DISCUSSION OF THE PATHOPHYSIOLOGY FOR TYPE 2 DIABETES MELLITUS Diabetes mellitus type 2, formerly known as non-insulin-dependent diabetes mellitus

(NIDDM) or adult-onset diabetes, is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Type 2 diabetes mellitus is a disorder that disrupts the way your body uses glucose (sugar). Normally, a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food substances. All the cells in your body need sugar to keep them in normal function. The two main problems related to insulin in type 2 diabetes mellitus are insulin resistance and impaired insulin secretion by the beta cells in the islets of Langerhans of the pancreas. Insulin resistance refers to decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. To overcome insulin resistance and to prevent the build up of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level. This is called metabolic syndrome, which includes hypertension, hypercholesterolemia, and abdominal obesity. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and type 2 diabetes mellitus develops. Despite the

impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies. Therefore, diabetic ketoacidosis does not typically occur in type 2 diabetes. However, uncontrolled type 2 diabetes may lead to another acute problem called hyperglycemic hyperosmolar nonketotic syndrome. This is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). The basic biochemical defect is lack of effective insulin. Persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. Because type 2 diabetes is associated with a slow, progressive glucose intolerance, its onset may go undetected for many years. If patient experiences symptoms, they are frequently mild. Clinical manifestations depend on the patients level of hyperglycemia. Classic manifestations of all types of diabetes include the three Ps: polyuria (excessive urination), polydipsia (excessive thirst) and polyphagia (excessive hunger). In polyuria, when there is an increase in amount of blood glucose, the amount of glucose reabsorbed by the glomeruli of the kidney exceeds the amount that can be reabsorbed by the renal tubules. By the time the kidneys filter the blood high in glucose level, not all of them may be reabsorbed and the excess will be excreted together with the urine resulting to glycosuria, accompanied with large losses of water in the urine. Polydipsia happens as a result from intracellular dehydration where in when glucose is not able to enter the cell; they tend to pull out the water within the body cell, including those in the thirst center, making the cell dehydrated. Polyphagia causes cellular starvation

since the glucose cannot be transported and metabolized for energy. Symptoms that would prompt a person to seek include fatigue, and weakness, sudden vision changes, tingling or numbness in the hands or feet (paresthesia), dry mouth and dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. Long term complications of diabetes include diabetic retinopathy, which is the leading cause of blindness, diabetic nephropathy or renal disease secondary to diabetic macrovascular changes in the kidney and diabetic neuropathy which refers to a group of disease that affect all types of nerves, including peripheral (sensimotor), autonomic and spinal nerves. Foot and Leg problems are also one complication of diabetes which may require lower extremity amputations to prevent the spread of infection, particularly if it involves the bone (osteomyelitis). Treatment includes lifestyle changes, diet modification, self care measures and medications. If all the signs and symptoms are left untreated and if there is no proper management of the disease, this may result to severe infection and death.

IX. MEDICAL MANAGEMENT A. CLINICAL MANAGEMENT 1. TREATMENT AND PROCEDURES These are interventions done to ensure the safety of patient. 1. Interviewing This is done by the physician or a nurse to gather patients significant health history and to assess the patient.

2. Procedures 1. Vital signs taking closely monitored, any changes are reported because this serves as a baseline data of the patient and will indicate whether the patients condition is progressing or reclining. It is a routine taking of the patients temperature, pulse rate, respiration rate and blood pressure. 2. Intravenous fluid monitoring this is important to prevent overloading and under loading on the patients body. It is also prescribed or given to replace the patients loss fluid and electrolytes and also to replace the excessive loss of blood in the womans body from giving birth or during delivery and to those who have just undergone surgery. 3. Administering oral medication oral medicines are administered or given to the patient as ordered by their physician such as multivitamins with iron this is to replenish the loss blood of the woman from giving birth, antibiotics this is to prevent infection related to the perineal incision and analgesicto relieve pain. 4. Bedside care this is to monitor the patient closely, to help her or assist her in ambulating or if she needs something when her accompanying is not with her. This is also to make the patients bed clean and free from dust. 5. Health teaching this is to provide information to the patient about her condition and the need for her to take her medication and so that she will also take it positively.

