insulin and somatostatin,respectively.when the blood sugar level falls below the normal levels.The alpha cells are stimulated to secrete glucagon which accelerates the conversion of glucogen to glucose in the liver .when the blood sugar level is above normal the beta cells secrete insulin. Which promotes both the metabolism of glucose by tissue cells and the conversion of glucose to glycogen which is then stored in the liver
VI. ETIOLOGYDiabetes Mellitus is the condition in which there is hyperglycemia, an excess of sugar in the bloodstream. This increase in the blood sugar level occur due to malfunctioning of the pancreas which secretes insulin. Insulin is the hormone that control the sugar level in the blood. Without insulin sugar will accumulate in the blood leading to diabetes mellitus. There are different causes of diabetes mellitus such as:-DIET
-LIFESTYLE
-ENVIRONMENT AND EXTERNAL FACTORS
-AGE AND HEREDITY
VII. SIGNS AND SYMPTOMS
a.excessive thirstb.frequent urinationc. extreme hungerd. unusual weight losse. increased fatiguef. blurred visiong. nausea, vomitingh. infections of the bladder, skin, & vaginal
areasi. elevated glucose level & leads to lethargy,
coma
VIII. INTERVENTION1. Administer insulin or an oral anti-
diabetic drug as prescribed.
2. Have the patient participate in a supervised exercise programs.
3. Treat hypoglycemic reactions promptly by giving carbohydrates in the form of fruit juice, honey or IV dextrose.
4. Provide meticulous skin care, especially feet and legs.
5. Assist the patient develops coping strategies.
6. Keep accurate record of vital signs, weight, fluid intake, urine output and caloric intake.
7. Monitor diabetic effect on the cardiovascular, peripheral, vascular and nervous system.
8. Observe for signs of urinary tract and vaginal infections and monitor the patient’s urine for protein and early signs of nephropathy.
9. Recommend regular ophthalmologic examinations.
10. Teach the patient how to care for his feet.
11. Teach the patient and families how to monitor the patient’s diet.
IX. TREATMENT- Monitoring blood glucose level
- Dietary management
- Maintaining physical activity
- Keeping weight and stress under control
- Monitoring oral medication and if required insulin via injection
X. COMPLICATIONSSHORT TERM:- Hypoglycemia
- Hyperglycemia
- Ketoacidosis and Hyperosmolar Syndrome
LONG TERM:- Heart diseases
- Kidney diseases
- Neuropathy
- Peripheral Vascular diseases
XI. PRIORITIZATION OF NURSING PROBLEMS
1. Fluid Volume Deficit related to osmotic dieresis due to hyperglycemia2. Risk for ineffective tissue perfusion related to
reduced vascular flow3. Imbalanced nutrition, less than body requirements, related to inability to use glucose4. Risk for infection related to impaired healing
accompanying condition5. Deficient fluid volume related to polyuria accompanying disorder
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:Not applicable Objective:-dry skin & mucous membrane-poor skin turgor; skin slowly returns back after pinching- weak peripheral pulses-urine output for 24hrs: 800ml-vital signs taken as follows: Temp: 37 C PR: 110 bpm RR: 20bpm BP: 97/60mmof Hg
Fluid Volume Deficit related to osmotic dieresis due to hyperglycemia
After 8hours of nursing interventions the patient will demonstrate adequate hydration
Independent:-Checked vital signs especially blood pressure and heart rate every 2h
-Checked temperature, skin color & moisture, skin integrity
-Monitored input & output. Note urine specific gravity
-Maintained fluid intake at least 2500ml/day within cardiac tolerance
Promoted comfortable environment. Provided good lighting, thermoregulation, and , free from noise.Collaborative:-Administered fluid such as Normal Saline 100ml/hr as indicated
Hypovolemia may be manifested by hypotension & tachycardia-Fever, chills and diaphoresis are common with infectious process. Fever with flushed dry skin may reflect dehydration, adequacy of circulating volume
-Indicators of level of dehydration, adequacy of circulating volume
-Provide the best assessment of current fluid status and adequacy of fluid
-Avoid over heating which could promote further fluid loss
-Maintain hydration & circulating volume
After 8hours of nursing interventions the patient will demonstrate adequate hydrationAs evidenced by stable vital signs, palpable peripheral pulses, good skin turgor , good capillary refill, urine output of 1,100ml for 24 hrs.,and V/S stable as follows:Temp: 36.8 CPR: 82 bpmRR: 20bpmBP: 124/74mmHg
ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:Not ApplicableObjective:- confined to bed-unable to move, turn to side to side-unable to abduct and adduct extremities-medium-sized body built-back area and buttocks slightly reddened
Risk for impaired skin integrity related to immobility
After 12hours of nursing intervention patient will display good skin texture and free from drynessAfter 3-5days of nursing intervention patient’s skin will remain intact and will not develop any skin breakdown during the stay at the facility.
• Repositioned the patient from side to side at least every 3hours
• Lifted the patient during turning, do not drag or pull. Encouraged use of lift sheets to move patient in bed
• Cleaned, dried, and moisturized skin, especially over bony prominences. Use powder and Elica creams as necessary
• Used good quality air mattress, avoid wrapped and wrinkled bed sheets
• Massaged on the area of pressure avoiding reddened skin part
Positioning interventions reduce pressure and shearing force to the skinFriction may cause break of skin
Moisture softens the skin and causes a break in the skin integrity. Creams or powder may help smoothen the skin
This helps in reducing pressure
Increase tissue perfusion by massaging around affected area
Goal met.Patient’s skin remained intact and did not develop any skin breakdown during the stay at the facility.
XIII. NURSING HEALTH TEACHING
For the watcher:
1. Teach her/him for signs and symptoms of hypoglycemia and hyperglycemia.
2. Explain about medication purpose, dosage and possible side effects.
3. Teach her/him how to do skin care.
XIV. CONCLUSION Diabetes Mellitus or simply
Diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin or because cell do not respond to the insulin that is produced. This high blood sugar produce the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger). There are three main types of Diabetes Mellitus: Type 1, Type 2 and Gestational Diabetics.
Type 1 is a result from the body’s failure to produce insulin and currently recurs the person to inject insulin or wear an insulin pump. Type 2 is a result from insulin resistance, a condition in which cells failed to use insulin properly, sometimes combined with an absolute insulin deficiency. Gestational Diabetics occur when pregnant woman without the previous diagnosis of Diabetes developed a high blood glucose level, it disappears after delivery and it is treatable.
There are different causes of DM such as factors related to diet, lifestyle, environmental and external factors, age and hereditary.
The goal of diabetes management is to keep blood glucose level as close to normal as safety as possible. Since diabetics may greatly increased risk for heart diseases and peripheral artery disease. Measure to control blood pressure and cholesterol levels are an essential part of diabetics treatment, people with diabetic must take responsibility for their day to day care.
XV. BIBLIOGRAPHY Lippincot Manual of nursing care Ninth edition.
httpllen.wikipedia .orglwikilDiabetes mellitus. Httplwww.medicinenet.comld/diabetes
mettitus/article.htm http/emedicine.medscape.com/article/
1163653-overview