I.

Introduction

Diabetes mellitus is a group of metabolic diseases characterized by high

blood sugar (glucose) levels that result from defects in insulin secretion, or

action, or both. Whereas the pancreas is no longer producing enough insulin

or cells stop responding to the insulin that is produced, so that glucose in the

blood cannot be absorbed into the cells of the body. Early signs are lethargy,

extreme thirst, frequent urination, gum disease, blurred vision and hunger.

The most common form of diabetes is Type II. This is also known as age-

onset or adult-onset diabetes, and this form of diabetes occurs most often in

people who are overweight and who do not exercise. Type II is considered a

milder form of diabetes because of its slow onset (sometimes developing

over the course of several years) and because it usually can be controlled

with diet, oral medication and daily injections of insulin. In some cases,

uncontrolled and untreated Type II diabetes are just serious like Type 1. This

form is called noninsulin-dependent diabetes, a term which is sometimes

misleading. There are lots of people with diabetes that could control the

condition with diet and oral medications. The three main factors that

determine the presence of the disease are lifestyle, diet and genetic
predisposition. The rapid modernization and industrialization allows the

individual more time for leisure thus lessening physical activity. This leads to

increased food consumption leading to weight gain and obesity.

DM is associated with a markedly increased risk of coronary artery

disease. In the Framingham study, the incidence of coronary artery disease

was increased in diabetic subjects. While the most common cardiac

manifestation in diabetic patients is coronary artery disease, DM also

appears to be strongly linked to heart failure (HF).

Approximately 15 to 25% of patients with HF are diabetics and it has been

suggested that DM may play an important role in the pathogenesis,

prognosis, and response to treatment of HF. The increased risk of

atherosclerosis in diabetic patients may also contribute significantly to the

increased risk of HF. Coronary artery disease is the underlying cause of HF

in approximately two thirds of patients with left ventricular systolic

dysfunction. Diabetes is a chronic medical condition, meaning that although it

can be controlled, it lasts a lifetime.

II. Objectives

a. General Objectives

At the end of the Individual Case study, the students will gain a lot and

essential knowledge, information, skills and desirable attitudes with regards

to the topic that will be used in broadening our knowledge in the condition of

the patient not only in the clinical area and during duty hours but everywhere

and anytime upon discussing the focused disease and other related topics.

Moreover, improve our abilities as future health care providers.

b. Specific

Upon the completion of this case study, the student shall have:

• Described and explained Diabetes Mellitus, Coronary Artery Disease and

Congestive Heart Failure.

• Reviewed the anatomy and physiology of the organs involved.

• Identified the risk factors contributing to the occurrence of the condition.

• Expounded on the laboratory and diagnostic procedures done with the

patient, their purposes, and specific nursing responsibilities before, during

and after the procedure.

• Enumerated the different medications administered for the condition, their

indications and specific nursing responsibilities.

• Formulated significant nursing diagnoses, with their significantly related

nursing care plans.

III. Anatomy and Physiology

 Every cell in the human body needs energy in order to function. The
body’s primary energy source is glucose, a simple sugar resulting from the
digestion of foods which contains carbohydrates (sugars and starches).
Glucose from the digested food circulates in the blood as a ready energy
source for any cells that need it. Insulin is a hormone or chemical produced
by cells in the pancreas, an organ located behind the stomach. Insulin bonds
to a receptor site on the outside of cell and acts like a key to open a doorway
into the cell through which glucose can enter. Some of the glucose can be
converted to concentrated energy sources like glycogen or fatty acids and
saved for later use. When there is not enough insulin produced or when the
doorway no longer recognizes the insulin key, glucose stays in the blood
rather entering the cells.

Anatomy of the 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 the
head) is the widest part of the organ and lies in the curve of the duodenum
(the first section of the small intestine). The tapered left side extends slightly
upward (called the body of the pancreas) and ends near the spleen (called
the tail).

The pancreas is made up of two types of tissue:

Exocrine tissue
The exocrine tissue secretes digestive enzymes. These enzymes are
secreted into a network of ducts that join the main pancreatic duct, which
runs the length of the pancreas.

Endocrine tissue
The endocrine tissue, which consists of the islets of Langerhans,
secretes hormones into the bloodstream.

