Tomas Del Rosario CollegeBalanga City, Bataan

College of Nursing

NURSING CASE STUDY

Uncontrolled Diabetes Mellitus Type

II;Cerebrovascular Accident Infarct in Left Posterior

Cerebral Artery Distribution

Name :GROUP II Date: March 16, 2012

• Lopez, Luis Aster• Mangalindan, John Carlo• Villaruel, Joseph• De Castro, Francis• Gonzales, Innamae• Jaring, Kimberly Kaye• Tadeo, Veniz Kim• Velez, April Anne

Year and Section: BSN IV

Introduction

“An ounce of prevention is

worth a pound of cure”

It simply means that it’s better to stop something bad from happening in the first place rather than trying to fix them once they arise.

The idiom is relevant to our case study for our patient’s lifestyle and pre-existing illnesses are great contributions to the development of Diabetes Mellitus Type II and occurrence of Cerebrovascular Accident.

“How do we get from telling to doing?”

There is a big difference between knowing that you should do something and actually doing it.

In a major shift of emphasis in the battle against an array of diseases such as our case study entitled, “Uncontrolled Diabetes Mellitus Type II and Cerebrovascular Accident Infarct in Left Posterior Cerebral Artery Distribution”, we urge people not only the hospital and the community but in our very home as well to embrace prevention rather than just trying to avoid risks long associated with the world’s leading killer. In addition, we choose such illnesses to be more acquainted with their etiology, how it develops, its predisposing factors, what alleviate and exacerbate such illnesses and how to prevent it.

DEFINITION OF THE DISEASE

Diabetes Mellitus

Diabetes mellitus type 2 – formerly 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. The classic symptoms are excess thirst, frequent urination, and constant hunger. Type 2 diabetes makes up about 90% of cases of diabetes with the other 10% due primarily to diabetes mellitus type 1 and gestational diabetes. Obesity is thought to be the primary cause of type 2 diabetes in people who are genetically predisposed to the disease.

Type 2 diabetes is initially managed by increasing exercise and dietary modification. If blood glucose levels are not adequately lowered by these measures, medications such as metformin or insulin may be needed. In those on insulin there is typically the requirement to routinely check blood sugar levels

PREVALENCE IN THE PHILIPPINES

The National Nutrition and Health Survey II (NNHES II) showed that diabetes prevalence increased from 3.4 percent in 2003 to 4.8 percent in 2008. The survey found that five in every 100 Filipinos have hyperglycemia (high fasting blood sugar), with hyperglycemia incidence peaking at age 50 to 59.

GLOBAL PREVALENCE

• Approximately 1 in 17 or 5.88% or 16 million people in USA• 346 million people worldwide have diabetes.• In 2004, an estimated 3.4 million people died from consequences of high blood sugar.• More than 80% of diabetes deaths occur in low- and middle-income countries.• WHO projects that diabetes death will double between 2005 and 2030.

Cerebrovascular Accident

Cerebrovascular accident is a very serious condition in which the brain is not receiving enough oxygen to function properly. A cerebrovascular accident is also called CVA, brain attack, cerebral infarction or stroke. A cerebrovascular accident often results in permanent serious complications and disability and is a common cause of death.

The brain requires a steady supply of oxygen in order to pump blood effectively to all of the body. Oxygen is supplied to the brain in the blood that flows through arteries. In a cerebrovascular accident, one or more of these arteries becomes blocked or ruptures or begins to leak. This deprives a portion of the brain of vital oxygen-rich blood. This damage can become permanent within minutes and result in the death of the affected brain tissue. This is called cerebral necrosis.

Symptoms of a stroke depend on the area of the brain affected. The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, and swallowing, breathing and even unconsciousness

Two types of cerebrovascular accidents:•An ischemic cerebrovascular accident occurs when a brain

artery has been blocked.oOccurs when the blood supply to a part of the brain is interrupted or totally occludedoCommonly due to thrombosis or embolism

Thrombotic (large vessel) strokeThe most common cause of ischemic strokeAtherosclerosis is the primary causeFatty materials deposit on large vessel walls (especially at arterial bifurcations) and eventually these plaques causes stenosis of the arteryBlood swirls around the irregular surface of the plaques causing platelets to adhere and the vessel becomes obstructedThese causes infarcts usually affecting the cortexMost common type of stroke in people with diabetes

2. A hemorrhagic cerebrovascular accident occurs when an artery ruptures or leaks.

Results from rupture of a cerebral vessel causing bleeding into the brain tissues

Bleeding results with edema, compression of the brain contents or spasm of the adjacent blood vessels

Often secondary to hypertension and most common after age 50

Other factors includes ruptured intracranial aneurysms, trauma, erosion of blood vessels by tumors, arteriovenous malformations, anticoagulant therapy, blood disorders

Usually produce extensive residual functional loss and slowest recovery

It is possible that a diagnosis of cerebrovascular accident can be missed or delayed because the symptoms may be mild and be similar to symptoms of other conditions and diseases.

