A Case Study
Diabetes Mellitus Type II
“The Weakest Link”
I. Health history
A. Demographic profile
? Name: R.G
? Gender: Male
? Age: 41 years old
? Birth date: September 23, 1967
? Birth place: Pasig , Metro Manila
? Marital status: Married
? Nationality: Filipino
? Religion: Born Again- Christian
? Address: Brgy. Pantihan 3, Maragondon, Cavite
? Educational background: High school graduate
? Occupation: Factory worker in Monterey
? Usual source of medical care: Doctor/Healthcare Professional
B. Source and reliability of information
? The patient R.G is the primary source of information. He is conscious and coherent, able to speak Tagalog fluently. His wife is also considered as source of information regarding patient status and condition.
C. Reasons for seeking care or chief complaint (Top 3)
? 1st – Loss of his weight
? 2nd – Insufficient sleep at night
? 3rd – Scaly of skin
D. History of present illness
Patient R.G was handled during our duty at Brgy. Pantihan 3, Maragondon,,Cavite with the chief complaint of insufficient sleep at night, loss of his weight and scaly of skin. The laboratory test and special treatment for the patient are not applicable because this case is base on community setting.
E. PAST MEDICAL HISTORY OR PAST HEALTH
-Incomplete immunization- (-) serious illness on this stage
* Injuries or accidents
-1992, right leg accident due to mishandling of machine
* Serious or chronic illness
-December 2003, Diabetes Mellitus diagnosed clinically
-2x FBS result 300mg/dl
-2006 Pulmonary Tuberculosis, diagnosed clinically
-Chest X-ray and sputum AFB examination
-2007 Urinary Tract Infections
-1992, Water Rose General Hospital
Admitting diagnosis: Right leg machine accident
-December 2003, Rizal Medical Center, Pasig City, Metro Manila
Admitting diagnosis: Diabetes Mellitus Type 2
* Obstetric History
-incomplete immunization (unrecalled)
-No known allergies to food and medication
1 tab TID p.c.
1 tab OD a.c.
-Vitamin B Complex tablet
1 tab OD
-Alaxan 500mg/tab (Paracetamol + Ibuprofen)
1 tab PRN for fever and pain
* Last Examination Date
-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila
F. FAMILY HISTORY
G. SOCIO-ECONOMIC STATUS
Mr. R.G. lives in their own house at Pantihan 3, Maragondon, Cavite. His wife is selling and making barbeque sticks as the source of their income while his 16 years old son works as a vendor in a wet market at Dasmarinas, Cavite as additional source of income. They also received financial support from their relatives in Pasig. They can be measured up as to poor class family. The patient is occasionally drinker of alcohol and cigarette smoking.
H. DEVELOPMENTAL HISTORY
Generativity vs Stagnation
Maturity (35-45 yrs old)
A person may experience midlife crisis between the ages of 35-45 years old, the “deadline decade”. This occurs when the individual recognizes that he has reached the halfway mark of life and according to Erik Erikson, the developmental task of the middle-aged adult is Generativity vs. Stagnation.
As to our patient, who belongs to a middle age group and is suffering from a life-threatening condition, he had experienced this developmental crisis, which led him to be non-productive.
Being non-productive led him to be stagnant after the occurrence and diagnosis of his disease which made him to be dependent with his family, he can’t attend, function and be able to accomplish his responsibilities as a father, a husband and as part of the community.
I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION
“Ito nangangayat na dahil sa sakit ko” as verbalized by the patient. Weight: 35 kg. (July 10, 2009)
87 kg. (December 2003)
(+) wt. loss 48kg.
