Name of Student :TEOPIZ, MARK JOVAN JR.

Section: BSN 3-A2

Concept: Case Study Individual

Clinical Instructor: Marie Christine Mercado

Patient’s Data

Name: Allan R. Bernados Nationality: Filipino

Gender: M Religion: Roman Catholic
Birthdate: June 12. 1943 Source of Data: SWU MEDICAL CENTER EMERGENCY ROOM RECORD
Birthplace: Cebu City Date & Time of Admission: 8/13/20 4:01 PM
Age: 77 Attending Physician: Dr. Quijano Address: Lawaan Talisay, Cebu Diagnosis: Diabetes type 2
Educational Level: Marital Status: Married
Occupation: :

Chief Complaint: L sided weakness, slurring of speech

AOG:
EDC:
VITAL SIGNS: BP: 160/100, Temperature: 36.7 Pulse Rate: , RR: 38, 02 Saturation: 97% Weight:
Brief History Upon Admission:

Admitting Diagnosis: dx type 2 DM

Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in
the bloodstream. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems.

In type 2 diabetes, there are primarily two interrelated problems at work. Your pancreas does not produce enough insulin — a hormone that regulates the movement of sugar
into your cells — and cells respond poorly to insulin and take in less sugar.

Type 2 diabetes used to be known as adult-onset diabetes, but both type 1 and type 2 diabetes can begin during childhood and adulthood. Type 2 is more common in older
adults, but the increase in the number of children with obesity has led to more cases of type 2 diabetes in younger people.

There's no cure for type 2 diabetes, but losing weight, eating well and exercising can help you manage the disease. If diet and exercise aren't enough to manage your blood
sugar, you may also need diabetes medications or insulin therapy.

Signs and symptoms of type 2 diabetes often develop slowly. In fact, you can be living with type 2 diabetes for years and not know it. When signs and symptoms are
present, they may include:

 Increased thirst

 Frequent urination

 Increased hunger

 Unintended weight loss

 Fatigue

 Blurred vision

 Slow-healing sores

 Frequent infections

 Numbness or tingling in the hands or feet

 Areas of darkened skin, usually in the armpits and neck

ANATOMY AND PHYSIOLOGY

Pancreas Pancreas endocrine function involves the secretion of insulin (produced by beta cells) and glucagon (produced by alpha cells) within the pancreatic islets. These two hormones
regulate the rate of glucose metabolism in the body.

The pancreatic islets each contain four varieties of cells:

 The alpha cell produces the hormone glucagon and makes up approximately 20 percent of each islet. Low blood glucose levels stimulate the release of glucagon.
 The beta cell produces the hormone insulin and makes up approximately 75 percent of each islet. Elevated blood glucose levels stimulate the release of insulin.
 The delta cell accounts for four percent of the islet cells and secretes the peptide hormone somatostatin. Recall that somatostatin is also released by the
hypothalamus, stomach and intestines. An inhibiting hormone, pancreatic somatostatin inhibits the release of both glucagon and insulin.
  The pancreatic polypeptide cell (PP cell) accounts for about one percent of islet cells and secretes the pancreatic polypeptide hormone. It is thought to play a role in
appetite, as well as in the regulation of pancreatic exocrine and endocrine secretions. Pancreatic polypeptide released following a meal may reduce further food
consumption; however, it is also released in response to fasting.

 Glucagon
 Glucagon stimulates the liver to convert its stores of glycogen back into glucose. This response is known as glycogenolysis. The glucose is then released into the
circulation for use by cells throughout the body.
 Glucagon stimulates the liver to take up amino acids from the blood and convert them into glucose. This response is known as gluconeogenesis.
 Glucagon stimulates lipolysis, the breakdown of stored triglycerides into free fatty acids and glycerol. Some of the free glycerol released into the bloodstream travels
to the liver, which converts the glycerol into glucose. This is also a form of gluconeogenesis.

Insulin
The primary function of insulin is to facilitate the uptake of glucose into body cells. Red blood cells, as well as cells of the brain, liver, kidneys, and the lining of the small
intestine, do not have insulin receptors on their cell membranes and do not require insulin for glucose uptake. Although all other body cells do require insulin if they are to
take glucose from the bloodstream, skeletal muscle cells and adipose cells are the primary targets of insulin.

