DIABETES MELLITUS TYPE II POORLY CONTROLLED

7/28/2019 DIABETES MELLITUS TYPE II POORLY CONTROLLED

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DIABETES MELLITUS TYPE II POORLY

CONTROLLED


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PATIENT HISTORY

Patient A (60), is a type 2 diabetes mellitus patient

since January 2008 ( 5 years)

Chief complaint fever for 4 days

Father is diabetic and hypertensive, mother ishypertensive

Does not smoke or drink alcohol

G3P3 (3003) all NSD, one baby is more than 8 lbs

No previous surgeries Prescribed to take Glimepiride 2 mg once a day and

Losartan 50 mg once a day but is not religiously

taking up medicines


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PATIENT HISTORY

Her BP 140/70, HR is 120, Temperature of 38.3 degrees

Celsius, RR is 26, waist circumference is 115cm, hip

circumference is 122cm, weight 74.2kg, height is 159 cm,

and Body Mass Index of 29.9

Desire to know more about her present condition

Verbalized need to have more diabetes education and fear

of its complications.

No exercise and is not following a diet

Not really taking her medications everyday

Admitted a diet high in carbohydrates, protein, fat, and

sugar


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PHYSICAL ASSESSMENT

Feet and hand is numb

3 liters of dilute urine per day before admission and no urineoutput on the day of admission, urine output resumed onday 2; total of 3 liters of fluid intake per day

report of extreme thirst and extreme cravings of fruits butcannot eat well because of easy fatigue and uneasy feeling.

exhibited dry skin and mucous membranes and poor skinturgor

complaining of cough, fever, pain at the upper abdomenwhich radiates to the back (flank pain), chest discomfort,difficulty of breathing (use of shoulders in breathing), andfatigue 2 weeks

crackles on the right lung field

hearing loss since admission

On Plain NSS 1L x 8 hours


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BLOOD CHEMISTRY

Blood Urea Nitrogen of

6.21 mmol/L

Creatinine of 100. 17umol/L (HIGH)

SGPT of 18.56 u/L

Sodium of 136.8

mmol/L Potassium of 3.88

mmol/L

FBS of 13.51 mmol/L(HIGH)

Cholesterol of4.03mmol/L

Blood Urea Nitrogen of9.25 mmol/L (HIGH)

Triglycerides of 2.23

mmol/L (HIGH) LDL of 0.60 mmol/L

SGOT of 2.42

Feb. 25, 2013 Feb. 26, 2013


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BLOOD CHEMISTRY

Feb 27, 2013

Creatinine of 85.41 umol/L (HIGH)

ECG

Feb 27, 2013 SINUS TACHYCARDIA

HR: 120 bpm


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COMPLETE BLOOD COUNT

Hemoglobin of 102 g/L(LOW)

Hematocrit of 0.30(LOW)

RBC Count of 3.21 x10/L (LOW)

WBC Count of 18.4 x

10/L (HIGH) Platelet is Adequate

Neutrophil of 0.89

Lymphocytes of 0.11

Hemoglobin of 85 g/L(LOW)

Hematocrit of 0.25(LOW)

RBC Count of 2.68 x10/L (LOW)

WBC Count of 16.90 x

10/L (HIGH) Platelet is 233

Neutrophil of 0.86

Lymphocytes of 0.14

Feb. 25, 2013 Feb. 27, 2013


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COMPLETE BLOOD COUNT

March 1, 2013

Hemoglobin of 112 g/L (LOW)

Hematocrit of 0.33 (LOW)

RBC Count of 3.53 x 10/L (LOW)

WBC Count of 10.0 x 10/L (HIGH)

Platelet is 321

Neutrophil of 0.72

Lymphocytes of 0.28


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BLOOD SUGAR MONITORING

Random Blood Sugar

6:00 PM : 212 mg/dL

Fasting Blood Sugar

5:00 AM : 231 mg/dL

Random Blood Sugar

11:00 AM 344 mg/dL

Random Blood Sugar

5:00 PM 273 mg/dL

FEB. 25, 2013 FEB. 26, 2013

Fasting Blood Sugar5:00 AM : 142 mg/dL

FEB. 27, 2013


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URINE EXAMINATION

Feb. 25, 2013

+1 Sugar

+3 Protein

6 to 8/hpf WBC

Many Bacteria

Many Crystal: Amorphous Urates, Alkaline Phosphatase

4 to 6/ LPF Fine Granular Casts


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CHEST PA FEB. 25, 2013

There are hazy densities in the right lower lobe. Hazyinfiltrates are seen in the left paracardiac area. Heart is

not enlarged. Atheromatous aorta. There is blunting of

the right costophrenic sulcus. Bonythorax is

unremarkable. Impression:

