A CASE PRESENTATION:

DIABETIC COMA 2 TO HYPERGLYCEMIA; DIABETIC NEPHROPATHY; NIDDM POORLY CONTROLLED

Name: Age: Date of birth: Address: Date admitted: Chief complaint:

NANCY TABUZO 59 years old October 10, 1951 Sta. Cruz, Virac Catanduanes September 24, 2011 Loss of consciousness

Attending Physician: Dr. Romano Tentative Diagnosis: Diabetic Coma 2 to Hyperglycemia; Diabetic Nephropathy; NIDDM poorly controlled

Mrs. Nancy Tabuzo was admitted at the hospital with the complaint of DOB and loss of consciousness. Two weeks prior to admission, she developed peripheral edema and increased abdominal girth. Upon interview, Mrs. Tabuzo reported that the edema and her abdomen eventually increases in size when she took Omeprazole to relieve her hoarseness of voice. Omeprazole was prescribed by Dr. de los Santos when she seek physician s advice. Another contributing factor according to her, was when she drank a lot of water because of intolerance to any kind of food. Eventually, she felt severe abdominal discomfort. And caught again the physician s advice, Dr. Balmadrid. She was given an antispasmodic drug. Yet, it was not relieved.

Until, she exhibited DOB and ultimately lost her consciousness on September 24, 2011 @ 9:45 PM. That prompted her family to rush her to the hospital. She was diagnosed of Diabetic Coma 2 to Hyperglycemia Diabetic Nephropathy; NIDDM poorly controlled. V/S was taken prior to admission: BP: 110/70 mm Hg T: 36.7 C P: 88 bpm R : 24 bpm Upon our assessment, she has a yellow-colored sclerae. With reported activity intolerance/ body weakness; increased abdominal girth; peripheral edema; weight loss; and facial grimace. She is also mentally oriented. She has decreased urinary output but normal bowel elimination pattern everyday.

Nancy Tabuzo has no known familial history of diabetes mellitus or liver disease. She is a sewer. She eats all kinds of food with little fat. She doesn t smoke nor drink alcohol. She never gone to a hospital before because of any illness.

 Ego Development Outcome: Integrity vs. Despair Basic Strengths: Wisdom As an adult, she demonstrates integrity rather than despair. She courageously faces her disease with sincere acceptance. She looks on her life with happiness and is contented, feeling fulfilled with a deep sense that her life has meaning and she have made a contribution to life. She is open to any possibilities regarding the prognosis of her disease.

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 containing 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.

ENVIRONMENTAL, INFECTION AND EMOTIONAL STRESSORS

INSULIN RESISTANCE

REDUCED TISSUE UPTAKE OF GLUCOSE

GLUCOSE ACCUMULATION IN THE BLOOD VESSELS

HYPERGLYCEMIA

OSMOTIC DIURESIS

HYPEROSMOTIC PLASMA

DEHYDRATION OF CELLS

RENAL INSUFFICIENCY

TISSUE HYPOXIA

NEPHROPATHY

HYPERGLYCEMIC COMA

Hematology Hematocrit

Result 0.27

NORMAL VALUES 0.37-0.47 (female) 0.40-0.54 (male) 120-140g/l (F) 140-160g/l (M) 5-10x10g/l

SIGNIFICANCE Values decrease in anemia, leukemia, cirrhosis and hyperthyroidism Values decrease in anemia, hyperthyroidism, cirrhosis of the liver, and severe hemorrhage Values increase in acute infections, trauma, some malignant diseases, and some cardiovascular diseases. Increase segmenters indicate viral infection.

Hemoglobin

89g/l

White blood cells

10.8x10g/l

Segmenters Lymphocytes Monocytes Eosinophil

0.85 0.07 0.04 0.04

0.58-0.66 0.21-0.3 0.04-0.06 0.02-0.04

Name of Medications

Dosage/Route of Administration
25 mg OD

Indications

Contraindications

Nursing Implications

Spironolactone

 Edema caused by heart failure, hepatic cirrhosis, or nephrotic syndrome Essential hypertension Hypokalemia Diagnosis and treatment of primary hyperaldosteronis m

Hypersensitivity to drug Anuria Hyperkalemia Concurrent use of other potassiumsparing diuretics or potassium supplements.

Monitor electrolytes levels. Monitor weight and fluid intake and output. Stay alert for indications of fluid imbalance. Advise patient to restrict intake of highpotassium foods.

Furosemide

20 mg TIVT q 8

Acute pulmonary edema Edema caused by heart failure hepatic cirrhosis, or renal disease Hypertension

Hypersensitivity to drug Anuria

Monitor BP, pulse, fluid intake and output, and weight. Monitor dietary potassium intake. Instruct patient to take in the morning with food to prevent nocturia. Instruct patient to move slowly when rising, to avoid dizziness from sudden Bp decrease.

