Prepared by: Josmy Joseph LTIM-Department

Name: Patient X Age: 56 yrs.old

Nationality: Saudi Date of Admission: July 9,2012

SKIN -

warm, slightly moist, smooth, hair evenly distributed HEAD -symmetric, no flaking of scalp, no lesions, no tenderness EYES - no redness, no discharges, sclera white and clear, pupils reactive to light and accommodation

NOSE & SINUSES – nasal septum straight, not perforated no discharge, naso gastric tube present MOUTH - no gum bleeding, tongue and uvula in midline position, oral cavity is pinkish in color, buccal mucosa smooth and moist, no ulcers, no swelling, no palpable masses NECK no palpable lymph nodes, trachea on midline position, Trache. Tube present

BREASTS - nipples at same level and protrude slightly, no palapable masses, no nipple discharges THORAX AND LUNGS – thorax is symmetric, no retraction of the intercostal spaces, no tenderness, back area slightly reddened

UPPER EXTREMITIES – decorticate position arms are unable to extend, abduct and adduct NAILS - convex curvature, smooth texture good capillary refill ABDOMEN – slight abdominal distention (+) bowel sounds

LOWER EXTREMITIES – unable to flex, abduct and adduct GENITALIA - skin of the glans penis is smooth, no ulceration, urethral meatus ventrally located on the end of the penis, no discharge, no palpable masses

Patient X – with Hypertension, Diabetes Mellitus controlled by long term use of insulin - brought to Prince Sultan Cardiac Center due to Cardiogenic shock and Ventricular febrillation, resuscitated for 30 mins.

- considered stable from cardiac point of view but he was admitted repeatedly due to recurrent infections - Echocardiography done and revealed impaired left ventricular function - no valvular lesion noted

Patient X is now admitted in Dr. Ahmed Abanamy Hospital since July 09, 2012 after he was transferred by Prince Sultan Cardiac Center for continuous long term nursing care and management. He is currently in tracheostomy tube supported by humidified oxygen at 5LPM.

He is nasogastric tube feeding. He is on long term use of foley catheter with no episodes of penile bleeding noted. Patient X is maintained with insulin NPH combined with regular insulin subcutaneously. He is also maintained with Amlodipine, Clopidogrel, Concor and Pantoprazole. He has stable vital signs with no recent episodes of desaturation noted.

DIABETES MELLITUS

    Diabetes Mellitus or simply Diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin or because cell do not respond to the insulin that is produced. This high blood sugar produce the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger). There are three main types of Diabetes Mellitus: Type 1, Type 2 and Gestational Diabetics.

Type 1 is a result from the body’s failure to produce insulin and currently recurs the person to inject insulin or wear an insulin pump. This form was previously referred to as Insulin dependent Diabetes Mellitus (IDDM) or childhood onset or Juvenile Diabetes.

Type 2 is a result from insulin resistance, a condition in which cells failed to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred o non- insulin dependent diabetes mellitus (NIDDM), obesity related diabetics or adult onset diabetics.

Gestational Diabetics occur when pregnant woman without the previous diagnosis of Diabetes developed a high blood glucose level, it disappears after delivery and it is treatable. (It may precede development of Type 2 Diabetes.

Pancreas

The pancreas is an elongated tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ called head and it is the widest part. It lies the curve of the duodenum. The left side ends near to spleen.The

homone administered by the pancreas are responsible for controlling and manipulating blood glucose level. The pancreas houses islets responsible for production and secretion of the hormone glycogen and insulin.

Endocrine cells or the lslets of langerban make up 1% of the pancreatic cells.there are most numerous in the tail region of the pancreas.the major endocrine cells of the pancreas are alpha ,beta,and delta cells.Which secrete glucagons,insulin and somatostatin,respectively.when the blood sugar level falls below the normal levels.The alpha cells are stimulated to secrete glucagon which accelerates the conversion of glucogen to glucose in the liver .when the blood sugar level is above normal the beta cells secrete insulin. Which promotes both the metabolism of glucose by tissue cells and the conversion of glucose to glycogen which is then stored in the liver

Diabetes Mellitus is the condition in which there is hyperglycemia, an excess of sugar in the bloodstream. This increase in the blood sugar level occur due to malfunctioning of the pancreas which secretes insulin. Insulin is the hormone that control the sugar level in the blood. Without insulin sugar will accumulate in the blood leading to diabetes mellitus. There are different causes of diabetes mellitus such as: -

DIET

-

LIFESTYLE

-

ENVIRONMENT AND EXTERNAL FACTORS

-

AGE AND HEREDITY

a.excessive thirst b.frequent urination c. extreme hunger d. unusual weight loss e. increased fatigue f. blurred vision g. nausea, vomiting h. infections of the bladder, skin, & vaginal areas i. elevated glucose level & leads to lethargy, coma

1. Administer insulin or an oral anti-diabetic drug as prescribed.

2. Have the patient participate in a supervised exercise programs.

3. Treat hypoglycemic reactions promptly by giving carbohydrates in the form of fruit juice, honey or IV dextrose.

4. Provide meticulous skin care, especially feet and legs.

5. Assist the patient develops coping strategies.

6. Keep accurate record of vital signs, weight, fluid intake, urine output and caloric intake.

7. Monitor diabetic effect on the cardiovascular, peripheral, vascular and nervous system.

8. Observe for signs of urinary tract and vaginal infections and monitor the patient’s urine for protein and early signs of nephropathy.

