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This case study is about diabetes mellitus type II. Diabetes is rising globally and one area that is seeing an increase is in the Philippines. According to the American Diabetes Association (ADA) diabetes is the 7th leading cause of death in the United States and the leading cause of both kidney disease and lower limb amputation. Furthermore, diabetes is an expensive disease to treat, costing the United States around $174 Billion in 2007. Thus, we selected this case to explore other factors that can enhance our knowledge in the field of our nursing practice.

A. Diabetes mellitus type 2

Diabetes dependent mellitus type 2 (formerly noninsulin(NIDDM) or adult-onset



diabetes) is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. This is in contrast to diabetes, in which there is an absolute insulin deficiency due to destruction of islet cells in the pancreas. The classic symptoms are excess thirst, frequent urination,

and constant hunger. Type 2 diabetes makes up about 90% of cases of diabetes with the other 10% due primarily to diabetes mellitus type 1 and gestational

diabetes. Obesity is thought to be the primary cause of type 2 diabetes in person who is genetically predisposed to the disease. Type 2 diabetes is initially managed by increasing exercise and dietary modification. If blood glucose levels are not adequately lowered by these measures, medications such

as metformin or insulin may be needed. In those on insulin, there is typically the requirement to routinely check blood sugar levels. Rates of type 2 diabetes have increased markedly over the last 50 years in parallel with obesity: As of 2010 there are approximately 285 million people with the disease compared to around 30 million

in 1985. Long-term complications from high blood sugar can include heart, strokes, diabetic retinopathy where eyesight is affected, kidney failure which may require dialysis, and poor circulation of limbs leading to amputations. The acute complication of ketoacidosis, a feature of type 1 diabetes, is uncommon. However, nonketotic hyperosmolar coma may occur. Signs and symptoms The classic symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger), and weight loss. Other symptoms that are commonly present at diagnosis include: a history of vision, itchiness, peripheral neuropathy, recurrent vaginal infections, and fatigue. Many people, however, have no symptoms during the first few years and are diagnosed on routine testing. People with type 2 diabetes mellitus may rarely present with nonketotic hyperosmolar coma (a condition of very high blood sugar associated with a decreased level of consciousness and low blood pressure). Complications Type 2 diabetes is typically a chronic disease associated with a ten-year-shorter life expectancy. This is partly due to a number of complications with which it is associated, including: two to four times the risk of cardiovascular disease, including ischemic and stroke; a 20-fold increase in lower limb amputations, and increased rates of hospitalizations. In the developed world, and increasingly elsewhere, type 2 diabetes is the largest cause of nontraumatic blindness and kidney failure. It has also been associated with an increased risk of cognitive dysfunction and dementia through disease processes such as Alzheimer's disease and vascular dementia. Other complications include: acanthosis

nigricans, sexual dysfunction, and frequent infections. Causes The development of type 2 diabetes is caused by a combination of lifestyle and genetic factors. While some are under personal control, such as diet and obesity, others, such as increasing age, female gender, and genetics, is not. A lack of sleep has been linked to type 2 diabetes. This is believed to act through its effect on metabolism. The nutritional status of a mother during fetal development may also play a role, with one proposed mechanism being that of altered DNA methylation.

