Case Presentation Medical C

Case Presentation

Medical Center Parañaque
STATION 3

NCM 103
Group 6
Balaguer, Jezza Ane I.
Blanco, Febe Gay S.
Buhay, Leslie Ann T.
Camello, Katherine J.
Castro, Christian Vincent D.
Contacto, Kareen F.
Concha, Christelle Elaine O.
Per, Emmanuel M.

Mrs. Rosa Reyes
Clinical Instructor

TYPE II DIABETES MELLITUS
(Non- Insulin Dependent Diabetic Mellitus -NIDDM)

CASE ABSTRACT
This is a case of Mr. M.J.S.J. a 77 year old male patient who was admitted on April 28, 2009 in Medical Center Parañaque, Emergency room with a complaint of infected wound on then left foot 5th digit. Initial Vital Signs were BP-110/70 mmHg; PR – 107 bpm; RR- 23 cpm; Temp.- 37.5°C. Initial interview and assessment revealed that the patient is Diabetic and his past hospitalization was on September 2008, where his first digit right foot was amputated and was hospitalized with hypoglycemic coma last March 2009. Patient undergone different laboratory procedures: Hematology, Urinalysis, Electrolytes and Glycosylated Hemoglobin (HBa1C). Final Diagnosis is Diabetic left foot.

LEARNING OBJECTIVES
1. To describe the nature of the disease process of Diabetes mellitus.
2. Assess the patient following the Gordon’s Functional Pattern through physical examination and obtain detailed patient’s history and other significant data through interview
3. Identify and analyze physiological, emotional, environment, cognitive, spiritual and moral factors that contribute to the wellness of the patient
4. Recognize nursing diagnoses and formulate appropriate nursing interventions that may assist the client and her family in the future
5. Complete the study
Introduction:

According to Black, 2008 Diabetes Mellitus is a chronic, progressive disease characterized by the body’s inability to metabolize carbohydrates, fats, and proteins, leading to hyperglycemia (high blood glucose level). Diabetes mellitus is sometimes referred to as “high sugars” by both client and health care providers. Diabetes mellitus is classified as one of four different clinical states including type 1, type 2, gestational, or other specific types of diabetes mellitus. Type 1 diabetes mellitus is the result of autoimmune beta-cell destruction, leading to absolute insulin deficiency. Type 2 DM is the result of a progressive insulin secretory defect along with insulin resistance, usually associated with obesity. Gestational diabetes mellitus is a type of diabetes mellitus diagnosed during pregnancy. Other types of DM may result of genetic defects in beta-cell function, diseases of the pancreas, or disease induced by drugs.
Type 2 diabetes mellitus was once called adult-onset diabetes. Now, because of the epidemic of obesity and inactivity in children, type 2 diabetes mellitus is occurring at younger and younger ages. Although type 2 diabetes mellitus typically affects individuals older than 40 years, it has been diagnosed in children as young as 2 years of age who have a family history of diabetes. Type 2 diabetes is characterized by peripheral insulin resistance with an insulin-secretory defect that varies in severity. For type 2 diabetes mellitus to develop, both defects must exist: all overweight individuals have insulin resistance, but only those with an inability to increase beta-cell production of insulin develop diabetes. In the progression from normal glucose tolerance to abnormal glucose tolerance, postprandial glucose levels first increase. Eventually, fasting hyperglycemia develops as inhibition of hepatic gluconeogenesis declines.
About 90% of patients who develop type 2 diabetes mellitus are obese. Because patients with type 2 diabetes mellitus retain the ability to secrete some endogenous insulin, those who are taking insulin generally do not develop DKA if it is stopped. Therefore, they are considered to require insulin but not to depend on insulin. Moreover, patients with type 2 diabetes mellitus often do not need treatment with oral antidiabetic medication or insulin if they lose weight or stop eating.
Maturity-onset diabetes of the young (MODY) is a form of type 2 diabetes mellitus that affects many generations in the same family with an onset in individuals younger than 25 years. Several types exist. Some of the genes responsible can be detected by using commercially available assays.
In our case the patient was diagnosed with Type II diabetes mellitus.
OLIVAREZ COLLEGE PARAÑAQUE
COLLEGE RELATED HEALTH RELATED SCIENCES
NURSING DEPARTMENT

BIOGRAPHIC DATA:

Name: Mr. J.S.J
Age: 77
Gender: Male
Civil Status: Married
Address: Parañaque city
Date of Birth: April 26, 1932
Place of Birth: Bulacan
Educational Attainment: College Graduate
Occupation: None
Dialect / Language Spoken: Tagalog, Bicolano
Health Insurance: none
Admitting Diagnosis: DM type II

NURSING HISTORY:

Major Concern: Infected wound on the left foot 5th Digit
History of Major Concern: On April 28, 2009 patient was admitted to Medical Center Parañaque, Emergency Room with a chief complaint of infected wound on left foot 5th digit. Days prior to admission patient caregiver observed a non-healing wound on the patients left foot.