Pneumonia with;

Consolidation, Right

Plueral Thickening Vs Effusion, RightAtheromatous Aorta


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CROSS MATCHING RESULT

Blood Source: Philippines National Red Cross

Blood Product: 1 unit Packed RBC, Type O Rh

Positive

Serial # 2012-557327 Pilot Tube # 580Y2092

Date of Extraction: 02/14/2013

Date of Expiration: 03/01/13 at 11:45 AM

Microscopic Results: Minor: Compatible

Major: Compatible


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PATHOPHYSIOLOGYDIABETES MELLITUS TYPE 2

with hypertension, urinary tract infection, and anemia


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DIABETES MELLITUS

In type 2 diabetes, either the body does not

produce enough insulin or the cells ignore

the insulin. Insulin is necessary for the body to be

able to use glucose for energy. When you eat food,

the body breaks down all of the sugars andstarches into glucose, which is the basic fuel for the

cells in the body. Insulin takes the sugar from the

blood into the cells. When glucose builds up in the

blood instead of going into cells, it can leadto diabetes complications.


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The Pancreas


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Fatty Acidsare presentaround the

cells just likesugar

Triglycerideis 2.23

mmol/LHIGH

Increasesinflammatory

cytokine

hormones whichblocks the

message fromthe insulin

receptor

Glucoseare left

outside the

cells andstimulatesBeta Cellsto secrete

insulin

WAIST HIP

115cm-122cm

BMI : 29.9

SERUM

WBC

18.4 X 10/L

URINE

WBC

6-8/hpf

FEVER

Diabetic for

5 years

Food high in

CHO, CHON,

Fats, andSUGAR


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cell

Insulin

Receptor

Glucose

Transport

Sodium

Potassium

Pump

INSULIN


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DIABETES MELLITUS TYPE 2

ChronicHyperinsulinemia

Beta cells burn out

Blood sugar risesExtracellular

Hyperglycemia

FBS: 231 mg/dL

RBS: 344 mg/dL

RBS: 212 mg/dL

Kidneys compensate

3L of urine

+1 sugar

+3 protein

DehydrationReports of Exhaustion

andFatigue

Chronic HyperglycemiaInflammation (cytokinesand cholesterol at the

basement of endothelialcells)

Atheroma in thePeripheries

-numbness of the foot


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PRIMARY HYPERTENSION

Risk Factors:

Father and Mother hasHypertension

60 years of age

BMI of 29.9

Glucose Intolerance

FBS: 231 mg/dL

RBS: 344 mg/dL

RBS: 212 mg/dL

Food high in CHO, CHON, Fats,and SUGAR

May be from

increased

activity of

sympathetic

nervous system

Blood Pressure of140/70


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URINARY TRACT INFECTION / ACUTE

PYELONEPHRITIS

Pyelonephritis comes from a greek word pyelum,

meaning "renal pelvis and nephros, meaning "kidney",

and -itis, meaning "inflammation. It is an

ascending urinary tract infection that has reached

the pyelum or pelvis of the kidney.Acute pyelonephritis is a potentially organ life-

threatening infection that often leads to renal scarring.

Acute pyelonephritis results from bacterial invasion of

the renal parenchyma. Bacteria usually reach the kidney

by ascending from the lower urinary tract. Bacteria mayalso reach the kidney via the bloodstream. Timely

diagnosis and management of acute pyelonephritis has

a significant impact on patient outcomes


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Diabetes affects the immune system by making

the patient vulnerable to risk of contracting other

infections of diseases. Persistent uncontrolleddiabetes tends to degenerate the immune system

of the body that they end up attracting bacteria

and viruses. Urine culture is a way of figuring out

what kind of bacteria is present to find out what

kind of antibiotic will be used for management.

Disclaimer: No urine culture was taken, patientwas given Cefuroxime.