Functions of the pancreas:

The pancreas has digestive and hormonal functions:
The enzymes secreted by the exocrine tissue in the pancreas help break
down carbohydrates, fats, proteins, and acids in the duodenum. These
enzymes travel down the pancreatic duct into the bile duct in an inactive
form. When they enter the duodenum, they are activated. The exocrine tissue
also secretes a bicarbonate to neutralize stomach acid in the duodenum.

The hormones secreted by the endocrine tissue in the pancreas are insulin
and glucagon (which regulate the level of glucose in the blood), and
somatostatic (which prevents the release of the other two hormones).

Anatomy and Physiology of the Heart

The Exterior of the Heart
The heart is the muscle in the lower half of the picture. The heart has
four chambers. The right and left atria are shown in purple. The right and left
ventricles are shown in red. Some of the main blood vessels—arteries and
veins—that make up the blood circulatory system are directly connected to
the heart. The ventricle on the right side of the heart pumps blood from the
heart to the lungs. When you breathe air in, the oxygen passes from the
lungs through the blood vessels and into the blood. Carbon dioxide, a waste
product, is passed from the blood through blood vessels to the lungs and is
removed from the body when you breathe out. The left atrium receives
oxygen-rich blood from the lungs. The pumping action of the left ventricle
sends this oxygen-rich blood through the aorta (a main artery) to the rest of
the body.

The Right Side of the Heart

The superior and inferior vena cavae are in blue to the left of the heart
muscle as you look at the picture. These veins are the largest veins in the
body. After the body's organs and tissues have used the oxygen in the blood,
the vena cavae carry the oxygenpoor blood back to the right atrium of the
heart. The superior vena cava carries oxygenpoor blood from the upper parts
of the body, including the head, chest, arms, and neck. The inferior vena
cava carries oxygen-poor blood from the lower parts of the body. The
oxygen-poor blood from the vena cavae flows into the heart's right atrium and
then on to the right ventricle. From the right ventricle, the blood is pumped
through the pulmonary arteries to the lungs. There, through many small, thin
blood vessels called capillaries, the blood picks up more oxygen. The
oxygen-rich blood passes from the lungs back to the heart through the
pulmonary veins.

The Left Side of The Heart

Oxygen-rich blood from the lungs passes through the pulmonary veins.
It enters the left atrium and is pumped into the left ventricle. From the left
ventricle, the oxygen-rich blood is pumped to the rest of the body through the
aorta. Like all of the organs, the heart needs blood rich with oxygen. This
oxygen is supplied through the coronary arteries as blood is pumped out of
the heart's left ventricle. The coronary arteries are located on the heart's
surface at the beginning of the aorta. The coronary arteries carry oxygen-rich
blood to all parts of the heart.

The Interior of the Heart

The Septum
The right and left sides of the heart are divided by an internal wall of
tissue called the septum. The area of the septum that divides the atria (the
two upper chambers of the heart) is called the atrial or interatrial septum. The
area of the septum that divides the ventricles (the two lower chambers of the
heart) is called the ventricular or interventricular septum.

Heart Chambers
The two upper chambers of the heart are called atria. The atria receive
and collect blood. The two lower chambers of the heart are called ventricles.
The ventricles pump blood out of the heart into the circulatory system to other
parts of the body.

Blood Flow
The arrows in the drawing show the direction that blood flows through
the heart.
The light blue arrows show that blood enters the right atrium of the heart from
the superior and inferior vena cavae. From the right atrium, blood is pumped
into the right ventricle. From the right ventricle, blood is pumped to the lungs
through the pulmonary arteries. The light red arrows show the oxygen-rich
blood coming in from the lungs through the pulmonary veins into the heart's
left atrium. From the left atrium, the blood is pumped into the left ventricle.
The left ventricle pumps the blood to the rest of the body through the aorta.
For the heart to work properly, the blood must flow in only one direction. The
heart's valves make this possible. Both of the heart's ventricles have an "in"
(inlet) valve from the atria and an "out" (outlet) valve leading to the arteries.
Healthy valves open and close in very exact coordination with the pumping
action of the heart's atria and ventricles. Each valve has a set of flaps called
leaflets or cusps that seal or open the valves. This allows pumped blood to
pass through the chambers and into the arteries without backing up or
flowing backward.