(+) numbness at times(lower extremities)
(+)excessive sweats, axilla
BP- 130/80 Temp. – 36.5 °C
“Hindi makati sa binti, pero ang braso, nangangati” as verbalized by the patient. (+)itchiness (upper extremities)
(-)history of skin disease
“Dati malago ang buhok ko” as verbalized by the patient. Thinning of hair, evenly distributed
(+)itchy scalp (scratching)
“Ito matigas na ang kuko ko kumpara dati” as verbalized by the patient. (+)clubbing of nails (long nails)
(+)Yellowish nail beds
Amount of sun exposure: Exposure to sunlight every morning
“Sumasakit ang ulo ko na parang tinutusok” as verbalized by the patient. (+)frequent headache
“Malabo na ang paningin ko” as verbalized by the patient. (+)blurry vision
“Malinaw pa naman ang pandinig ko, pero may sumasakit minsan” as verbalized by the patient. Both ears hears well when the examiner is 3 feet away
Mouth and Throat:
“Medyo hirap akong lumunok” as verbalized by the patient. (+)difficulty in swallowing
(+)lesions on tongue
(+)hoarseness of voice
(+) gag reflex
“Wala naming problema sa leeg ko” as verbalized by the patient. (-)stiffness
(+)palpable bilateral lymphs
Breasts and Axillae:
“Pawisin ang kilikili ko” as verbalized by the patient. (+)excessive sweating, axilla
“Medyo nahihirapan akong huminga” as verbalized by the patient. RR – 28 bpm
(+)difficulty of breathing
History of lung disease: pneumonia, PTB, 2006
Last chest x-ray: 2007
“Paminsan- minsan sumasakit ang dibdib ko” as verbalized by the patient. (+)chest pain
(+)dyspnea on exertion (bed to chair)
(+)pallor in hands
(+)clubbing of nails
(+)tingling (sole of feet)
0-1 second, capillary refill
“Eto madalas magan ako kumain” as verbalized by the patient. (+)good appetite
Food intake tolerated
Frequency of BM: 3x a week
Characteristic of stool: yellowish- brown in color, formed in consistency
(+)constipation (arch and formed stool)
“Ihi ako ng ihi” as verbalized by the patient. (+)polyuria
Dark Yellow in color
History of urinary disease: UTI(2006)
“Kumikirot ang kasukasuan at buto-buto ko” as verbalized by the patient. (+)minimal pain, knee area and ankle
(+)pain, calf area
(+)lower back pain, radiating
(+)weakness, leg muscles
“Alam ko pa naman ang mga sinasabi ko ngayon” as verbalized by the patient. (-)history of seizure, stroke, fainting
Self-pity and crying
Oriented to time, person and place
“Pagkakaalam ko,wala naman akong sakit sa dugo” as verbalized by the patient. (-)bruises
(+)palpable lymph nodes
(+)bleeding tendency of skin (scaly skin)
(-)history of Blood Transfusion
“Sa pamilya naming may Diabetes, kaya ako merong Diabetes” as verbalized by the patient. (+)DM, type II
(+)change in skin texture, scaly skin
(+)excessive sweating, axilla
Cranial Nerves Assessment
I. Olfactory Nerve – Normal
II. Optic Nerve – Blurry vision
III. Oculomotor – Normal
IV. Trochlear – Normal
V. Abducens – Normal
VI. Trigeminal – Normal
VII. Facial – Normal
VIII. Acoustic – Normal
IX. Glossopharyngeal – Normal
X. Vagus – Normal
XI. Spinal Accessory – Normal
XII. Hypoglossal – Normal
J. FUNCTIONAL ASSESSMENT
I. Health Perception/Health Management Pattern
Mr. R.G. is a 41 yrs old, male and seriously ill person. Once he felt something wrong about his condition, he seeks for medical advice. Occasionally, he also had colds in the past. Last December 2003, after a consultation from a physician and with accompanying lab result of blood sugar level (2x done, result is increased 300mg/dl) he was diagnosed of DM type 2. The client believes that he acquired his illness from his grandfather who also had Diabetes Mellitus. According to Mr. R.G., eating nutritious food, exercise and religiously taking of prescribed medication or what nurse’s and Doctor’s advise/suggest will keep him healthy. Due to financial incapacity, this regimen was not taken into consideration.
II. Self Esteem, Self Concept/Self Perception Pattern
Before he was diagnosed with DM type 2, Mr. R.G. is a responsible husband and father to his wife and kids. He was able to provide the needs of his family. The client possessed a jolly and fun loving type of personality.
Since his illness started, most of the time, he felt self-pity and worthless. He is always irritable and angry when he thinks that he was ignored. Because of his condition he became more depress and the only thing that gave him hope and strength is through prayer.