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UTI (ACUTE PYELONEPHTRITIS)PredisposingFactor:Urinary Retention

Attachment andProliferation ofbacteria to the

UrethraURETHRITIS

PrecipitatingFactors:

Diabetes Mellitus

60 years old

Urethravesicle reflux:inflammation of the

bladder

CYSTITIS

Ureterovesicle reflux:introduction ofbacteria to the

ureters

URETERITIS

URINARYTRACTINFECTION /PYELONEPHRITIS

Activation of Immune Response

(prostaglandin and pyogens):

FEVER of Temp: 38.3 deg celcius

General feeling ofbeing unwell

BODY MALAISE

Infection and Dysuria

Urine WBC of 6-8/hpfSerum WBC of

18.4x10/L

Serum Creatinine 100.17

umol/L and BUN of 9.25mmol/L : FLANK PAIN

Decreased

erythropoeitin

production and bone

marrow stimulation

ANEMIA

Hdb : 85 g/dL


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Blood Transfusion

Blood Source: Philippines

National Red Cross

Blood Product: 1 unit Packed

RBC, Type O Rh Positive

Serial # 2012-557327

Pilot Tube # 580Y2092Date of Extraction:

02/14/2013

Date of Expiration: 03/01/13

at 11:45 AMMicroscopic Results:

Minor: Compatible

Major: Compatible

Impaired Kidney

Function

Kidneys do notsecrete or secretes

few hormones

specifically

erythropoeitin

Less erythropoeitin

leads to less bone

marrow stimulationleads to less RBCs

ANEMIA

Hgb: 85 g/L


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COMMUNITY ACQUIRED PNEUMONIA


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COMMUNITY ACQUIRED PNEUMONIA

MODERATE RISK 60 years oldNo history of Pneumococcal

Vaccination

Pre-existing condition of DIABETESMELLITUS Type 2 poorly Controlled

Environmental Factors

Minerals, microbes,

anaerobes, bacteria

introduced to lungs

Minerals, microbes, anaerobes,

bacteria causes widesread damage

to the delicate lung tissue

CHEST PA FEB. 25, 2013

There are hazy densities in the

right lower lobe. Hazy infiltrates

are seen in the left paracardiac

area. Heart is not enlarged.

Atheromatous aorta. There is

blunting of the right

costophrenic sulcus.

Bonythorax is unremarkable.

Impression:Pneumonia with;

Consolidation, Right

Plueral Thickening Vs

Effusion, Right

Atheromatous Aorta

Infectious organism and


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Pleural membrane thicken due

to attempt of lungs to repair the

damage

Infectious organism and

irritating agents penetrate the

airway mucosa and multiply in

alveolar spaces

White Blood Cell migrate to

area of infection

Serum WBC of 18.4x10/L

FEVER

Temp: 39.3Capillary leak which

spreads infection to other

areas of lunc

Extends to pleural cavity

Resulting in Emphyema

These fluids collected around the

alveoli and alveolar

walls thicken

PURULENT

SPUTUM

Reduces ability

of lungs to

oxygenate the

blood moving

through it

Arterial Oxygen Tension Fall

use of shoulders in breathing

and fatigue 2 weeks DYSPNEA

AND CHEST DISCOMFORT


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NURSING

CARE PLAN


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TYPE 2 DIABETES MELLITUS

Deficient Fluid Volume from

Hyperglycemia related to

Osmotic Diuresis

As evidenced by increased urinaryoutput, dilute urine, excessive thirst, dry

skin and mucous membranes, poor skin

turgor, hypotension, tachycardia.

INDEPENDENT

1.Monitor intake and output; note urine specific

gravity to know the ongoing estimate of volumereplacement needs, kidney function and

effectiveness of therapy

2.Assess peripheral pulses, capillary refill, skin

turgor, and mucous membranes to know the levelof hydration and adequacy of fluid replacement

3.Maintain fluid intake of at least 2500 mL/day within

cardiac tolerance to maintain hydration

4.Promote comfortable environment. Cover clientwith light sheets to avoid overheating which could

promote further fluid loss

COLLABORATIVE

1.Monitor :HCT to assess level of hydration,

BUN/CREATININE may signal dehydration or

renal failure, Serum Osmolality which may be

elevated because of hyperglycemia anddehydration, high sodium may indicate severe fluid

loss, Potassium may be lost in the urine and

should be replaced to prevent hypokalemia.