PREVALENCE IN THE PHILIPPINES

Cerebrovascular accident is the second leading cause of death in the Philippines with total of 51,680 according to Department Of Health, along with this are 37,092 who survived with it.

GLOBAL PREVALENCE

• CVA is the leading cause of adult disability in the world.• Worldwide, one-quarter of all strokes are fatal.• Stroke is the third leading cause of death in the United States and the leading cause of disability.• Two-thirds of strokes occur in people over the age of 65.• Strokes affect men more often than women, although women are more likely to die from a stroke.• The incidence of strokes among people ages 30 to 60 is less than 1%. This figure triples by the age of 80.

Objectives

• To alleviate the signs and symptoms of the patient’s disease

• To render a comfortable environment to the patient

• To provide health teachings for the patient’s condition and to his family as well

• To identify risks and measures for the patient’s family to minimize occurrence of the disease

• To develop the family’s support system and involve them in promoting in the health care of the patient

Patient Centered:

Student Centered:•To know more about the development of the disease•To identify the signs and symptoms of the patient’s condition•To determine the appropriate nursing intervention for the patient•To construe the administered medications, laboratory results and diagnostic procedures done with the patient including its significance and corresponding nursing interventions•To formulate significant nursing diagnoses with their significantly related nursing care plans

Assessment

Demographic Profile

Patient JD is a 64 year old male, who was born on July 20, 1947 and currently resides in Pilar, Bataan. He is married, with three sons a daughter. According to his wife, he’s a good provider and a loving husband, father and grandfather. He’s a Filipino and a Roman Catholic. Prior to admission, he earns a living as a family driver. His occupation served as his exercise, travelling into places but his wife admitted that he has a sedentary lifestyle. He is an occasional alcoholic but doesn’t smoke. He is fond of eating bread, vegetables but also meat and salty foods despite having Diabetes Mellitus.

He was admitted on January 12, 2012 at 7:20pm in Bataan Doctors Hospital and Medical Center, under the service of Dr. Del Rosario with chief complaint of right sided body weakness, slurred speech, blurred vision and high blood pressure of 170/100mmHg.

History of Present Illness

Three days prior to admission, Patient JD had been experiencing body weakness, nauseas and vomiting, headache, dizziness and blurring of vision. A day prior to admission, there is persistence of signs and symptoms and his wife confirmed that her husband had slurred speech, right sided body weakness, fever of 38.4 degrees Celsius, and blood pressure of 160/100 mmHg.

History of Past Illness

In the year 2001, patient JD was diagnosed of having Diabetes Mellitus Type II, since then he

was advised to take Regular Insulin 10 “u” injection and Metformin 500mg tab. He is also hypertensive but his wife can hardly remember the exact year her husband was diagnosed of having such disease, that’s why she told us that the hypertension is there for a very long time. His husband was prescribed Captopril 25g tab, as his maintenance medication.

In the past five years, aside from the illnesses stated above, he experienced cough and common colds and has no known allergies with any foods and drugs.

Genogram

Family History With

Genogram

Patient JD is the eldest son among seven children of Mr. and Mrs. D. He is married with 4 sons and a daughter. His paternal grandfather died because of myocardial infarction and had hypertension. His paternal grandmother and maternal grandfather died with an unknown cause. His maternal grandmother died because of an abdominal pain.

Patient J’s father died because of cardiovascular accident. He has an uncle with hypertension. His mother died because of an old age (94 years old). His brother died because of colon cancer. And he has a brother with Diabetes Mellitus Type II and a sister with hypertension. Further than that, other brothers and sisters and his children do not manifest any illness.

Genogram:

Hypertension/ MI unknown (Deceased) abdominal pain

(Deceased) (Deceased) (Deceased)

Hypertension

old age

CVA (deceased)

(deceased)

Patient hypertension DM type II (deceased)

Colon cancer

Interpretation: The genogram shows that the patient’s family history has a direct connection with the development of the patient’s disease.