III. Activity-Exercise Pattern
Perceived ability for: (Refer to Functional Level Code)
Feeding Level II Grooming Level II Bathing Level II General Mobility Level II Toileting Level II Cooking Level IV Bed Mobility Level II House Maintenance Level IV Dressing Level II Shopping Level IV
Functional Level Code
Level 0 Full Self Care Level I Requires Use of Equipment or Device Level II Requires Assistance or Supervision from Another Person Level III Requires Assistance or Supervision from Another Person and device Level IV Is Dependent and Does Not Participate
IV. Sleep/Rest Pattern
The patient had altered sleep pattern. Each day he only had a maximum of 2 hours of sleep and despite of that he still fells god upon waking up. He said sometimes the pain he felt put him into sleep.
V. Nutritional/ Elimination
The patient usually takes a glass of milk in his breakfast and he takes heavy meals more frequently but after eating he usually felt stomach ache. He has supplements of vitamin B-complex. He typically drinks more than an 8 glasses of water per day. Patient stated that prior to his illness he weighted 87kgs but at present he weighs 39kgs.
We noticed that the patient skin is scaly all over his body. He also have lesion in his tongue and positive dental carries.
The patient usually had 3x bowel movement per week with a dark yellowish brown color stool, with hard formed in consistency. On the other hand he noted that he frequently void with dark yellow in color urine and felt some discomfort when urinating.
During the day patient is experiencing excessive sweating in his armpit.
VI. Sexually- Reproductive Pattern
The patient is inactive in sexual intercourse due to present condition
VII. Interpersonal Relationship / Resources
Patient can speak and understand English and Tagalog. He can clearly express himself. He has 6 children and they were close to each other.
Before patient is very active and usually socializes with his neighbors.
Patient R.G’s family was very supportive and understanding, now that he is battling with his disease.
The patient is dependent due to his illness.
VIII. Coping and Stress Tolerance
Before when patient R.G is anxious he wants to be alone, when he is stressed, he prefers to drink liquor and involved himself in gambling.
When he was diagnosed of DM Type 2 there have been many changes occurred that made difficult for him to adjust. He cannot perform the usual activities that he had before. When patient R.G is stressed, he prefers to cry until he falls asleep. When it comes to problem, he tried to calm himself through prayers.
IX. Values-Belief Pattern
Patient R.G is a Born Again Christian, before according to the client he always hears mass every Sunday with his family.
Due to his illness he wasn’t able to go to mass. According to the patient there are many practices affects his illness.
He wasn’t able to follow therapeutic regimen due to financial problem and a strong faith to God helps him to get through all the suffering he has.
After what happened, patient R.G is still not seeking for medical assistance due to financial problem. Religious effort is still a part of patient R.G.’s life.
X. Personal Habits
Before, patient R.G. used to maintain a good personal hygiene and had a diet without restriction. He used to work as a factory worker 6 days per week and was able to help in doing household chores when he got home. He had a good sleep pattern of almost 8 hours at night. Every Sunday he goes to mass with his family and occasionally at his free time he drinks and smoke with his friends.
At present, due to his illness, patient R.G wasn’t able to perform his usual routine. He had to stopped from working in able to attend his health needs and become dependent to his family.
XI. Concept Map
II. PROBLEM LIST
1. Imbalanced Nutrition Less than body requirements
2. Disturbed Sleep Pattern
3. Impaired Skin Integrity
4. Activity Intolerance
5. Risk for Infection
A.) ACTUAL OR ACTIVE PROBLEM
Problem No. Problem Date Identified Date Resolved Remarks
Imbalanced Nutrition Less than body requirements July 09, 2009 July 16, 2009 Client appetite was increase. 2
Disturbed Sleep Pattern July 09, 2009 July 16, 2009 The client can sleep now from 4-6 hours unlike before.
3 Impaired Skin Integrity July 09, 2009 July 16, 2009 The wound is clean and dry.
4 Activity Intolerance July 09, 2009 July 16, 2009 The client able to perform some minimal ADL
B.) High Risk or Potential
Problem Date Identified 1 Risk for infection July 09, 2009
IV. NURSING CARE PLAN ( At The Last Page)
V. ANATOMY AND PHYSIOLOGY
Homeostasis depends on the precise regulation of the organ and organ systems of the body. The nervous and endocrine system are two major systems responsible for that regulation. Together they regulate and coordinate the activity of nearly all other body structures. When these system fail to function properly, homeostasis is not maintained. Failure ofsome component of the endocrine system to function can result in disease such as Diabetes Mellitus or Addison’s 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 sytem, whichh carries to all parts of the body. The cell that can detect those chemical signal produce reponses.