Celemin Sorbitol

500 cc OD to run for 8 as side drip

Prophylaxis and therapy for protein deficiency

Hypersensitivity to drug Disturbances of the amino acid metabolism Hyperkalemia

Monitor for adverse reactions.

Cefuroxime

750 mg TIVT q 8 ANST (-)

Moderate to severe infections

Hypersensitivity to drug

Monitor patient for lifethreatening adverse effects. Monitor kidney and liver function test results and intake and output. Monitor temperature.

Bisacodyl

2 tabs @ H.S.

Constipation

Hypersensitivity to drug Intestinal obstruction Gastroenteritis Appendicitis

Assess stools for frequency and consistency. Monitor patient for electrolyte imbalances and dehydration. Advise not to use bisacodyl or other laxatives habitually because this may lead to laxative dependence.

Vitamin K

1 amp q 8

Hypoprothromb Hypersensitivity inemia caused by anticoagulant therapy to drug

Monitor for adverse reactions.

Kalium Durule

1 tab TID

Hypokalemia. As prophylaxis during treatment w/ diuretics.

Renal Insufficinecy, Hyperkalemia

Monitor for adverse reactions

HNBB

1 amp TIVT now

Treatment of spasm and hypermotility of GIT

Closed angleglaucoma, paralytic ileus

Monitor for adverse reactions

HOME MEDS
Silymarin
1 cap OD for 2 days Treatment of chronic inflammatory diseases of the liver or hepatic cirrhosis Hypersensitivity to drug Advise patient to report any adverse reactions.

Essentiale Forte

1 cap OD for 2 days

Acute, sub acute Hypersensitivity & chronic hepatitis to drug

Advise patient to report any adverse reactions

Furosemide & Spironolactone

1 cap OD for 2 days

CUES

NURSING DIAGNOSIS

Ang sakit-sakit ng tiyan ko , patient verbalized Tachycardiac Tachypneic With facial grimace With pain scale of 8/10 Restless Uncomfortable Irritable

ALTERED COMFORT R/T ABDOMINAL PAIN

INFERENCE

NURSING OBJECTIVES

Kidney problem/Liver damage/ Excess excretion of albumin Albuminuria/ inadequate amount of albumin

After 8 hours of effective nursing interventions, the patient will report pain is relieved/controlled and appear relax and able to rest and sleep appropriately.

Accumulation in peritoneal cavity

Ascites

Abdominal discomfort

NURSING INTERVENTIONS Encourage patient to report pain. Assess reports of abdominal cramping or pain pain, noting location, duration, intenstiy (0-10 scale). Investigate and report changes in pain characteristics. Note nonverbal cues, e.g., restlessness, reluctance to move, abdominal guarding, withdrawal and depression.

RATIONALE May try to tolerate pain rather than request analgesics. Changes in pain characteristics may indicate spread of disease/developing complications, e.g., bladder fistula, perforation, toxic megacolon.

Body language/ nonverbal cues may be both physiologic and psychologic, and may be used in conjunction with verbal cues to identify extent/ severity of problem. Review factors that aggravate or alleviate May pinpoint precipitating or pain. aggravating factors or identify developing complications.

NURSING INTERVENTIONS Permit patient to assume position of comfort, e.g., kness flexed. Provide comfort measures ( back rub, reposition and diversional activities).

RATIONALE Reduces abdominal tension and promotes sense of control. Promotes relaxation, refocuses attention, and may enhance coping abilities. May indicate developing intestinal obstruction from infalammation, edema, and scarring. Complete bowel rest can reduce pain and cramping. Pain varies from mild to severe and necessitates management to facilitate adequate rest and recovery. Relieves spasms of GI tract and resultant colicky pain.

Observe/ record abdominal distention, increased temperature, dcreased BP. COLLABORATIVE: Implement prescribed dietary modifications. Administer medications as indicated: ANALGESICS

ANTICHOLINERGICS

EVALUATION After 8 hours of effective nursing interventions, the patient reported pain is relieved/controlled and appeared relax and able to rest and sleep appropriately.

CUES Wala akong ganang kumain , patient verbalized. With distended abdomen Lack of interest in food Weakness Poor muscle tone Restless

NURSING DIAGNOSIS RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS R/T Abdominal distention & discomfort and anorexia

INFERENCE

NURSING OBJECTIVES

Ascites Distended abdomen and abdominal discomfort Intolerance to a variety of foods Lack of appetite Inadequate intake Weight loss Imbalanced nutrition

After 8 hours of effective nursing interventions, the patient will: Ingest appropriate amounts of calories/ nutrients. Display usual energy levels. Demonstrate stabilize weight or gain toward usual or desired range with normal laboratory values.

NURSING INTERVENTIONS Weigh daily or as indicated. Ascertain patient's dietary program and usual pattern; compare with recent intake. Auscultate bowel sounds. Note reports of abdominal pain/ bloating, nausea and vomiting of undigested food. Maintain NPO status as indicated. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids; progress to more solid food as tolerated. Identify food preferences, including ethnic/ cultural needs.