PATHOPHYSIOLOGY
 In type 2 diabetes, the body either produces inadequate amounts of insulin to meet the
demands of the body or insulin resistance has developed. Insulin resistance refers to when cells of the body such as the muscle, liver and fat cells fail to respond to insulin,
even when levels are high. In fat cells, triglycerides are instead broken down to produce free fatty acids for energy; muscle cells are deprived of an energy source and liver
cells fail to build up glycogen stores.

This also leads to an overall rise in the level of glucose in the blood. Glycogen stores become markedly reduced and there is less glucose available for release when it may be
needed. Obesity and lack of physical activity are thought to be major causes of insulin resistance.

LABARATORY/ DIAGNOSTIC PROCEDURES

 Date/ Patient’s Normal Significance/Interpretation
Exam Results Values
8/20/21
Hematology/Complete Blood Count A low RBC count could also indicate a
3.64 4.50-5/90 vitamin B6, B12 or folate deficiency. It
RBC may also signify internal bleeding, kidney
disease malnutrition (where a person's
diet doesn't contain enough nutrients to
meet their body's needs).
A high RBC count may be a result of
sleep apnea pulmonary fibrosis, and
other conditions that cause low
oxygen levels in the blood.

A high eosinophil count can indicate that

WBC 2.3 0.0-7.0
the body is producing lots of new
Eosinophil
eosinophils to try to fight a bacterium
virus parasite.
Therefore, high eosinophil count can
be indicative of an infection.

Basophil 0.2 0.0-2.5 An abnormally high basophil level is

called basophilia. It can be a sign of
chronic inflammation in your body or it
can mean that a condition is causing too
many white blood cells to be produced in
76.0 37.0-80.0 your bone marrow. Having a high
Neutrophil percentage of neutrophils in your blood is
called neutrophilia. This is a sign that
your body has
an infection. Neutrophilia can point to a
 number of underlying conditions and
factors including: infection most likely
bacterial non- infectious inflammation

A low platelet count may also be called

Platelet 166 150-450 thrombocytopenia . This condition can
range from mild to severe, depending on
its underlying cause. For some, the
symptoms can include severe bleeding
and are possibly fatal If they're not
treated.
Hemoglobin, the substance that gives
Hemoglobin color lo red blood cells, the substance
10.8 14.0-17.5 that allows for the transport of oxygen
throughout the body. Low hemoglobin
levels lead to anemia, which causes
symptoms like fatigue and trouble
breathing.
A low hematocrit level means there are
too few red blood cells in the body. In
Hematocrit 32.8 41.5-50.4 these cases, a person may experience
symptoms that signal anemia.
A higher than normal hematocrit can
indicate: Dehydration. A disorder, such
as polycythemia, causes your body to
produce too many red blood cells. Lung
or heart
disease
8/20/21 +1 Albuminuria is a sign of kidney disease
Urine analysis and means that you have too much
Albumin albumin in
your urine. Albumin is a protein found in
the
 blood. A healthy kidney doesn't let
albumin pass from the blood into the
urine. A damaged kidney lets some
albumin pass into the urine. The less
albumin in your urine better.
Fasting Blood Sugar
253 70-100 This measures your blood sugar after
an overnight fast (not eating). A fasting
blood sugar level of 99mg /dL or lower
is normal, 100 to 125mg / dL indicates
you have prediabetes and 126mg / dL
or higher indicates you have diabetes.