9.

Recommend regular ophthalmologic examinations.

10. Teach the patient how to care for his feet.

11. Teach the patient and families how to monitor the patient’s diet.

- Monitoring blood glucose level - Dietary management - Maintaining physical activity - Keeping weight and stress under control - Monitoring oral medication and if required insulin via injection

SHORT TERM:

- Hypoglycemia - Hyperglycemia - Ketoacidosis and Hyperosmolar Syndrome

-

Heart diseases - Kidney diseases - Neuropathy - Peripheral Vascular diseases

1. Fluid Volume Deficit related to osmotic dieresis due to hyperglycemia 2. Risk for ineffective tissue perfusion related to reduced vascular flow 3. Imbalanced nutrition, less than body requirements, related to inability to use glucose 4. Risk for infection related to impaired healing accompanying condition 5. Deficient fluid volume related to polyuria accompanying disorder

ASSESSMENT

Subjective: Not applicable Objective: -dry skin & mucous membrane -poor skin turgor; skin slowly returns back after pinching - weak peripheral pulses -urine output for 24hrs: 800ml -vital signs taken as follows: Temp: 37 C PR: 110 bpm RR: 20bpm BP: 97/60mmof Hg

DIAGNOSIS PLANNING

Fluid Volume Deficit related to osmotic dieresis due to hyperglycemia After 8hours of nursing interventions the patient will demonstrate adequate hydration

INTERVENTION

Independent: -Checked vital signs especially blood pressure and heart rate every 2h -Checked temperature, skin color & moisture, skin integrity -Monitored input & output. Note urine specific gravity -Maintained fluid intake at least 2500ml/day within cardiac tolerance

RATIONALE

Hypovolemia may be manifested by hypotension & tachycardia -Fever, chills and diaphoresis are common with infectious process. Fever with flushed dry skin may reflect dehydration, adequacy of circulating volume -Indicators of level of dehydration, adequacy of circulating volume -Provide the best assessment of current fluid status and adequacy of fluid

EVALUATION

After 8hours of nursing interventions the patient will demonstrate adequate hydration As evidenced by stable vital signs, palpable peripheral pulses, good skin turgor , good capillary refill, urine output of 1,100ml for 24 hrs.,and V/S stable as follows: Temp: 36.8 C PR: 82 bpm RR: 20bpm BP: 124/74mmHg Promoted comfortable environment. Provided good lighting, thermoregulation, and , free from noise.

Collaborative: -Administered fluid such as Normal Saline 100ml/hr as indicated -Avoid over heating which could promote further fluid loss -Maintain hydration & circulating volume

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Not Applicable Objective: - confined to bed -unable to move, turn to side to side -unable to abduct and adduct extremities -medium-sized body built -back area and buttocks slightly reddened Risk for impaired skin integrity related to immobility After 12hours of nursing intervention patient will display good skin texture and free from dryness After 3-5days of nursing intervention patient’s skin will remain intact and will not develop any skin breakdown during the stay at the facility.

• Repositioned the patient from side to side at least every 3hours • Lifted the patient during turning, do not drag or pull. Encouraged use of lift sheets to move patient in bed • Cleaned, dried, and moisturized skin, especially over bony prominences. Use powder and Elica creams as necessary • Used good quality air mattress, avoid wrapped and wrinkled bed sheets Positioning interventions reduce pressure and shearing force to the skin Friction may cause break of skin Moisture softens the skin and causes a break in the skin integrity. Creams or powder may help smoothen the skin This helps in reducing pressure Goal met.

Patient’s skin remained intact and did not develop any skin breakdown during the stay at the facility.

• Massaged on the area of pressure avoiding reddened skin part Increase tissue perfusion by massaging around affected area

For the watcher:

1. Teach her/him for signs and symptoms of hypoglycemia and hyperglycemia.

2. Explain about medication purpose, dosage and possible side effects.

3. Teach her/him how to do skin care.

Diabetes Mellitus or simply Diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin or because cell do not respond to the insulin that is produced. This high blood sugar produce the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger). There are three main types of Diabetes Mellitus: Type 1, Type 2 and Gestational Diabetics.

Type 1 is a result from the body’s failure to produce insulin and currently recurs the person to inject insulin or wear an insulin pump. Type 2 is a result from insulin resistance, a condition in which cells failed to use insulin properly, sometimes combined with an absolute insulin deficiency. Gestational Diabetics occur when pregnant woman without the previous diagnosis of Diabetes developed a high blood glucose level, it disappears after delivery and it is treatable.

There are different causes of DM such as factors related to diet, lifestyle, environmental and external factors, age and hereditary.

The goal of diabetes management is to keep blood glucose level as close to normal as safety as possible. Since diabetics may greatly increased risk for heart diseases and peripheral artery disease. Measure to control blood pressure and cholesterol levels are an essential part of diabetics treatment, people with diabetic must take responsibility for their day to day care.

  Lippincot Manual of nursing care Ninth edition.

httpllen.wikipedia .orglwikilDiabetes mellitus.

 

Httplwww.medicinenet.comld/diabetes mettitus/article.htm

 

http/emedicine.medscape.com/article/1163653-overview