PAST MEDICAL HISTORY:

Childhood Illness: Not recalled
Allergies: none
Hospitalization: March 2009 patient had hypoglycemic stroke, first amputation was on Nov. 2008 on his right foot first digit
Medications: Humulin , Mosegal Vita.

FAMILY HISTORY:

Health state of
Parents: Father is diabetic
Siblings: Not recalled
Spouse: Hypertension
Illness in the family similar to the patient’s illness: Diabetes Mellitus (father)

GORDON’S FUNCTIONAL HEALTH PATTERN

1. HEALTH PERCEPTION / HEALTH MANAGEMENT

According to the care giver the patient’s activity before hospitalization was walking for 30 min to 1 hr every day. Financing health care wouldn’t be a problem for his children’s are capable of providing everything. He is taking Humulin for his diabetes mellitus, and taking Mosegal vita with doctor’s prescription. Patient has no allergies. His father has Diabetes Mellitus. He was hospitalized on April 28, 2009 due to infected wound left foot on the 5th digit.

2. NUTRITIONAL METABOLIC PATTERN

Patient’s present diet is diabetic low puretic diet and his usual diet was high in salt and high in fat. There are no religious restrictions in terms of food. His usual meal is composed of carbohydrates, protein, fats, water and vitamin. He doesn’t take any food supplements. He has a good appetite. His highest weight 150 lbs and his lowest weight is 145 lbs. His last food ingested was Pinakbet and nesvita.

3. ELIMINATION PATTERN

Patient uses 3 diapers per day during his stay in the hospital as a measurement for his voiding pattern. His urine has a characteristic of yellow in color and aromatic. His bowel pattern is ones a day with a characteristic of soft and brown stool. He perspires heavily in certain instances like when walking, and when the weather is humid or hot. Patient drinks a lot of water. He has no disease on digestive, urinary and integumentary system.

4. ACTIVITY – EXERCISE PATTERN

The patient exercises 30 minutes to 1 hour a day before he was hospitalized by means of walking. He doesn’t feel any serious discomfort after patient exercised.

5. COGNITIVE PERCEPTUAL PATTERN

The patient has occasional blurring of vision as claimed due to aging but doesn’t use eyeglasses. Also patient has slight deafness due to aging. And has no problem in other senses. He cannot express himself clearly and logically. The patient experience multi facet Dementia

6. PATTERN OF SLEEP AND REST

The patient normally sleeps 7 hours at night and 1 hour nap within the day. And patient feels restless at night without taking medication.
7. SELF PERCEPTION AND SELF CONCEPT

Patient was not able to express his perception because he was always lethargic as caused by the drugs given during hospitalization.

8. ROLE AND RELATIONSHIP PATTERN

According to patient care giver the patient cares about his family and community. He was then a good provider and very supportive to his children and his grand children. But now as he age and cannot take care of himself alone, his children sent him money for others to take good care of him. He considers God to be the most important in his life and next is his family. His love ones helped him solve all the problems and worries in life.

9. SEXUALLY REPRODUCTIVE PATTERN

The patient has an inflammation in his testicles with the presence of desquamation and reddish scrotum. Also he has rashes on his butt ark reddish due to bedsores.

10. COPING STRESS TOLERANCE

As what the care giver noticed when there are family problems he copes up by expressing emotions. The patient has not undergone treatment for emotional distress.

11. VALUES BELIEF PATTERN

Patient is Roman Catholic. And has no other significant beliefs that affect his health status. He is not active to any organizational group in his community but also a member of the senior citizen.

PHYSICAL EXAMINATION

1. VITAL SIGNS

The patient is normothermic with a temperature of 37.5 °C . Pulse rate was 107 beats per minute. Patient is tachycardic. Respiratory rate of 23 cycles per minute and his blood pressure was 110/70 mmHg.

2. GENERAL SURVEY

The patient stands 5 feet and 7 inches and weighs 145 lbs. Patient is restless, uncooperative, bedridden, but not in cardiopulmonary distress. Patient is drowsy, incoherent and disoriented. His developed is mesomorph. He looks according to his age, well nourished and restless.

3. SKIN
The patient has brown complexion, the texture is rough and dry. His skin turgor was fair and warm to touch.

4. HEAD
The configuration of the head is normocephalic. The hair is fine, equally distributed and has no dandruff seen on the scalp. The lids are drooping and have dark discoloration on the periorbital region. Conjunctiva is pale. Sclera is anicteric. Cornea and lens have arcus senilis. The pupil sizes are equal of 3 mm and it reacts to light sluggishly with unequal constriction. Visual acuity and convergence was not assessed.

5. EARS
The external pinnae are normoset with scanty cerumen. There were no discharges.

6. NOSE
The nasolabial folds are symmetrical. The septum is in the midline. There were no discharges and mucosa is pink. Both nostrils are patent and there were non-tender sinuses.