Diagnosis The World Health Organization definition of diabetes (both type 1 and type 2) is for a single raised glucose reading with symptoms otherwise raised values on two occasions, of either: fasting plasma glucose 7.0 mmol/l (126 mg/dl) or with a glucose tolerance test, two hours after the oral dose a plasma glucose 11.1 mmol/l (200 mg/dl) A random blood sugar of greater than 11.1 mmol/l (200 mg/dL) in association with typical symptoms or a glycated hemoglobin (HbA1c) of greater than 6.5% is another method of diagnosing diabetes. In 2009 an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended that a threshold of 6.5% HbA1c should be used to diagnose diabetes. This recommendation was adopted by the American Diabetes Association in 2010. Positive tests should be repeated unless the person presents with typical symptoms and blood sugars >11.1 mmol/l (>200 mg/dl). Threshold for diagnosis of diabetes is based on the relationship between results of glucose tolerance tests, fasting glucose or HbA1c and complications such as retinal problems. A fasting or random blood sugar is preferred over the glucose tolerance test, as they are more convenient for people.[4] HbA1c has the advantages that fasting is not required and results are more stable but has the disadvantage that the test is more costly than measurement of blood glucose. It is estimated that 20% of people with diabetes in the United States do not realize that they have the disease. Diabetes mellitus type 2 is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. This is in contrast to diabetes mellitus type 1 in which there is an absolute insulin deficiency due to destruction of islet cells in the pancreas and gestational diabetes mellitus that is a new onset of high blood sugars in associated with pregnancy. Type 1 and type 2 diabetes can typically be distinguished based on the presenting circumstances. If the diagnosis is in doubt antibody testing may be useful to confirm type 1 diabetes and C-peptide levels may be useful to confirm type 2 diabetes.

Management Management of type 2 diabetes focuses on lifestyle interventions, lowering other cardiovascular risk factors, and maintaining blood glucose levels in the normal range. Self-monitoring of blood glucose for people with newly diagnosed type 2 diabetes was recommended by the British National Health Service in 2008,]however the benefit of self monitoring in those not using multi-dose insulin is questionable. Managing other cardiovascular risk factors, such as hypertension, high cholesterol, and microalbuminuria, improves a person's life expectancy. Intensive blood pressure management (less than 130/80 mmHg) as opposed to standard blood pressure management (less than 100 140160/85

mmHg) results in a slight decrease in stroke risk but no effect on overall risk of death. Intensive

blood sugar lowering (HbA1C<6%) as opposed to standard blood sugar lowering (HbA1C of 77.9%) does not appear to change mortality. The goal of treatment is typically an HbA1C of less than 7% or a fasting glucose of less than 6.7 mmol/L (120 mg/dL) however these goals may be changed after professional clinical consultation, taking into account particular risks of hypoglycemia and life expectancy. It is recommended that all people with type 2 diabetes get regular ophthalmology examination. Lifestyle A proper diet and exercise are the foundations of diabetic care, with a greater amount of exercise yielding better results. Aerobic exercise leads to a decrease in HbA1C and improved insulin sensitivity. Resistance training is also useful and the combination of both types of exercise may be most effective. A diabetic diet that promotes weight loss is important. While the best diet type to achieve this is controversial a low glycemic index diet has been found to improve blood sugar control. Culturally appropriate education may help people with Type 2 diabetes control their blood sugar levels, for up to six months at least. If changes in lifestyle in those with mild diabetes have not resulted in improved blood sugars within six weeks, medications should then be considered.

B. Patients Profile Name: Mr. P.D. Gender: Male Civil Status: Married History of present illness 3 weeks PTA patient experienced dizziness described as a feeling of falling down associated with cold, clammy sweat. Patient also complains of painful urination felt before he starts urinating, associated with dribbling. Other associated symptoms noted such as fever, nausea and vomiting. No consultation was done, no medications taken. Persistence of the above condition, prompted patient to seek consults hence admission. Past medical history: (+) HPN Family history: (+) HPN Physical Assessment Vital Signs > BP- 120/80 mmHg >CR: 79bpm >RR: 20cpm >T: 36.8 C Conscious, coherent, not in cardio respiratory distress Anicteric sclera, pink palperbral conjunctivae, no naso oral discharge, no tonsil pharyngeal congestion Symmetrical chest expansion, no retraction, no wheezes, clear breath sounds Normal rate regular rhythm, (-) murmur Flabby soft, normoactive bowel sounds, non tender Grossly normal extremities, (+) cyanotic nail both lower extremities, (+) pallor nails both hands, (+) melasma, (+) grade 2 bipedal edema Impression: DM type II uncontrolled HPN stage II t/c Diabetic dermopathy (+) DM (+) asthma - mother side (+) DM (-) asthma (-) allergy to food and drugs Age: 48 years old Address: Marilao, Bulacan Religion: Catholic