6. Intake and Output measurement this is done to monitor patients hydration status. 7. Bed making and environmental sanitation this is done to provide comfort to patient and prevent infection caused by soiled linens and dusty environment. 2. MEDICATIONS 1. piperacillin + tazobactam 4.5 gm IV infusion every 8 hours ANST left arm Date ordered: August 22, 2011 2. catapres 75 mcg SL 1 tab q 6 prn for BP 160/100 Date ordered: August 22, 2011 3. Lifezar 100 mg tab, 1 tab OD Date ordered: August 22, 2011 4. Humulin R 4 U SQ now Date ordered: August 23, 2011 5. Atorvastatin (Avamax) 20 mg, 1 tab once a day q HS Date ordered: August 23, 2011 6. amlodipine 10 mg / tab OD 1st dose now

Date ordered: August 23, 2011 7. Actos 30 mg / tab, 1 tab after lunch Date ordered: August 24, 2011 8. Glucophage 1x XR 750 g / tab,1 tab OD presupper Date ordered: August 24, 2011 9. 0.9% Sodium Chloride (Plain Normal Saline Solution) to run at 20 gtts/min Date ordered: August 22-25,2011 3. DIET The patient was advised to have a strict compliance to her low salt, low fat, and low cholesterol diet. Patient was instructed to increase her fluid intake and increase her in take of foods high in fiber. B. ACTUAL NURSING MANAGEMENT B.1 ACTUAL CARE GIVEN As early as 7:30 in the morning, just a few minutes after the endorsement, the researcher took the vital signs of the patient and plotted it in the chart. She also measured her Intake and Output and recorded it. She checked patient's intravenous fluid whether it needs to be replaced or not or if it still follows its

ordered rate of flow. She asked her patient few questions for her additional data needed for the completion of patients history taking and when patient verbalized some of her concerns, she listened. She stayed for a while in the patients room to attend to her patients needs. She gave her health teachings about

management of her constipation, teachings on infection control and management of her diabetes. She evaluated her patient as to how she responded to her teaching. She also performed bed making on her patient and assured that her patients room would be organized. She was also able to perform sponge bath on her patient and change patients clothes. She was able to perform hand hygiene before and after she entered her patient's room to reduce transmission of microorganisms. She made an FDAR for her patient where in it emphasizes on the management of patients constipation. B.2 PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION OF NURSING CARE One of the problems encountered by the researcher during the implementation of her nursing care was the inconsistency of patients mood to cooperate on her plan of care. Patient is greatly affected regarding her misunderstanding with her eldest son. Patients emotions often get in her way resulting to her depression. The patient is often seen lying on bed with less

physical activity. Patient often talks about her son and her deceased husband. Patient experiences self pity and depression which led her to her verbalization of

kahibaw ko pait ug luoy akong kahimtang pero okay ra man pud kung mamatay nako kay wa naman sad koy rason mabuhi which now supports patients less interest to listen to the researcher and less interest to the improve the state of her condition. She views researchers entry to her room as a very soothing one because she knows very well that with the researcher around, she can vent out her feelings. Handling someones feelings is a very crucial responsibility because it requires a pure heart to listen and sincere soul understand. Now this becomes a challenge to gain the trust of the patient. Hence, researchers basic knowledge, skills and positive attitude are now made use in the clinical setting as to how she would create a smooth relationship between her and her patient. B.3 PATIENT TEACHING The researcher conducted a one on one discussion between her and her patient regarding the plan of care. The researcher encouraged the patient to become an active participant to the implementation of her care. She emphasized few instructions that are needed to be followed such as strict compliance to her prescribed diet. The patient should understand that she needs to avoid eating foods high in sodium, fat and cholesterol to prevent the occurrence of further complications. In addition, the patient needs to increase her fluid intake and eat foods high in fiber such as wheat grains, oatmeal, decaffeinated coffee, tea, pineapple and watermelon to manage constipation which is one of the side effects of some of her medications. She also included in her teaching that the patient