2.Administer isotonic fluids as ordered to preventdehydration


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NURSING DIAGNOSIS: FATIGUE

R/TALTEREDBODYCHEMISTRY: INSUFFICIENTINSULIN

As evidenced by verbalization of lack of energy, inability

to maintain usual routines

The Client will verbalize increase in energy level anddisplay improved ability to participate in desired activitiesinte

rvention

Discuss withthe client theneed foractivity planschedule with

client andidentifyactivities thatlead to fatigue.

rationale

Education mayprovidemotivation toincreaseactivity level

even thoughclient may feeltoo weakinitially

inte

rvention

Alternateactivity withperiods ofrest/

uninterrupted sleep

rationale

Preventsexcessivefatigue

inte

rvention

Monitorpulse,respiratoryrate, and

BP before/after activity

rationale

Indicatesphysiologiclevels oftolerance

inte

rvention

Increaseclientparticipationin ADLs astolerated ra

tionale

Increaseconfidencelevel/ self-esteem andtolerancelevel


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NURSING DIAGNOSIS: DEFICIENT

KNOWLEDGE R/T UNFAMILIARITYWITH

INFORMATIONRESOURCES

Possibly evidenced by

As evidenced by questions/request for information, verbalization of the problemInaccurate follow-through of instructions, development of preventable

complications

DESIRED OUTCOMES/EVALUATION CRITERIA-CLIENT WILL:

Verbalize understanding of disease process, potential complicationsIdentify relationship of signs/symptoms to the disease process and correlate

symptoms with causative factors.

Correctly perform necessary procedures and explain reasons for the actions.

Initiate necessary lifestyle changes and participate in treatment regimen

inte

rvention

Select a varietyof teachingstrategies; e.g.,demonstrateneeded skillsand have clientdo returndemonstration;incorporate newskills into thehospital routine.

rationale

Use of differentmeans ofaccessinginformationpromoteslearnerretention.

inte

rvention

Discusstiming ofinsulininjection

andmealtime.

rationale

One of the manyinconveniencespeople withdiabetes cope withis having to decideat least 30-60minutes in advancewhen they aregoing to have ameal for the timelyadministration ofregular humaninjections

inte

rvention

Discussfoods toavoid attime whenclient iseating high-iron foods

r

ationale

These foodsblock absorptionof iron and shouldbe taken at adifferent meal.For example , red

meat and milktaken at the sametime can blockabsorption of theiron from the

meat.


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NURSING DIAGNOSIS: NURSING DIAGNOSIS:

RISK FOR INFECTION R/THIGHGLUCOSELEVELSANDUTI

Risk factor may include

Inadequate primary defenses; chronic disease,

malnutrition

inte

rvention

Select a varietyof teachingstrategies; e.g.,demonstrateneeded skillsand have clientdo returndemonstration;incorporate newskills into thehospital routine.

rationale

Use of differentmeans ofaccessinginformationpromoteslearnerretention.

inte

rvention

Perform/promotemeticuloushand

washing bycaregiversand client.

rationale

Prevent cross-contamination/bacterialcolonization.

inte

rvention

Encouragefrequentpositionchanges/ambulation,coughing,and deepbreathingexercises.

rationale

Promotesventilation of alllung segmentsand aids inmobilizingsecretions topreventpneumonia.in

te

rvention

Monitortemperature.Notepresence ofchills andtachycardiawith/withoutfever.

rationale

Reflective ofinflammatoryprocess/infection,requiringevaluation andtreatment


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NURSING DIAGNOSIS: ACTIVITY

INTOLERANCER/T IMBALANCEBETWEENOXYGEN

SUPPLY (DELIVERY)ANDDEMANDANDEASYFATIGABILITY

As evidenced by

Weakness and fatigue

Palpitations, HR: 120, RR: 26, BP: 150/80

Desired outcomes/Evaluation Criteria-Client will:

Report an increase in activity tolerance.