Blood Gas Analysis

pH 7.250 7.350-7.450 Uncompensated Metabolic Acidosis is a
pCO 46.4 35.0-45.0 clinical disturbance characterized by an
2 120.7 80.0-100.0 increase in plasma acidity. Metabolic
pO2 20.1 22.0-26.0 acidosis should be considered a sign of
HCO -7,10 ± 2.0 an underlying disease process.
3 97.5 >95.0 Identification of this
BE underlying condition is essential to
(ecf) initiate appropriate therapy.
O2
SAT
Real-time reverse transcription
polymerase chain reaction It's a test to detect genetic material
(rRT-PCR) Negativ Positiv from a specific organism, such as a
test IgG e e virus. The test detects the presence of
IgM Negativ Positiv a virus if you have
e e the virus at the time of the test.
Activated Partial Thromboplastin Time
Activated Partial Thromboplastin time is
Patien 38.9 secs 25.4-38.4 normal. The partial thromboplastin time
t 34.4 secs is a screening test that helps evaluate a
Contro person's ability to appropriately form
l blood clots. It
measures the number of
seconds it takes for a clot to
form in a sample of blood
after
substances are added.
Name of the Drug Mechanism of Action Indications Side effects Nursing
Responsibilities
Generic name: Inhibits HMG- CoA To increase HDL-C in CNS: Headache, Before:
Atorvastatin reductase, the patients with primary asthenia  Secure doctor’s
Brand name: enzyme that catalyzes hypercholesterolemia order
Lipitor the first ste in the and mixed GI: Flatulence,
Classification: cholesterol synthesis dyslipidemia abdominal pain,  Do hand
Antihyperlipidemic pathway, resulting in cramps, constipation, washing
a decrease in serum Adjunct to diet to treat nausea, dyspepsia,
Dosage: 80 mg cholesterol, serum elevated serum heartburn, liver failure  Assess
LDLs triglyceride leves patient’s
Frequency: (associated with Respiratory: condition
increased risk of Contraindications Sinusitis, pharyngitis
OD CAD), and increases Contraindicated with  Allergy to
serum HDLs allergy to clopidogrel,
Route: NGT (associated with atorvastatin, fungal pregnancy,
decreased risk of by products, active lactation,
CAD); increase liver disease or bleeding
Timing: hepatic LDL recapture unexplained and disorders,
persistent elevations hepatic
of transaminase impairment,
levels, pregnancy peptic ulcer
lactation. During:
 Give
Use cautiously with medication on
impaired endocrine right timing
function
 Take daily as
prescribed.
May be taken
with meals