Endocrine System
Homeostasis depends on the precise regulation of the organ and organ systems of the body. The nervous and endocrine systems are two major systems responsible for that regulation. Together they regulate and coordinate the activity of nearly all other body structures. When these systems fail to function properly, homeostasis is not maintained. Failure of some component of the endocrine system to function can result in disease such as Diabetes Mellitus or Addisons disease. The regulatory function of the nervous system and endocrine systems are similar in some respects, but they differ in other important ways. The nervous system controls the activity of tissues by sending action potentials along axons, which release chemical signals at their ends, near the cell they control. The endocrine system releases chemical signals into the circulatory system, which carries to all parts of the body. The cells that can detect those chemical signals produce responses. The nervous system usually acts quickly and has short term effects, whereas the endocrine system usually response more slowly and has longer-lasting effects. In general, each nervous stimulus controls a specific tissue or organ, whereas each endocrine stimulus controls several tissues or organ. Functions: It regulates water balance by controlling the solute concentration of the blood. It regulates uterine contractions during delivery of the newborn and stimulates milk release from the breast in lactating females. It regulates the growth of many tissues, such as bone and muscles, and the rate of the metabolism of many tissues, which helps maintain a normal body temperature and normal mental function. Maturation of tissues, which result in the development of adult features and adult behavior, are also influence by the endocrine system. It regulates sodium, potassium and calcium concentrations in the blood.

It regulates the heart rate and blood pressure and helps prepare the body for physical activity. It regulates blood glucose levels and other nutrient levels in the blood It helps control the production and function of immune cells. It controls the development and the function of the reproductive systems in males and females. Pancreas An elongated gland extending from the duodenum to the spleen; consist of a head, body, and the tail. There is an exocrine portion, which secretes digestive enzymes that are carried by the pancreatic duct to the duodenum, and pancreatic islet, which secrete insulin and glucagon. The endocrine part of the pancreas consists of pancreatic islets (small islands; islet of Langerhans) dispersed among the exocrine portion of the pancreas. The islets secrete two hormones insulin and glucagonwhich function to help regulate blood nutrient levels, especially blood glucose. Alpha cells of the pancreatic islets secrete glucagon. Beta cells of the pancreatic islet secrete insulin. It is very important to maintain blood glucose levels within a normal range of values. A decline in the blood glucose levels within a normal range causes the nervous system to malfunction because glucose is the nervous systems main source of energy. When blood glucose decreases, other tissues to provide an alternative energy source break fats and proteins rapidly. As fats are broken down, the liver to acidic ketones, which are release into the circulatory system, converts some of the fatty acids. When blood glucose levelare very low, the breakdown of fats can cause the release of enough fatty acid and ketones to cause the pH of the fluids to decrease below normal, a condition called acidosis. The amino acids of proteins are broken down and used to synthesize glucose by the liver. If blood glucose levels are too high, the kidneys produce large volumes of urine containing substantial amounts of glucose because of the rapid loss of water in the form of urine, dehydration result. Insulin is released from the beta cells primarily response to the elevated blood glucose levels and increased parasympathetic stimulation that is associated with digestion of a meal. Increase blood levels of certain amino acids also stimulate insulin secretion. Decreased result from decreasing blood glucose levels and from stimulation by the sympathetic of the nervous system. Sympathetic stimulation of the pancreas occurs during physical activity. Decreased insulin levels allow blood glucose to be