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.
* It regulates water balance by controlling the solute concentratiuon 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 muslces, 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 regulaytes 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 glucoce 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.
> 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 glucagon-which 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 system’s 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 level are very low, the break down 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 stimulates 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.
Diabetes Mellitus Type 2 is referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM).In case our patient we classified the risk factor into two categories the modifiable and non-modifiable. Under modifiable is the diet because diet high in cholesterol increases number of adipose tissue and this tissue are resistant to insulin therefore glucose uptake by cell is poor and the stress because stress stimulates secretion of epinephrine, norepinephrine and glucocorticoids and this neurotransmitters increases glucose level. In the non-modifiable factor hereditary because it can be transfer from parents to offspring. In the case of our his father has a diabetes also. And the age with strong heritability patterns which present as type 2 diabetes early in life, usually before 30 years in the case of our patient he was diagnosed at the age of 37 years old. In type 2 diabetes, can still produce insulin, but do so relatively inadequately for their body’s needs, beta cells are primary affected and there is a poor production of insulin. Insulin is also the principal control signal for conversion of glucose to glycogen for internal storage in liver and muscle cells. Lowered glucose levels result both in the reduced release of insulin from the beta cells and in the reverse conversion of glycogen to glucose when glucose levels fall. If the insulin is deficient the intracellur and the intravascular space are affected. In the intracellular space there is a failure of glucose to enter in the intracellular space because there is a lack of insulin and insulin acts as the key to be able the glucose to enter in the cell. And when this happened the glucose supposed to be absorb by the cells are staying in the blood and this term is hyperglycemia. If cell was not able to absorb the sugar their will be intracellular and extracellular dehydration and body will compensate and the person will have the urge to drink more water it is term polydipsia. Also if cell has no glucose intake their will be cellular starvation and the person will have the urge to eat and eat and it is termed polyphagia.
In the intravascular area if the insulin is insufficient and glucose are not absorb by the cell the glucose is staying in the blood stream and the glucose level in the blood will increase as the sugar in blood increase the blood circulation will become viscose. Prolonged high blood glucose level leads to sluggish circulation and when the glucose concentration in the blood is raised beyond its renal threshold, reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine (glycosuria). This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water held in body cells and other body compartments, causing dehydration and increased thirst. In a sluggish circulation due to high blood content in blood the oxygen supply in the peripheral site is insufficient and when this happened there is a proliferation of microorganism in the case of our patient his wound doesn’t easily heal due to poor oxygen delivery and microorganism take place and multiply.
VII. MEDICAL MANAGEMENT
Classification stock Indication
Dosage and Frequency Nursing Responsibilities
(Pre,Intra,Post) Generic Name: Metformin
Brand Name: Formet
Classification: Anti-diabetic agent Indication:
> Treatment for NIDDM (Type II) not responding to dietary modification
Dosage and Frequency:
1 tab TID
> Check for allergies
> Ask for history of heart disease (for dose adjustment)
> Take with meal
> Tell patient not to crush, chew or break (may cause too much of drug to be released at one time)
> Test blood (to assure that Metformin is helping the patient’s condition)
> Advice patient to avoid drinking alcohol (may decrease blood sugar and increase risk of lactic acidosis)
Generic Name: Gliclazide
Brand Name: Ritemed Gliclazide
Classification: antidiebetic agent
> Type 2 diabetes not controlled by diet alone
Dosage and frequency:
1 tab OD
> Check the patient for allergies
> Take with meal
> Instruct the patient to swallow the tablet whole, without breaking, crushing or chewing it, it may cause too much of drug to be released at one time
> Advice the patient not to drink alcohol because it may cause severe decrease of blood sugar Generic Name:
Vitamin B Complex
Classification: food supplement Indication:
> Dietary supplement for certain patient who do not receive a proper amount of vitamin from the diet
Dosage and frequency:
1 tab OD Pre:
> Ask patient if he is taking any prescription or non prescription medicine, herbal preparation or dietary supplement
> Ask the patient if he has allergies to medicines, foods or other substances (some meds may interact with vitamin B)
> May be given with or without food, if stomach upset occurs, take with food to reduce stomach irritation
> Advise the patient to take it as soon as possible if he missed a dose
> Tell the patient to skip missed dose if it is almost time for the next dose and go back to the regular dosing schedule
> Remind patient not to take two doses at once Generic Name: Iboprofen+Paracetamol
Brand Name: Alaxan
Classification: NSAID Indication:
> Relief of mild to moderately severe pain of musculoskeletal origin
Dosage and frequency:
1 tab PRN Pre:
> Check the patient for allergies
> Take with food to lessen stomach upset
> Instruct patient not to continue taking drug more than 10 days for pain or 3 days for fever
VIII. DISCHARGE HEALTH TEACHING PLANS
Content Strategy 1.Compliance Medication Metformn(Formet)
500mg/tab, 1tab TID, take with meal.