After:
 Inform patient

DRUG STUDY
 about possible
side effects of
the drugs

 Instruct patient
to be cautious
of the
contraindication
s of the drugs

.
Drug name Mechanism of action Indication Adverse Nursing
reaction responsibilities
Generic Mannitol is an osmotic diuretic that is OSMITROL Injection CNS: Confusion, BEFORE:
Name: metabolically inert in humans and (Mannitol Injection, headache Check vital signs and
Mannitol occurs naturally, as a sugar or sugar USP) is indicated for: urine output.
alcohol, in fruits and vegetables. The promotion of EENT: Blurred Assess signs of
Brand Name: Mannitol elevates blood plasma diuresis, in the vision, Rhinitis dehydration and
Osmitrol osmolality, resulting in enhanced flow of prevention and/or muscle weakness
water from tissues, including the brain treatment of the oliguric CV: Monitor neurologic
Classification and cerebrospinal fluid, into interstitial phase of acute renal Transient volume status and intracranial
Osmoc fluid and plasma. As a result, cerebral failure before expansion, pressure
edema, elevated intracranial pressure, irreversible renal failure Chest pain ,CHF,
Dosage: 1 and cerebrospinal fluid volume and becomes established; pulmonary edema, DURING:
g/tab, 1 tab pressure may be reduced. As a diurectic The reduction of tachycardia Administer over
Route: PO mannitol induces diuresis because it is intracranial pressure 30min
Frequency: not reabsorbed in the renal tubule, and treatment of GI: Nausea, thirst, Monitor urine output
OD thereby increasing the osmolality of the cerebral edema by vomiting and refer in
glomerular filtrate, facilitating excretion reducing brain mass; accordance with
of water, and inhibiting the renal tubular The reduction of GU: renal failure, parameters set by
reabsorption of sodium, chloride, and elevated intraocular urinary retention physician
other solutes. Mannitol promotes the pressure when the Ensure safety and
urinary excretion of toxic materials and pressure cannot be F&E: Dehydration, report signs of
protects against nephrotoxicity by lowered by other hyperkalemia, electrolyte imbalance
preventing the concentration of toxic means, and Promoting hypernatremia,
substances in the tubular fluid. As an the urinary excretion of hypokalemia, AFTER:
Antiglaucoma agent mannitol levates toxic substances. hyponatremia Check effectiveness
blood plasma osmolarity, resulting in of therapy
enhanced flow of water from the eye CONTRAINDICATIONS Local: Phlebitis@ Continuously monitor
into plasma and a consequent reduction OSMITROL Injection IV site neurologic status and
in intraocular pressure. As a renal (Mannitol Injection, urine output
function diagnostic aid mannitol is freely USP) is contraindicated Reassess
filtered by the glomeruli with less than in patients with: Well signs/symptoms of
10% tubular reabsorption. Therefore, its established anuria due dehydration
urinary excretion rate may serve as a to severe renal disease, Watch out for
measurement of glomerular filtration Severe pulmonary abnormal responses
rate (GFR). congestion or frank
The exact mechanism of action of pulmonary edema,
inhaled mannitol in the symptomatic Active intracranial
maintenance treatment of cystic fibrosis bleeding except during
remains unclear.7,8 It is hypothesized craniotomy, Severe
that mannitol produces an osmotic dehydration,
gradient across the airway epithelium Progressive renal
that draws fluid into the extracellular damage or dysfunction
space and alters the properties of the after institution of
airway surface mucus layer, allowing mannitol therapy,
easier mucociliary clearance. including increasing
oliguria and azotemia,
https://go.drugbank.com/drugs/DB00742 and Progressive heart
failure or pulmonary
congestion after
institution of mannitol
therapy
 Drug Name Classification Mechanism of Action Indication Contraindication Adverse reactions Nursing
Responsibilities
Generic Name: Proton pump Inhibits both basal Duodenal and Known Occasionally Assess underlying
inhibitors. and stimulated gastric gastric ulcer, hypersensitivity to headache or condition before
Pantoprazole acid secretion by moderate and any of the diarrhea. Isolated therapy and
suppressing the final severe reflux constituents of cases of edema, thereafter to monitor
Generic name: step in acids esophagitis. Pantoloc or of the blurred vision, drug effectiveness.
production, through Eradication of combination fever, dizziness, Assess GI
Pantoloc the inhabitation of the H. pylori in partners. Mild thrombophlebitis, symptoms:
proton pump by patient with gastrointestinal depression or epigastric/abdominal
Patient dose: binding to and peptic ulcer, complaints eg, myalgia subsiding pain, bleeding and
40 mg IVTT/1 inhibiting hydrogen- pathological nervous after termination of anorexia. Monitor for
vial, after potassium adenosine hyper secretory dyspepsia. therapy. possible drug
breakfast triphosphatase, the conditions. Pantoloc must not induced adverse
enzyme system Symptomatic be used in reaction.
located at the improvement combination
secretory surface of and healing of treatment for
the gastric parietal mild reflux eradication of H.
cell. esophagitis. pylori in patients
Prevention with moderate to
gastro-duodenal severe hepatic or
ulcers induced renal dysfunction.
by NSAID in
patients at risk
with a need for
continuous
NSAID
treatment.
 Drug Name Classification Mechanism of Action Indication Contraindication Side Effects/ Nursing
Adverse reactions Responsibilities
Generic Name: Calcium channel Inhibits calcium ion Chronic stable In cancer patients, CNS: Before:
blockers from entering the angina with bone Headache,
Nicardipine “slow channels” or metastasis and in dizziness, Inform prescriber
select voltage- Management of patients with somnolence, if you are/or
Generic name: sensitive areas of essential ventricular paresthesia intend to become
Cardene vascular smooth hypertension fibrillation, pregnant. Breast
muscle and hypercalcemia, CV: feeding is not
Patient dose: myocardium during hypophosphatemia, Flushing recommended.
10 mg + 90 cc depolarization, or renal calculi palpitations,
PNSS at 20 cc/hr producing a relaxation tachycardia, Inform prescriber
of coronary vascular peripheral edema, of all prescription,
Route: Oral smooth muscle and increased angina, OTC
coronary vasodilation; hypotension medications, or
increases myocardial orthostasis herbal products
oxygen delivery in you are taking,
patients with Skin: Rash and any allergies
vasospastic angina. you have.
GI:
Nausea, dry mouth
During:
GU: polyuria
Report
MS: myalgia, immediately any
weakness swelling,
redness, burning,
Other: Diaphoresis or pain at infusion
site.

Do not crush or
chew sustained
release forms;
swallow whole.

Take with non-

fatty food. Avoid
caffeine and
alcohol

After:

May cause
orthostatic
hypotension
(change position
slowly from sitting
or lying to
standing, or when
climbing stairs)

May cause sore

mouth (inspect
gums for swelling
or redness- use
soft toothbrush,
waxed dental
floss, and
frequent mouth
rinses).

May cause
dizziness or
fatigue (use
caution when
driving or
engaging in tasks
that require
alertness until
response to drug
is known)

May cause
nausea and dry
mouth ( small
frequent meals,
 frequent mouth
care, chewing
gum, or sucking
lozenges may
help).