conserved to provide the brain with adequate glucose and to allow other tissues to metabolize fatty acids and glycogen stored in the cell.The major target tissues for insulin are the liver, adipose tissue, muscles, and the area of the hypothalamus that controls appetite, called satiety center (fulfillment of hunger).Insulin binds to membrane-bound receptor and, either directly or indirectly, increases the rate of glucose and amino acid uptake in these tissues. Glucose is converted to glycogen or fat, and the amino acids used to synthesize protein. Glucagon is released from the alpha cell when blood glucose level is low. Glucagon binds to membrane-bound receptors primarily in the liver and caused the conversion of glycogen storage in the liver to glucose. The glucose is then released into the blood to increase blood glucose level. After a meal, when blood glucose levels are elevated a glucagon secretion is reduced. Insulin and glucagon function together to regulate blood glucose levels. When blood glucose increase, insulin secretion increases, and glucagon secretion decreases. When blood glucose levels decrease, the rate of insulin secretion declines and the rate of glucagon secretion increase. Other hormones, such as epinephrine, cortisol, and growth hormones, also function to maintain blood levels of nutrients. When blood glucose level decrease, these hormones are secreted at a greater rate. Epinephrine and cortisol caused the breakdown of protein and fat and the synthesis of glucose to help increase blood levels of nutrients. Growth hormone slows protein breakdown and favors fat breakdown.



Genetic factor

Increasing age

Failure to produce insulin and/or insulin resistance

Production of excess glucagon

Elevated blood sugar Increased osmolarity due to glucose Chronic elevations in blood glucose

Production of glucose from protein and fat stores


Wasting of lean body mass Weight loss

Glycoprotein cell wall deposits

Accelerated atherosclerosis


Small vessel disease Diabetic retinopathy Diabetic nephropathy Loss of vision/ blindness

Increased LDL levels




EXAM: Chest AP/ Apico Lordotic view INTERPRETATION: -LUNGS are clear. -Heart is enlarged. -Diaphragm and Castopherinic sulci are intact. - Bony structures are unremarkable. URINALYSIS (FEBRUARY 14, 2013) MACROSCOPIC Color: light yellow Transparency: slightly turbid MICROSCOPIC RBC: 1-3/HPF PROTEIN: trace GLUCOSE: +4 KETONE: NEGATIVE UROBILINOGEN: NORMAL BILIRUBIN: NEGATIVE LEUKOCYTES: NEGATIVE specific gravity: 1.015 ph: 6.0


The color, specific gravity, ph level and RBC are normal. Semen, mucus, and lipid may cause turbidity in normal urine. "Trace" protein is equivalent to 10 mg/100 ml or about 150 mg/24 hours (the upper limit of normal). Finding glucose in the urine is not a normal finding. Typically, this is found in patients with diabetes. Presence of few epithelial cells in a sample can be cause by improper collection of the urine, meaning that the sterile specimen has been contaminated.

CLINICAL CHEMISTRY (FEBRUARY 15, 2013) RESULT 132.2mmol/L 3.8mmol/L 2.22 1.4 106.9 NORMAL VALUE 137-144mmol/L 3.5-5.0mmol/L 2.2-2.9 1.1-1.4 98-108 REMARKS LOW NORMAL NORMAL NORMAL NORMAL


- Decrease in sodium is seen in states characterized by intake of free water or hypotonic solutions, as may occur in fluid replacement following sweating, diarrhea, vomiting, and diuretic abuse. Dilutional hyponatremia may occur in cardiac failure, liver failure, nephrotic syndrome, malnutrition, and SIADH. There are many other causes of hyponatremia, mostly related to corticosteroid metabolic defects or renal tubular abnormalities. Drugs other than diuretics may cause hyponatremia, including ammonium chloride, chlorpropamide, heparin, aminoglutethimide, vasopressin, cyclophosphamide, and vincristine. RESULT 4.2mmol/L 0.37mmol/L 14.7% NORMAL VALUE 3.9-5.8mmol/L 0.21-0.43mmol/L <6.4% REMARKS NORMAL NORMAL HIGH



RESULT 9.9mmol/L 24.0 U/L

NORMAL VALUE 2.2-7.1mmol/L 0-0.41 U/L


- Serum urea nitrogen (BUN) is increased in acute and chronic intrinsic renal disease, in states characterized by decreased effective circulating blood volume with decreased renal perfusion, in postrenal obstruction of urine flow, and in high protein intake states.