Demonstrate a decrease in physiological signs of intolerance;

pulse, respirations, and BP remain within clients normal range.inte

rvention

Assess clientsability toperform normaltasks/ADLs,noting reports ofweakness,fatigue, anddifficultyaccomplishingtasks.

rationale

Influenceschoice ofinterventions/neededassistance.

inte

rvention

Notechanges inbalance/gait

disturbancemuscleweakness.

rationale

May indicateneurologicchangesassociatedwith vitamin

B12 deficiency,affecting clientsafety/risk ofinjury

inte

rvention

Suggestclientchangeposition

slowly,monitor fordizziness.

rationale

Posturalhypotensionor cerebralhypoxia may

causedizziness,fainting, andincreasedrisk of injury.


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Deficient knowledge about

self-care skills r/t

unfamiliarity with informationresources as evidenced by

request for information

INDEPENDENT

1.Work with client in setting of mutual goals for

learning because participation in planningpromotes enthusiasm and cooperation with the

principles learned.

2.Select variety of teaching strategies to promote

learner retention3.Discuss normal blood glucose levels compared to

clients level, the type of diabetes, and the

relationship of insulin deficiency and high glucose

levels, and complications.4.Encourage self-monitoring of blood glucose levels.

Tight control on serum glucose prevent/delay

complications

INDEPENDENT

5. Discuss dietary plan, limiting intake of sugar, salt,

fat. Eat complex carbohydrates specially foods

high in fiber and ways to deal with meals outsidethe home. Awareness of dietary control aids client

to sticking in the regimen

6. Review medication regimen, including onset,

peak, duration, and timing of prescribed insulin to

promote proper use. Glargine (Lantus) has

minimal peak and is used as basal insulin.

7. Sick day rules, sugar rises during illness, stress,surgery, or use of steroids.

8. No smoking because nicotine constricts the small

blood vessels and insulin absorption is delayed for

as long as this vessels are constricted

INDEPENDENT

9. Establish regular exercise/activity schedule and

identify corresponding insulin concerns because

exercise should not coincide with the peak of action of

insulin.

10. Identify symptoms of hypoglycemia (weakness,

dizziness, lethargy, hunger, irritability, diaphoresis,

pallor, tachycardia, tremors, headache, changes in

mentation to promote early detection and treatment.

Early morning hyperglycemia or the dawn

phenomenon and rebound response to hypoglycemia

during sleep of Somogyi Effect. Test at 3AM. Instruct

to eat candy or inject glucagon

11. Discuss importance of follow-up care, social support

or family support


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Risk For Disturbed Sensory

Perception

(numb feet and hand)Risk Factors: glucose and insulin

imbalance

INDEPENDENT

1. Schedule nursing time to provide uninterrupted rest

periods to promote restful sleep, reduces fatigue,

and may improve cognition

2. Protect client from injury specially at night

3. Keep patient in the preferred comfortable position.

Keep hands/ feet warm, avoiding exposure to cool

AIR DRAFTS or HOT WATER. This reduces

discomfort and potential for dermal injury


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MEDICATIONS (FEB. 25 TO 26, 2013)

Paracetamol 500mg/tab per orem if Temperature of

>37.8

Paracetamol (Aeknil) 1 amp TIV every 4 hours if

Temperature of >38.5

Humulin R TIV was given as stat order

Regular Insulin

Metoclopromide 1 amp TIV was given as stat order


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MEDICATIONS (CONT..)

Cefuroxime 750 mg IV every 8 hours

Furosemide 40 mg IV once a day

Omeprazole 40 mg IV once a day

Diphenhydramine 50 mg IV one hour prior to BT(Feb. 28, 2013 1:30 PM)

Paracetamol 300 mg IV prior to BT (Feb 28, 2013

1:30 PM)


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DISCHARGE SUMMARY

COURSE IN WARD: Regular insulin

scale started upon addmission, labs

done, Cefuroxime started furosemideand nebulzation O2 support given.

On 1st hospital day azithromycin

started, ferrous sulfate, lantus and

flumucil. Blood transfussion done.Discharged, improved on 4th hospital

day.


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HOME MEDICATIONS

Cefuroxime 500 mg BID x 4 days

Flumicil 600 mg in glass of Water twice a day x 2

days

Fenofibrate 135 mg once a day at hour of sleep

Lantus Solostar 15 units after dinner

Metformin 500 mg three times a day

Enalapril 50 mg once a day


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REFERENCES

Textbook of Medical Surgical Nursing by Brunner &

Suddarth

Understanding Pathophysiology by Huether and

McCance

DIABETES MELLITUS TYPE II POORLY CONTROLLED

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