IV. Patient’s Data

Name: Mrs. M. B.
Age: 48 years old
Sex: F
Address: Daga, Panay , Roxas City
Civil Status: Married
Religion: Roman Catholic
Date and Time Admitted: 3: 00 pm, January 14,2010
Ward: IHM Room 226
Chief Complaint: Vomiting
Admitting Diagnosis: Diabetes Mellitus Type II contolled w/ nephropathy
 Final Diagnosis: Hypertension, Hypertensive, Coronary Artery Disease
CHF class II w/ pericardial and pleural effusion
Attending Physician: Dr. Belasoto

V. Clinical Assessment
a. Nursing History
Pt is a diagnosed DM for >5 years. A month PTA, had met postprandial
vomiting preceded by dizziness (+) on and off grade 1 bipedal nonpitting edema,
(+) blurring of vision.

b. Past Health Problem/ Status

Diabetic >5 yrs
Nonhypertensive
nonasthmatic
VI. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND

Educational Background:
Unrevealed.
Occupational Background:
She is aunapplicable
Religious Practices:
She is a Roman Catholic.

Economic Status:
She is supported by himself and his family.

A. Physical Assessment
Admission
Vital Signs:
BP- 130/80mmHg; T- 36.4ºC; PR- 78 bpm; RR- 23 bpm

Assessment:
Skin:
• Pallor is noted
Head-EENT:
− Pale palpebral conjunctiva
-Sluggish capillary refill

Chest:
• Lungs: (+) Rales
Abdomen:
• Flabby, normal abdominal bowel sounds, soft, non-tender, hematoma
noted in the abdomen in both right and left

Extremities:
• With equal pulses
• No edema
• No cyanosis

Cephalocaudal Assessment:
Vital Signs:
BP- 140/80 mmHg; T- 36.6°C; PR- 78 bpm; RR- 19 rpm
General Appearance:
Mrs. M.B was seen lying on her bed with an IV fluid of PNLSS 1l x KVO
in the left metacarpal veins and regulated at10 cc/hr.

Assessment:
Skin
−Dry and warm to touch
-With fair skin complexion
-With pallor

Head
− With short hair, black and equally distributed
Eyes
− With dark brown iris
−With pale palpebral conjunctiva
Ears
−Pinna recoils after folding
− Absence of discharge
Mouth and Throat
− With pale lips
Neck
− Without palpable masses
Abdomen
− Flabby

Upper and Lower Extremities

• With non-pitting edema on both lower extremities
• Capillary refill: 1-2 secs.

VII. Laboratory and Diagnostic data

1/14/10
Test Result Normal Range Significance
sodium 136.6 mmol/L 137-145 Low
Indicates chronic
heart failure, lung
disease, liver
disease, and
cancer.
potassium 2.97 mmol/L 3.50-5.10 Abnormal
It constitutes the
predominant
intracellular
excitability and
muscle
 contraction.

1/14/10 Differential count

1/15/10
Glucose 6.16 mmol/L 4.10-5.90 Abnormal
It indicates that
don’t have enough
insulin in your
body.
cholesterol 6.49 0-5.20
LDL 4.80 1.71-4.60 Abnormal
A cholesterol that
circulates in the
blood. It can
slowly build up in
the inner walls of
the arteries that
feed the heart and
brain. It indicates
form plaque, a
thick, hard deposit
that can narrow
the arteries and
make them less
flexible.
1/19/10
hematocrit 0.33 M: .40-.54 Abnormal
F: .37-.53 Indicates blood
loss, over
hydration, dietary
deficiency and
anemia.

Hemoglobin 110 g/L M: 135-180 Abnormal

F: 120-160 It is responsible in
carrying O2 to the
cells and CNO2
away from the cell.
Indicates dietary
deficiency,
hemorrhage and
leukemia.

Platelet 380 x 10^9/L 150-350 10 9/L Abnormal

These are
fragments of
cytoplasm that
function in blood
coagulation. It
indicates
 malignant tumor.

Date 1/20/10
Chest PA

Xray findings:
Follow up study done, as compared with the previous chest x-ray taken
12/17/09 shows haziness in both lung bases obliterating the hemidiaphragm and
costophillic sulci.
There is a regression of haziness in the ( R ) upper lung field. The rest of
the findings are unchanged.