ESOMEPRAZOLE MAGNESIUM (NEXIUM) -proton pump inhibitor antisecretory drug

> Suppresses gastric acid secretion by specific inhibition of hydrogen-potassium ATPase system at the secretory surface of the gastric parietal cells

(gastroesophageal reflux disease), duodenal ulcer disease, and erosive esophagitis > Crohn's disease



>Monitor for S&S of adverse CNS effects (vertigo, agitation, depression) especially in severely ill patients. >Monitor phenytoin levels with concurrent use. >Monitor INR/PT with concurrent warfarin use. >Lab tests: Periodic liver function tests, CBC, Hct & Hbg, urinalysis for hematuria and proteinuria.

Contraindicated with > headache, diarrhea, hypersensitivity to nausea, flatulence, omeprazole or other decreased appetite, proton pump inhibitor. constipation, dry mouth, and abdominal pain, severe allergic reactions, chest pain, dark urine, fast heartbeat, fever, paresthesia, persistent sore throat, severe stomach pain, unusual bruising or bleeding, unusual tiredness, and yellowing of the eyes or skin

ISOPHANE INSULIN (HUMULIN N) - Antidiabetic drugs

> Increase glucose transport across muscle and fat cell membranes to reduce blood glucose level. Promotes conversion of glucose to its storage form, glycogen; triggers amino acid uptake and conversion to protein in muscle cells and inhibits protein degradation; stimulates triglyceride formation and inhibits r3elease of free fatty acids from adipose tissue; and stimulates lipoprotein lipase activity, which converts circulating lipoproteins to fatty acids.

> Diabetic ketoacidosis, Type I diabetes, adjunct to type II diabetes inadequately controlled by diet and oral antidiabetic agents

> contraindicated with hypersensitivity to drug; diabetic ketoacidosis; cirrhosis; inflammatory bowel disease

> Common: lipoatrophy, lipohypertrophy >Uncommon: urticaria, pruritus, swelling, redness, stinging, warmth at injection site, hypersensitivity reactions >Life-threatening: anaphylaxis, hypoglycemia

>Dosage is always expressed in USP units remember to use only the syringes calibrated for the particular concentration of insulin administered >To mix insulin suspension, swirl vial gently or rotate between palms or between palm and thigh. dont shake vigorously. > Regular insulin may be mixed with NPH or lente insulins in any proportion. When mixing regular insulin with intermediate or long acting insulin, always draw up regular insulin into syringe first.








Ineffective tissue perfusion (Renal) related to Increase Nahihirapan decrease blood akong umihi, as glucose as verbalized by the circulation manifested by patient. decreased urine output. Objective: > presence of bipedal edema >Decreased urine output- <30cc/hr

Within 5 hours of >Monitor nursing output blood intervention, the client will be able to urinate without pain. >Restrict intake

urine >To come with a After 5 hours of baseline data nursing intervention, the patient was able to urinate without fluid >To avoid severity pain. of the problem.

Decrease blood circulation

>Apply warm >To stimulate the compress on the urge to urinate. bladder

>Administer diabetic medication ordered Decrease perfusion renal

>To stimulate as urination

Decrease output









Risk for falls related to visual Nanlalabo ang difficulties Increase to glucose mga mata ko, as secondary verbalized by the hyperglycemia as manifested by patient. elevated Hgt= 442mg/dl Objective: BP: 120/80 CR: 79 RR: 20 T: 36 >Hgt level 442mg/dl of

Within 3hours of nursing blood intervention the patients blood glucose will be lower from 442mg/dl to 110mg/dl.

