Pathophysiology (disease process and/or medical diagnosis) 1) Hypoglycemia- Imbalance of glucose production and utilization.

Glucose utilization exceeds production which results in a low blood glucose level (< 60 mg/dL). 2) Diabetes Type II- There is a reduced amount of insulin being produced in the body and the target cells become resistant to the insulin that is produced. This means that insulin is unable to perform at the target tissues to breakdown glucose and make it available to the cells. Insulin enhances the membrane transport of glucose into fat and muscle cells where it provides energy for the cells. 3) Hypertension- Higher than normal blood pressure over subsequent measurements. The major contributing factors of hypertension are cardiac output, peripheral resistance and blood volume. The kidneys release renin which converts Angiotensinogen to Angiotensin I. Angiotensin I is converted to Angiotensin II. Angiotensin II stimulates the Adrenal gland to release aldosterone which increases the sodium and water retention in the kidneys which increases blood volume. Angiotensin II also causes vasoconstriction in the blood vessels which in turn increases blood pressure. Medical Diagnoses: 1) Hypoglycemia 2) Diabetes Type II 3) Hypertension

Uncontrolled diabetes caused the hypoglycemia. It can also lead to hypertension which can cause kidney damage.

Textbook signs and symptoms 1) Hypoglycemia- tremors, palpations, nervousness, anxiety, sweating, hunger, irritability, confusion, drowsiness, weakness, difficulty speaking, unresponsiveness, unconsciousness, seisures, and coma 2) Diabetes Type II- elevated blood glucose, glucose in urine, increased urination, low blood pressure, increased heart rate, increased thirst, increased appetite, weight loss, fatigue, dehydration 3) Hypertension- silent killer high blood pressure is asymptomatic in the beginning, higher than normal bp over time, headache, dizziness, sleepiness, nausea, vomiting, irritability, visual disturbances, myocardial infarction, heart failure, renal failure

Clients sign and symptoms 1) Hypoglycemia- weakness, blood glucose 29-50 upon admission. 2) Diabetes Type II-elevated blood glucose ranging from (118-193), fatigue while in hospital. 3) Hypertension- blood pressure 150/76

Chief Complaint: History of Illness: Past History:

Weakness, not feeling well Hypoglycemia related to Diabetes Type II, Hypertension Bilateral Blindness, Acute Renal Failure, Congestive Heart Failure, Dyslipidemia, GERD, Anemia, Leukocytosis, Morbidly Obese. Fell a couple of weeks ago; brought to hospital, but no broken bones; sent home. No known family history of disease. 73 year old female. Lives alone, but daughter comes during the day to help. Fear of isolation. Worried about lack of continuity of healthcare. Hypoglycemia Subjective Data Weak Not feeling well Objective Data Lower extremity edema Blood glucose level at admission 29 Blood glucose levels during hospitalization elevated (ranging from 118-193) Small amount of blood in urine Blood pressure 150/76 Morbidly Obese Decreased ROM in upper and lower extremities Limited mobility Bilateral blindness

Family History: Social Data: Psychological Data: Adm.Medical Diagnoses: ASSESSMENT

DIAGNOSES

Nursing Diagnosis(es): Imbalanced nutrition related to poor dietary habits and excessive intake related to metabolic needs as evidenced by morbid obesity. Impaired physical mobility related to weakness and fatigue as evidenced by limited ROM and inability to ambulate purposefully within physical environment (bed, chair, and other transfers required for ADLs). Self-care deficit related to impaired mobility, fatigue, weakness as evidenced by inability to feed, dress, bathe and groom, and ambulate independently. Ineffective health maintenance related to lack of caregiver support, morbid obesity, physical disabilities and challenges, as evidenced by inability to follow programs for proper dietary requirements.