needs to comply on her medication regimen that was ordered by her physician. The researcher also encouraged the patient to exercise within limits of individual ability. Compliance to dietary restriction and exercise plays an important role in the improvement of patients condition. The researcher promoted infection control to her patient. She then encouraged her patient to practice hand hygiene at all times. She instructed patient to do frequent self-perineal care every after voiding and do proper personal hygiene such as taking a bath to prevent infection. X. CONCLUSION AND RECOMMENDATION After having experienced taking care of a patient with type 2 diabetes, the researcher was able to develop sympathy for all patients with this kind of condition. As a future health care provider handling this kind of case, the primary concern is to impart knowledge to the patient/s so that they will know what are the dos and donts with regards to their condition, and to their significant others so that there will be a continuation of care in and out of the hospital or the absence of health care provider/s. Rendering care is not also an easy task but having the right attitude and sincere purpose of doing such, everything would just be light.

The study was accomplished under an encouraging ambiance that facilitated for an undisturbed atmosphere both for the patient and the student nurse. The patient in spite of the discomforts of condition and the distress she felt

was still very accommodating which enabled the researcher to obtain pertinent information and data.

The researcher would like to recommend to all the future researchers to give a holistic care to their patients. This will truly help the patient, for what they are going through lies between life and death. She also recommends them to gather as much data as possible, and a very detailed one. The researchers should be geared towards realizing and restoring the patient's biopsychospiritual well being and assisting the client to live a dignified and normal life where in the patient would feel loved, cared for, trusted and understood.

This study aims every nurse, and student nurse alike, to widen and share this knowledge and skills with regards to the care given to anyone family, friends, or even strangers. This study will offer information in the minds of those non-medically oriented and affix superfluous details to health care provider, and so as to every human being. Thus, student nurses must think wholly in bestowing worth to their patient/s, especially the diabetic ones as individuals that dont just need care but also support and encouragement. XI. IMPLICATION OF THE STUDY TO A. NURSING EDUCATION

Education primarily is the highlight of this case study. This serves as a momentous tool for every health care provider. It stresses out all the information on the concept of type 2 diabetes mellitus. This serves as a magnifier to dissect and observe all the information and gives extensive grasp on the said concept. The study is one tool in giving way to a more holistic and effective care in patients who have diabetes. Having a good outlook and positive attitude is another thing we could get out of this case study. Being a positive and confident in dealing with these patients will make the patients feel at ease and trust their nurses more which aids in giving effective and better care. B. NURSING PRACTICE It is when you know that this study is geared towards the optimal care for clients who have this particular case. Doing a case study contributes much to nursing education as it widens our knowledge base and apply them to appropriate situations, which is in turn contributes to our efficacy. The study focuses on the skill that is essential to provide best possible care. Knowledge should be supported with skills and practice. Skills that is refined with constant practice and an open mind for improvements, and the appropriate stance, to understand patients situation. And as time progresses, it also needs revision to cope with the changing need and demands. C. NURSING RESEARCH

Research is the heart of more scientific based care. It is a vital part to every theory, formula and newly concepts rendered to the society. To do research, benefits not only students who are taking up nursing but for those nurses who practice their profession. Also, it is in research that we update ourselves to the very fast paced track and trends in nursing. Nursing is an ever-changing field. What may not be applicable today may be applicable tomorrow.

This study can be a good basis for the future researchers and professionals so that better interventions and knowledge will soon be made and imparted to all patients, their significant others and professionals dealing with this condition. It serves as reference and it provides valuable data on how to care for individuals with type 2 diabetes mellitus. Through this, they can attain information and the appropriate measures in giving nursing care.