>Assist client >To avoid possible After 3hours of during ambulation injuries nursing intervention the patients blood glucose would be from >Provide side rails > To avoid the lowered 442mg/dl to in the patients existence of falls 110mg/dl. bed side

Decrease blood circulation

> Provide health teaching to > To promote clients significant safety precautions others that never leave the client alone especially in the comfort room

Decrease perfusion

tissue > Administer diabetic medications as ordered

Impaired sensory function

> Helps in lowering down blood glucose level

Subjective: Parang manhid ang mga paa ko, as verbalized by the patient. Objective: >(+) cyanotic nail both lower extremities >(+) pallor nails both hands >(+) grade bipedal edema >Hgt level 442mg/dl 2







Ineffective tissue Within 8 hours of >Monitor urine perfusion thorough nursing output related to Increase blood intervention, the increased blood glucose patients viscosity secondary to Blood glucose >Restrict fluid hyperglycemia as level of 442mg/dL intake manifested by will be 110mg/dl grade 2 bipedal and the edema edema and will be reduced. Hgt=442mg/dl. >Apply warm compress on the Decrease blood bladder circulation

>To come with a After 8 hours of baseline data thorough nursing intervention, the patients glucose >To avoid severity Blood level of 442mg/dL of the problem. would be 110mg/dl and the edema would be >To stimulate the reduced. urge to urinate.

of Decrease perfusion tissue

>Administer diabetic medication, ordered

>To stimulate as urination

Edema formation


FIRST DAY OF ADMISSION Admitted to ROC under the service of Dr. Santos. Secured consent for admission and consent. Vital signs monitored and recorded every shift. IVF of PNSS 1liter was ordered and cosumed for 12 hours. Diabetic diet was ordered. Diagnostic procedures like CBC, BUN,BUA, FBS, SGPT, CBG, urinalysis, serum creatinine and lipid profile were ordered. Amlodipine (NORVASC), 5mg was given. AP was informed, complete history and physical examination was done. CBG was done with a result of 400mg/dl. Refered back to Dr. Deduyo and Dr. Miranda. Requested for 2D echo with Doppler andarterial duplex scan andcarotid duplex scan. Dilostazol (Pletoal) 50 mg. was given.

SECOND DAY OF ADMISSION FBS AND HBAIC were requested. Iberet active was given. Requested PSA. CBG result was 425 mg/dl. Creatinine clearance, TPA, GFR. were requested. 10 U HR SQ was given. Referred And examined at the ophthalmology department. Seen and examined by Dr. Aquino. Ordered to continue present management.


Hypoglycemic medicines are given to decrease the amount of sugar in the blood. Hypoglycemic medicine helps to move the sugar in cells, where it is needed for energy. Insulin is needed to take insulin if diabetes cannot be controlled with nutrition, exercise, or other diabetes medicine. There may be a need for 1 or more doses of insulin each day. Insulin can be injected or given through an insulin pump.

Exercise / Activity
Exercise can help keep blood sugar level steady, decrease risk of heart disease, and help lose weight. Advise to exercise for at least 30 minutes, 5 days a week. Include muscle strengthening activities 2 days each week, such as push-ups, sit-ups, and lifting weights. A need to eat a carbohydrate snack before, during, or after exercises is also advice. If blood sugar level is less than 100 mg/dL, have a carbohydrate snack before exercise. Examples are 4 to 6 crackers, banana, 8 ounces (1 cup) of milk, or 4 ounces ( cup) of juice.

Remind the patient about the drugs he will be taking at home. Also inform the patient about the benefits of taking the drugs regularly and the risk if it is not taken every day. Emphasize the need to check blood sugar level at least 3 times each day.

Health Teaching
Educate client how to manage diabetes. Teach them on what they can do if blood sugar level goes too high or too low. Teach the patient how to use a glucose monitor. Advise patient to check blood sugar level at least three times each day. Teach the patient to dispose used needles and syringe properly.

Advise patient to have a regular checkup regarding his condition. Inform patient of the different complications about his disease and to consult a doctor immediately when he experience one of the complications.

A low fat, low salt diet is advised. Advise to eat foods high in fiber like vegetable, whole grain and breads. Encourage to limit alcohol intake and quit smoking.


Keeping an open communication with the family will help him cope with this situation. The love and support that he will get from his family will help him ease his sufferings.