Impression:
Bilateral pleural effusion
Atherosclerotic Aorta
Bibasal pneumonia
Cardiomegaly, borderline

VIII. Pathophysiology

Predisposing Factors: Precipitating Factors:

Age : 48 - Obesity
Heredity - Lifestyle
- Diet
- Environmental
Factor/Stress

Low Production of Insulin

High Insulin Resistance

 Hyperglycemia

Chronic High Blood Viscous Blood Dyslipidemia

Glucose

Atherosclerosis
Increase Osmotic Poor Circulation
Pressure
Deposition of Fats in
Low Blood Supply
Fluid Goes to the Aorta
vascular space

Nerve Damage Narrowing and

High Blood Volume
Blockage of the Aorta

Hypertension Neuropathy
Low Blood to
Coronary Artery
Peripheral Nervous
System/ Sensory
Low Blood to Heart

• Pain
Myocardial Ischemia

COMPLICATIONS
• Angina
• Chest
• CHF
Pain
• Weakness
• Dyspnea
• Nausea
• Vomitting
Trade
Names
Generic Classification Action Indication Side Effect Contraindication Nursing
&
Name Responsibility
Dosage
140 mg. simvastatin cholesterol- reduces cholesterol In patients with headache, Pregnant Ask the pt. if they
OD lowering drug by inhibiting an coronary heart nausea, women, fungal are allergic to it.
antihyperlipidermic enzyme in the liver disease,diabetes, vomiting, diarrhea byproducts, Limit alcoholic
(HMG-CoA peripheral vessel , abdominal lactation beverages of the
reductase) that is disease, or history pain, muscle pain, pt.
necessary for the of stroke or other and abnormal Give in the
production of cerebrovascular liver test.Most evening; the
cholesterol. disease and serious potential highest rates of
In the blood, nonfatal side effects are cholesterol
statins(HMG-CoA myocardial liver damage and synthesis are
reductase) lower infarction (heart muscle between midnight
total and LDL attack) inflammation or and 5 am
("bad") cholesterol breakdown.
as well
as triglycerides

10 mg ½ Norvasc Antianginal Decreases cardiac Chronic stable Allergies to headache and Assess skin
Antihypertensive oxygen angina, alone or in amlodipine, heart edema (swellin lesions, edema,
t consumption, combination with block,lactation,us g) of the lower baseline
Calcium channel
a Increased delivery other drugs. e cautiously with extremities, ECG,ausculation,
blocker
b of oxygen to Essential heart failure dizziness GI normal output.
cardiac cells, block hypertensive,
O
the transport of alone or in Monitor patient
D calcium into the combination with carefully
smooth muscle other (BP,cardiac
cells lining the antihypertensives rhythm and
coronary arteries output)
and other arteries
of the body.
40 mg Clexane Anticoagulants, -treats blood clots renal impairment: Haemorrhage, • major Assess for tingling
Antiplatelets & -treats certain types Treatment of thrombocytopenia blood weakness,
 IX. Nursing Management (NCP)
Problem 1

Assessment Nursing Diagnosis Planning Intervention Evaluation

Objective Risk for infection r/t After 1 hour of nursing Independent

glucose level After 1 hour of
= 6.16 mmol/dL interventions, >Stress proper hand
hygiene by washing hands nursing interventions,
(glucose) and using sanitizers.
the patient have
> weakness the patient will identify >Increase intake of Vit C
> Observe for signs of identified interventions
interventions to prevent infection and inflammation.
to prevent risk of infection
risk of infection >Maintain aseptic
technique for IV like being aware of eating
insertion procedure,
administration of foods that will decrease
medications, and
providing
the risk of infections.
maintenance and site
care. Rotate IV sites
as indicated.

>Provide skin
care by keeping the skin
dry,
linens dry and
wrinkle free.
Problem 2

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective Imbalanced Nutrition:

“Sadto matambok ko Less Than Body After the nursing Independent Goal partially met as
ya.Galing ky sang requirements related to intervention: evidenced by patient are
>Discouraged beverages
nagmaskit ko sang increased metabolic The patient will be threatened by the factors
that are caffeinated or
diabetes nga ni gulpi needs caused by the -encourage the patient to occur. Avoided drinking
carbonated
akon pagniwang”, as disease eat well balanced diet carbonated drinks. Eat
> Encouraged low fat diet
verbalized -maintain blood glucose well.
and high fiber foods
level >Achieve and maintain
Objective -Achieve and maintain reasonable weight
Wt. 110 lbs reasonable weight >Practiced good
Non-elastic skin nutritional
habits
>Use less salt
>Eat less sugar
>Eat less fat
>Eat more complex
carbohydrate
Problem 3