NURSING CARE PLAN

Defining Nursing Scientific Goal of Care Nursing Interventions Rationale
Characteristics Diagnosis Analysis

Subjective Cues: Ineffective The general Short term: Independent: Independent:

“Maglisud kog likay coping related well-being After 8 hours of 1. Determine the 1. To identify and treat
ug kaon sa to chronicity of (“I’m not nursing cause of the causative
pagkaon nga di the disease feeling sick”), interventions, ineffective coping factors and
angay nako,” as and complex the complexity the patient will and the stressful stressors.
verbalized by the treatment of the be able to
patient. protocols and therapeutic demonstrate an events that disturb
need for regimen, effective coping the coping
lifestyle required skills by mechanism. 2. To reduce stress
changes lifestyle following the 2. Teach and and improve coping
changes, and therapeutic encourage the mechanism.
Objective Cues: side effects of regimen and client to perform
- Anxiety medications lifestyle
stress reduction
- Worried and usually result modifications 3. Family and friends
depressed in the inability and take steps strategies like
can help the client
- Verbalizes inability of the patients to avoid yoga, meditation
to alleviate the
to cope with to cope. potential and prayers.
stressors and
treatment stressful 3. Identify the family,
- Inappropriate use situations. improve coping
peer or
of defense mechanism.
community
mechanism
support systems
Long Term:
After 3 days of who can help the 4. To cope with the
nursing client and therapeutic regimen
interventions, encourage them by making adequate
the patient will to provide support lifestyle changes.
be able to to the client.
identify 4. Advice the client
potential and family about
stressful 5. To prevent obesity
situations and the need for
and divert the mind
steps to lifestyle
of client from
avoid/modify modifications like
them. stressful situations.
strictly avoid
smoking, drug
6. To relieve tension
abuse, and
and treat
alcoholism.
hypertension.
5. Encourage the
client to do
household
activities and
avoid sedentary
lifestyle. 7. To provide support
6. Provide and help the client
psychological to meet the goals.
support by
explaining the
Dependent:
disease process 1. To treat
and explain the hypertension and
client about the improve coping
need to follow the mechanism.
therapeutic
regimen as
prescribed.
7. Provide positive
reinforcements
and help the client
to set realistic
 goals.

Dependent:
1. Teach the client to
follow the drug
regimen as
prescribed by
physician.

Defining Nursing Scientific Goal of Care Nursing Rationale

Characteristics Diagnosis Analysis Interventions
 SHORT TERM:
Impaired Renal failure After 8 hours of Independent Independent
OBJECTIVES: Urinary is a problem nursing intervention,
 Urinary Elimination which results the patient will: 1. Determine 1. To assess
retention related to to loss of client’s pattern of degree of
 Intake: decrease kidney  Achieve elimination interference
1,220 ml; glomerular functions and normal
Urinary filtration as GFR urinary 2. Determine 2. To help
output: 340 rate decreases, elimination client’s usual determine
ml (I&O the kidney pattern daily fluid intake level of
monitoring cannot  Verbalize hydration
sheet- excrete understanding 3. Observe for
8/14/20) nitrogenous of condition signs of infection 3. To help in
products and treating urinary
fluid causing LONG TERM: 4. Emphasize alterations
impairment in After 4 days of importance of
urinary nursing intervention, having good 4. To promote
elimination. the patient will: hygiene wellness
 Identify
Reference: 5. Encourage to
causative
Doenges, E., verbalize
factors 5. To allow client
Moorhouse, concerns
Demonstrate to deal with
F. M., & Murr behaviors or Collaborative feelings and
A. 2010. techniques to cope begin problem
Nursing Care with condition properly 1. solving
Plans:
Collaborate Collaborative
Guidelines for
with dietitian 2. To manage
Individualizin
symptoms and treat
g Client Care to review
underlying
Across proper conditions
the Life dietary plan 1. To prevent
Span
for patient aggravation of
 disease condition
2. Administer
medications as
indicated

Reference:
Doenges, E.,
Moorhouse, F. M.,
& Murr A. 2010.
Nursing Care
Plans: Guidelines
for Individualizing
Client Care
Across the Life
Span

EVALUATION

After 8 hours of nursing intervention, the patient was able to have a normal urinary elimination pattern and was able to
show full understanding regarding the condition.

After 4 days of nursing intervention, the patient Identified the causative factors
And demonstrated behaviors or techniques to cope with condition properly.