7. MOUTH

He has dry and chapped lips, with the tongue deviated to the right. The gums and mucosa are pale. There are presence of dentures and has a slurred speech.

8. PHARYNX

The uvula is in the midline. The mucosa is pinkish and has no inflamed tonsils.

9. NECK

The trachea is in the midline. There are palpable cervical lymph nodes. Thyroid is non-palpable. Patient neck is rigid.

10. CHEST AND LUNGS

The inspiration and expiration ratio is 1:2. The patient is tachypneic with 23 cycles per minute. The Anterio – Posterio – Lateral ratio is 1:2. Lung expansion and vocal/tactile fremitus are symmetrical. Resonant on all lung fields was revealed during percussion.

Breath sounds: Bronchial over the manubrium; Bronchovesicular: 1st and 2nd interspaces; Vesicular over the lung fields

11. HEART

There is no bulging of the precordial. The point of maximal impulse is at the 5th intercostals space midclavicular line. Heart sounds are regular with negative extra heart sounds. The S1 sound is best heard in the apex. And the S2 sound is best heard in the base.

12. BRAST AND AXILLAE

The patient breast is equal and symmetrical. The color is fair with a rough surface.

13. ABDOMEN

The patient has a flabby abdominal configuration with some presence of scars. The bowel sounds are normoactive. Tympanitic in the abdominal area with positive dullness over the right upper quadrant. There are no tenderness.

14. GENITO-URINARY

The patient penis is tender with some abrasion. The scrotum is reddish, inflamed and tender. And there are pressure sore in the area.

15. BACK AND EXTREMITIES

The peripheral pulses are symmetrical, equal and full in the upper extremities. There are also full and equal pulses on the femoral and popliteal bilaterally. Absent pulses on dorsalis pedis and posterior tibialis on the right lower extremity with bandage on the left foot. The nail beds are pinkish. Patient range of motion is very limited. The muscle tone and strength is full on the right upper extremity and rigid on the left extremity. The bilateral lower extremities are weak and have muscle dystrophy. His is kyphotic.

16. NEUROLOGIC ASESSMENT
Drug – induced lethargy
GCS: Eye opening= 4 (spontaneous)
Verbal= 2 (incomprehensible sounds)
Motor= 5 (localizes pain)
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ANATOMY AND PHYSIOLOGY
Overview of Endocrine System

Homeostasis depends on the precise regulation of the organs and organ system of the body. Endocrine system is one of the major systems responsible for that regulation. Failure of some component of the endocrine system to function can result in diseases.

The main regulatory function of the endocrine system includes:
* Water Balance
* Uterine contractions and milk release
* Growth, metabolism and tissue perfusion
* Ion regulation
* Heart rate and blood pressure metabolism
* Blood Glucose Control
* Immune system regulation
* Reproductive functions control

The PANCREAS

The pancreas is located retroperitoneal, posterior to the stomach in the inferior part of the left upper quadrant. It has a head near the midline of the body and a tail that extends to the left where it touches the spleen.
* It is a pinkish white glandular, long and soft organ
* Second largest gland that is connected to the digestive tract, after the liver
It is a complex organ composed of both endocrine and exocrine tissues that performs several functions. The pancreas’ exocrine function involves the secretion of bicarbonate which neutralize the acidic chyme that enters and small intestines from the stomach. Its endocrine function involves the regulation of blood sugar levels by secreting the hormones insulin, glucagon, and somatostatin directly into the blood.

ENDOCRINE FUNCTION
The endocrine part of the pancreas consists of pancreatic islets (Islets of Langerhans). It secretes three hormones that regulate blood glucose level: (1) alpha cells secrete glucagons, (2) beta cells secrete insulin, (3) delta cells secrete somatostatin, identical to the growth hormone inhibitory hormone secreted by the hypothalamus. The close proximity of these cells within the islets allows coordinated paracrine regulation of pancreatic secretion because insulin inhibits glucagon release and somatostatin inhibits both insulin and glucagon release.
INSULIN:
* Insulin binds to receptors on the surface target tissues and enhances glucose transport across the membrane
* It decreases blood glucose level by enhancing uptake, use and storage of glucose in hepatic, muscle and adipose tissues
* It stimulates skeletal muscle and liver to convert glucose to a storage form called glycogen.
* It also enhances amino acid transport into cells, it acts synergistically with growth hormone to promote cell hypertrophy and hyperplasia

GLUCOSE
* Glucagon is an extremely potent hormone that is revealed when blood glucose levels drop below 90 mg/dL.
* It acts on the liver to elevate plasma glucose levels, an action opposite that of insulin, it stimulate glucose production by breaking down glycogen and converting protein and fat into glucose

SOMATOSTATIN
* Somatostatin is released after ingestion of a meal and inhibits the release of both insulin and glucagon.
* The net action of somatostatin is to delay nutrient absorption by the GI tract, thus prolonging the duration of intestinal food absorption after a meal.