P L A N N Interventions and caregivers participate in nutrition counseling. I Patient, family, appropriate dietwill diabetes and hypertension. information on for N G

Desired Outcome: (Goal(s) Patient will verbalize appropriate meal selections for diabetic diet by October 16. Patient will reduce weight by 5 - 10% (approximately 16 - 30 pounds) by April 2012. Patient will move between bed, chair, and bedside toilet, with the aid of assistive devices by October 27. Patient will demonstrate ability to self-feed simple foods such as crackers, cut pieces of fruit, bread when placed directly in front of them or in their hand by the end of the day on October 13. Patient will demonstrate ability to bathe face and upper extremities, and provide toilet hygiene for urination when provided with appropriate tools and assistive devices by October 27. Rationales Provide Dietitians have a greater understanding of the nutritional value of foods and can help develop a nutritional plan for the patient to follow. Success rates are higher when the family participates in a healthy eating plan. A record will allow the dietician to help patient with making adjustments to the diet to ensure nutritional needs are being properly met. Physical and occupational therapists can provide specialized services to promote effective mobility. Prevents further debilitation of mobility and provides patient with small achievable goals. Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength and endurance. Assistive devices increase independence in performance of ADLs

Nutrition Monitoring- Patient will keep a daily log of food and liquid consumed.

Have patient work with physical therapist to increase ROM and ambulation.

Keep patient as functionally active as possible.

Perform ROM exercises to all extremities.

Assess the need for assistive devices.

Encourage the patient to provide as much participation/ completion of ADLs as he Caregivers are often in a hurry and do more for or she is capable of. Assist with feeding, completion of bath, brushing teeth, etc, patients than needed, this can slow the patient's efforts only as needed. of resuming ADLs. An appropriate level of assistive care can prevent injury and decrease frustration. Evaluate the safety of the immediate environment. Obstacles such as throw rugs and pets can hinder ability to ambulate safely. Regular assessment of skin will allow for prevention or early treatment of pressure ulcers. Reduced activity and immobility decrease gastrointestinal mobility. Small accomplishments will encourage them to keep working towards long term goals. Helps the patient to remain more independent and continue or improve ability to perform ADL with less assistance from caregivers.

Assess skin integrity for signs of redness and tissue breakdown.

Assess elimination status.

Compliment the patient on positive accomplishments.

Use consistent routines and allow adequate time for the patient to complete tasks

E V A L U A T I O

Clients response to each intervention (If modifications necessary, what intervention would be appropriate?) Patient willingly participated in exercises from physical therapist. Willing to attempt self-feeding only when specifically requested to do so. Patient expects and accepts more help than is needed with certain tasks; make sure caregivers get her to try things on her own first. Was the desired outcome achieved? (Met unmet, partially met) Why? Patient was able to feed herself crackers and peanut butter when placed in her hand. Patient was able to wash her own face when provided with a washcloth to do so. Patient is progressing towards other goals that have not reached their time to be completed. Patient went beyond goals that physical therapist had set for her on October 13.

Learning Needs/Discharge Needs Patient and family/ caregiver need to meet with nutritionist and be given information on appropriate diet for diabetes and hypertension. Patient needs to be taught proper usage of assistive devices. Patient is being discharged to rehabilitation facility.

Nutritional/ Fluid Needs while hospitalized 1800 calorie diabetic diet Normal Saline IV 75mL/hour Growth and Development

Expected Developmental Adjust to: decreased physical strength and health, retirement and lower fixed income, death of parent, spouse, friends, new relationships with adult friends. Physiological Increased skin dryness, pallor, fragility. Skin wrinkling, age spots, thickening of nails with ridges. Joint stiffness, impaired balance, loss of visual acuity, progressive hearing loss, decreased sense of taste and smell. Decreased lung expansion, increased residual volume, difficult, short, heavy, rapid breathing following exercise. Reduced cardiac output and stroke volume. Increase in blood pressure. Increased tendency for indigestion and constipation. Impaired renal function, urinary urgency and frequency, nocturnal urination. Shrinkage and atrophy of reproductive organs, decreased vaginal lubrication. Decreased immune response, poor response to immunization. Increased insulin resistance, decreased thyroid function. Psychosocial Integrity vs despair. Positive: Acceptance of worth and uniqueness of ones own life. Acceptance of death. Negative: Sense of loss, contempt for others.

Actual Developmental Adjusted to decreased physical strength and health, death of spouse.

Physiological Skin wrinkling, thickened and ridged nails, joint stiffness, impaired balance, bilateral blindness, high blood pressure, GERD and constipation, type II diabetes, acute renal failure, congestive heart failure,

Psychosocial Recognizes worth of own life. Feels important to family members.