RATIONALE Assesses adequacy of nutritional intake ( absorption and utilization) Identifies deficits and deviations from therapeutic needs. Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/ function ( distention or ileus) affecting choice of interventions. Oral route is preferred when patient is alert and bowel function is restored.

If patient's food preferences can be incorporated into the meal plan, cooperation may be facilitated after discharge. Promotes sense of involvement; provides information for SO to understand nutritional needs of the patient.

Include SO in meal planning as indicated.

NURSING INTERVENTIONS Observe for signs of hypoglycemia, e.g., changes in LOC, cool/ clammy skin, rapid pulse, hunger, irritability, anxiety, headache, li light- headedness, shakiness. COLLABORATIVE: Perform fingerstick glucose testing.

RATIONALE Once carbohydrate metabolism begins ( blood glucose level reduced), and as insulin is being given, hypoglycemia can occur.If patient is comatose, hypoglycemia may occur without notable change in LOC.

Monitor laboratory studies, e.g., serum glucose, acetone, pH, HCO3

Bedside analysis of serum glucose is more accurate than monitoring urine sugar, which is not sensitive enough to detect fluctuations in serum levels and can be affected by patient's individual renal threshold or the presence of urinary retention/renal failure. Blood sugar will decrease slowly with controlled fluid replacement and insulin therapy.

NURSING INTERVENTIONS Administer glucose solutions, e.g., dextrose and half- normal saline.

RATIONALE Glucose solutions are added after insulin and fluids have brought the blood glucose to approximately 250 mg/dL. Useful in calculating and adjusting diet to meet patient's needs; answers questions and can assist patient/ SO in developing meal plans.

Consult with dietician.

EVALUATION After 8 hours of effective nursing interventions, the patient : Ingested appropriate amounts of calories/ nutrients. Displayed usual energy levels. Demonstrate stabilized weight or gained toward usual or desired range with normal laboratory values.

CUES

NURSING DIAGNOSIS

Peripheral edema Increased oral fluid intake

RISK FOR FLUID VOLUME EXCESS R/T Ascites and edema formation

INFERENCE

NURSING OBJECTIVES After 8 hours of nursing interventions, the patient will :

Ascites and edema formation Demonstrate stabilize fluid volume. With balance I & O. Stable weight. Vital signs within patient s normal range. Absence of edema.

Increase fluid volume Hypervolemia

NURSING INTERVENTIONS Measure I & O, noting positive balance ( intake in excess of output). Weigh daily, and note gain greater than 0.5 kg/d. Monitor BP. Note JVD/ abdominal vein distention.

RATIONALE Reflects circulating volume status, developing/ resolution of fluid shifts and response to therapy. BP elevations are usually associated with fluid volume excess but occur because of fluid shifts out of the vascular space. Distention of external jugular and abdominal veins is associated with vascular congestion. Indicative of pulmonary congestion/ edema. Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications.

Assess respiratory status, noting increased respiratory rate, dyspnea. Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds.

NURSING INTERVENTIONS Monitor for cardiac dysrhythmias.

RATIONALE May be caused by HF, decreased coronary arterial perfusion, and electrolyte imbalance. Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased ADH. Reflects accumulation of fluid resulting from loss of plasma proteins/ fluid into peritoneal space. May promote recumbency- induced diuresis.

Assess degree of peripheral/ dependent edema. Measure abdominal girth.

Encourage bed rest when ascites is present. COLLABORATIVE: Monitor serum albumin and electrolytes ( particularly potassium and sodium) Restrict sodium and fluids as indicated.

Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct/ prevent dilutional hyponatremia.

NURSING INTERVENTIONS Administer medications as indicated: Diuretics

RATIONALE

Used with caution to control edema and ascites, block effect of aldosterone, and increase water excretion while sparing potassium, when conservative therapy with bed rest and sodium restriction do not alleviate problem. Serum and cellular potassium are usually depleted because of liver disease as well as urinary losses.

Potassium

EVALUATION After 8 hours of nursing interventions, the patient will : Demonstrate stabilized fluid volume. With balanced I & O. Stabled weight. Vital signs within patient s normal range. Absence of edema.

This study aims to widen the knowledge of people concerned about the disease process and the signs and symptoms of the disease as well as the underlying complications.

To nursing research, this challenges researchers to find ways on how to lessen the occurrence of disease and add more efficient information that can help the students easily determine the difference of this disease from the other.

To improve nurses' preparedness to manage the real medical emergencies that confronts them in professional practice, without risk to human patients. This study also encourages the health care provider to properly determine the appropriate interventions needed by the patient having this kind of case.

Presented by:
JOHN REY D. HESITA EMLYN JOSEPHINE M. LANON

MARIA LESLYN S. ROMERO

SARAH JEAN B. TUPUE

GENEVIVE T. TAWAY

SHEILA MARIE R. TABLATE