80mg/tab, 1tab OD
Vitamin B complex
1tab OD, take with/ without food.
Ibuprofen+paracetamol 500mg/tab, 1 tab PRN, take with food. * Do not crush, chew or break. Avoid drinking alcohol.
* Take with meal swallow whole, without breaking, chewing or crushing it (it may cause too much of drug to be released at one time.
* Do not drink alcohol (it may cause severe decrease of blood sugar.
* If missed a dose, take as soon as possible skip-missed dose if it is almost time for the next dose and go back to regular dosing schedule.
* Do not continue taking drug more than 10 days for pain or 3 days for fever. 2. Diet Low carbohydrate diet
High fiber diet
* Reduce intake of rice
* Eat fruits and vegetables
* Teach patient to read labels of “health” foods because they contain sugar product such as honey, brown sugar and corn syrup. 3.Exercise Light stretching
Chin to chest
Head to shoulder * Flexing and extending very slowly of upper and lower extremities. Rotating of the extremities at a very light and slow motion.
* Touch chin to the chest slowly
* Flex the head to the right and to the left shoulder at a very slow movement.
* Note: the exercise should be done with assistance of significant others at a very slow motion to avoid further complication. 4. Activity/Lifestyle Positive reinforcement * Give positive reinforcement for self-care behaviors.
Changes instruct family to assist in the situation of the client.
* Have a regular interaction with patient to avoid low self-esteem.
Social support is very important to the client.
IX. SUMMARY OF CLIENT STATUS OR CONDITION AS OF LAST DAY OR CONTACT
Date Problems encountered (actual and resolved)
July 9, 2009 Actual problems that are identified are and have been resolved last July 16, 2009:
First is imbalanced nutrition: less than body requirements. As evidence by verbalization of the client and based on the assessment done that the client really loss weight. It should be the first priority, to meet the metabolic needs of the body by intake of sufficient nutrients and able to gain weight. Because of the necessary nursing interventions that have been done the client’s appetite increased.
Second is disturbed sleep pattern. As evidence by verbalization of the client “di ako masyado makatulog sa gabi, lagi akong pagising gising”. And based on the assessment done that there are (+) sunken eyeballs and weakness. It should be the second priority because the client is experiencing a insufficient time or period of sleep. The necessary nursing interventions should be done for the client to be able to maintain a comfortable environment. After doing so, the client verbalized improvement in sleep pattern and can sleep now from 4-8 hours.
Third is impaired skin integrity. As positively evidence by skin disruption of skin surface and as verbalized by the client that “para na nga akong isda na kinakaliskisan eh, naniniklap na yung balat ko”. Necessary nursing interventions should be done; and after doing so the client’s wound becomes dry and clean.
And Forth is activity intolerance. It should be identify for the client to have sufficient energy to endure or complete required or desired daily activities. The problem was evidence by verbalization of the client that “di na ko makalabas ng bahay at di na rin ako makatayo ng matagal” and positive immobility, weakness and weight loss based on the assessment done. Because of the necessary nursing interventions that have been formulated the client was able to perform some minimal ADL.
July 9, 2009
There is a potential problem that had been identified during our contact with the client and this is risk for infection due to the disruption of the skin which is the primary defense. Necessary nursing interventions should be done to prevent infection and complications.