Diagnostic Studies: TEST Glucose NORMAL 60-110 mg/dL CLIENT 158 mg/dL NURSING IMPLICATIONS Ask client for glucose testing method and past results. Answer client questions. Discuss procedure with client and have them demonstrate the procedure. Discuss the course of action if test result is abnormal. Instruct client to take insulin or oral hypoglycemic agent at prescribed time. Tell client to report immediately signs and symptoms of hypoglycemia or hyperglycemia. Instruct client to keep accurate records of glucose test. Encourage client to keep all medical appointments. Elevated BUN is associated with dehydration; meds such as Furosemide can also cause elevated level. If BUN and Creatinine are elevated, suspect kidney disease. Instruct client with slightly elevated BUN to increase fluid intake. Care should be taken in forcing fluids in clients with heart and kidney problems. Relate elevated levels to clinical problems ex: muscle mass. Hold medications for 24 hours before test if permissible. Check urine output for 24 hours; less than 600 mL can indicate renal insufficiency. If BUN and Creatinine are elevated, suspect kidney disease. Instruct client to eat less beef, poultry, and fish if the level is severely elevated. Observe for signs and symptoms of hyperkalemia, abdominal cramps, oliguria or anuria, tingling, twitching or numbness of extremities. Assess urine output; should be at least 600 mL/ 24 hours. Report serum potassium levels greater than 5.3 mEq/L. No more than 10 mEq KCl per hour by IV. Check age of whole blood before administering (older than 2 weeks has elevated potassium level). Assess level every 6-8 hours if over 6.5 mEq/L. Restrict potassium intake if greater than 6.0 mEq/L. Notify health care provider if client is receiving a digitalis preparation when calcium gluconate is given. An elevated serum calcium level enhances the action of digitalis, causing digitalis toxicity. Instruct client not to self-medicate when receiving anticoagulant therapy; take anticoagulants as ordered by health care provider. Inform client not to consume excess alcohol because it can affect liver function. Relate decreased level to clinical problems. Check for blood loss and obtain history of anemias, renal insufficiency, chronic infection, or leukemia. Determine if client is overhydrated. Observe for signs and symptoms of andvanced iron deficiency anemia (fatigue, pallor, dyspnea on exertion, tachycardia, and headache. Instruct client to follow medical regimen. Instruct client to eat foods rich in iron (liver, red meats, green

BUN

5-25 mg/dL

41 mg/dL

Creatinine

0.5- 1.5 mg/dL

1.90 mg/dL

Potassium

6.0 mEq/L

RBC

4.0-5.0

3.19

HGB

12-15g/dL

9.4 g/dL

HCT

36-46%

28.7%

Lymph %

B cells 6-16% T cells 60-80%

15.1

vegetables). Explain to client taking iron supplements that the stools usually appear dark in color. Tell client to take iron medication with meals. Milk and antacids can interfere with iron absorption. Recognize clinical problems and drugs that could decrease HGB. Anemia is a common cause if HGB <10.5 g/dL. Observe client for signs and symptoms of anemia (dizziness, tachycardia, weakness, dyspnea at rest). Check hematocrit level if HGB level is low. Instruct client to maintain adequate fluid intake. Frequently older adults tend to drink less fluid. Relate decreased hematocrit to clinical problems and drugs. HCT <30 indicates moderate to severe anemia. Assess for signs and symptoms of anemia (fatigue, paleness, and tachycardia). Assess changes in vital signs to determine whether shock is present because of blood loss. Symptoms include rapid pulse, rapid respirations, and normal or decreased blood pressure. Instruct client to stay away from persons with colds or communicable diseases. Listen to client concerns.

Risk Factors for Medical Diagnoses: Hypoglycemia- Poorly controlled diabetes, skipping meals, kidney disease, liver disease, medications, alcohol consumption. Diabetes Type II- Family history of diabetes type II, obesity Hypertension- Advanced age, alcohol abuse, diabetes, family history of high blood pressure, high cholesterol, high salt intake, kidney disease, lack of exercise, obesity, smoking, stress

DRUG NAME NovaLog Insulin Aspart

ACTION Anti-diabetic, RapidActing Insulin. Provide glucose control. Anticoagulant, antithrombotic. Prevent DVT; anticoagulation after surgery.

DOSE 2- 14 units = 0.2- 1.4 mL subq ACHS

SIDE EFFECTS

NURSING CONSIDERATIONS Monitor S&S of hypoglycemia, hold drug and notify physician if patient is hypokalemic. Notify physician if platelet count less than 100,000mm3, monitor for S&S of unexplained bleeding, monitor closely if pt has renal insufficiency Monitor BP during dosage adjustment, obtain frequent blood count, monitor blood and urine glucose in diabetics, monitor I&O and report decrease or unusual increase in output, weigh patient daily.

Lovenox Enoxaparin Sodium

Lasix Furosemide

Diuretic, antihypertensive. Decreases edema and intravascular volume.

Amaryl Glimepiride

Anti-diabetic. Lowers blood sugar by increasing secretion of insulin.

Oscal D Calcium Carb 250 + Vit D

Antacid, nutritional supplement. Relieves symptoms of acid indigestion and useful as calcium supplement.

Hypoglycemia, lypokalemia, injection site reaction, lipodystrophy, pruritus, rash 30 mg = 0.3 mL subq NQ day Allergic reaction (rash), fever, pain and inflammation at injection site, peripheral edema, fever, dyspnea, rash, pruritus 40 mg = 1 tab po ACBS Hypotension, dizziness, dehydration, elevated BUN, nausea, vomiting, oral and gastric burning, abdominal cramping, constipation, jaundice, renal failure, vertigo, blurred vision, photosensitivity, increased perspiration, muscle spasms, weakness. 4 mg = 1 tab po qday Dizziness, headache, blurred vision, nausea, vomiting, diarrhea, abdominal pain, hypoglycemia, rash, pruritus, erythema. 2 tab po qday Constipation or laxative effect, nausea, flatulence, vomiting, hypercalcemia, mood and mental changes, polyuria.

Monitor glucose frequently, monitor for hypoglycemia.

Note number and consistency of stools, monitor for S&S of hypercalcemia.

Catapres Clonidine HCL

Antihypertensive, analgesic. Decreases systolic and diastolic BP and heart rate. Minimizes S&S associated with withdrawal of heroin, methadone, and other opiates.

0.1 mg = 1 tab po q6h 0.2 mg = 1 tab po q6h

Apresoline Hydralzine HCL

Vasodilator, antihypertensive. Reduces BP, vasodilation improves CO and renal and cerebral blood flow.

50 mg = 1 (0.5) tab po qday 120 mg = 2 (0.6) tab po qday

Zantac Ranitidine

Antisecretory (H2 receptor antagonist), antiulcer. Blocks nocturnal basal gastric acid secretion by histamine, and reduces gastric acid release in response to food, caffeine, pentagastrin, and insulin.

150 mg = 1 tab po bid

Hypotension, peripheral edema, tachycardia, bradycardia, flushing, rapid increase in bp, dry mouth, constipation, abdominal pain, altered taste, nausea, vomiting, hepatitis, weight gain, drowsiness, sedation, dizziness, headache, fatigue, weakness, dyspnea, nervousness, restlessness, depression, rash, pruritis, thinning of hair, dry eyes, impotence. Rash, fever, chills, headache, dizziness, palpitation, tachycardia, arrhythmia, shock, conjunctivitis, anorexia, nausea, vomiting, diarrhea, constipation, abdominal pain, difficulty urinating, anemia, nasal congestion, muscle cramps, edema. Headache, dizziness, insomnia, mental confusion, depression, constipation, nausea, abdominal pain, diarrhea, rash, decrease in WBC count, hypersensitivity.

Monitor BP closely, monitor I&O during dosage adjustment, record weight daily, monitor for depression.

Monitor BP and HR closely. Monitor I&O.

Potential for toxicity from slow clearance rate, Be alert for Jaundice, long term therapy may lead to B12 deficiency.

Zocor Simvastatin

Antilipidemic, Statin. Decreases serum triglycerides, LDL, cholesterol and moderate increases in HDL cholesterol. Antidiabetic, hormone modifier. Increases insulin secretion reduces glucagon secretion. Lowers glucose levels.

20 mg = 1 tab po HS

Onglyza Saxagliptin

2.5 mg = 1 tab po qday

Angina, dizziness, headache, vertigo, fatigue, insomnia, nausea, diarrhea, vomiting, abdominal pain, constipation, flatulence, heartburn, fatigue, rhinitis, cough. Peripheral edema, headache, abdominal pain, vomiting, hypoglycemia, upper respiratory infection, facial edema, sinusitis, urinary tract infection

Report unexplained muscle pain, monitor cholesterol levels.

Monitor for S&S of GI distress and hypoglycemia.