.

Legend:

Paternal grandfather

maternal grandfather

Patient’s mother

Paternal grandmother

maternal grandmother

patient

Patient’s Father

Patient’s Paternal

Uncle

Patient Brother

Patient Sister Maternal Aunt Maternal Uncle

Review of Systems

IntegumentaryThe skin texture is dry.

Poor capillary refill (>3 seconds)

Impaired wound healing on both feet.Poor skin turgorEqual skin distribution.

With blurring of visionHearing range below normalDecreased smelling condition.Impaired swallowing due to right sided hemiparesis

Eyes/Ears/Nose/Mouth/Throat

Voiding pattern is normal and there is no alteration

CardiovascularNormal heart rate but

increased blood pressure.

Pulses are threadyRespiratory

With crackles upon auscultation

GastrointestinalNormal bowel habits

Genitourinary

No allergies to food, drugs, insects and flowers.

Musculoskeletal

Right sided hemiparesisBody weaknessNeurologic/Psychiatric

Disoriented to time, place and person, semi-conscious

Allergic/Immunologic/Lymphatic/Endocrine

PHYSICALASSESSMENT

Functional

Health Pattern

Developmental Task

THEORIES Normal Patient

Eric Erickson- Psychosocial

Generativity vs StagnationAdulthood (25-65yrs old)

The desire to expand one’s influence and commitment to family, society, and future generations. The middle adult is concerned with forming and guiding the next generation.

Achieved by the patient as he made every individual of his family to become successful in what they do.

Havighurt’s Age Periods and Developmental Task

Middle adulthood (40-65yrs old)

Achieving adult civic and social responsibility.Establishing and maintaining economic standard of living.Assisting teenage children to become responsible and happy adults.Developing adult-leisure time and activities.Relating oneself to one’s spouse as a person.

Achieved by the patient. He was able to make his children responsible and maintained an economic standard of living also he was able to provide complete education for them.

Kohlberg’s Stages of Moral Development

Middle Age or Older Adult Social Contract Legalistic Orientation

The social rules are not the sole basis for decisions and behavior because the person believes a higher moral principle applies such as equality justice or due process.

Achieved by the patient in times of crisis or extreme situations.

ANATOMY

Andphysiology

Pathophysiology

NON INSULIN DEPENDENT DIABETES MELLITUS

(DM TYPE II)

Decreased tissue sensitivity to Insulin

Weight Loss

Modifiable Factors Non Modifiable Factors Sedentary lifestyle Age

Diet Family History Hypertension Race

Impaired beta cell functioning

Decreased Insulin Production Decreased absorption of glucose by the cell

Intracellular hypoglycemia

Cell starvation

Breakdown of fats (lipolysis) Degradation of proteins Stimulation of hunger mechanism via hypothalamus

Extracellular hyperglycemia

Hunger

Polyphagia

Impaired kidney filtration mechanism

Polyuria

Sodium Ion Loss

Increased serum glucose level

Glucose (RBS) = 19.635 mmol/L

Normal= 3.3-6.1 mmol/L

Potassium Ion Loss

Hypokalemia K = 2.25 mmol/L

Normal 3.6 – 5.4 mmol/L

Hyperglycemia

Non healing ulcers in the feet

Muscle wasting Body malaise

Nerve demyelization

Neuropathy

Increased blood Hyper osmotic plasma Paresthesias viscosity and numbness

Cell dehydration Impaired pain Poor circulation Thickening of sensation blood vessels Increased thirst Occlusion of Polydipsia

Delayed wound Edema plaque Healing Hyponatremia Na

+ = 127.8 mEq/L

Blood flow is blocked

Normal = 134-148 mEq/L Increased BP

Contributes to the occurrence of Cerebrovascular accident

Hypertension

160/100 mmHg

Modifiable Factors

Hypertension

Diabetes Mellitus

Hyperlipidemia

Excessive Alcohol Consumption

Sedentary Lifestyle

Non - Modifiable Factors

Age

Family History

Gender (Men)

Constant exposure to offending agents

Artery wall thickens from the accumulation of fatty materials

CEREBROVASCULAR ACCIDENT

Atherosclerosis

Formation of plaque deposits

Blood flow is obstructed

Hyperlipidemia Increased Cholesterol Levels = 321 mg/dL

Normal = 140 – 250 mg/dL

Increased Triglycerides = 215 mg/dL Normal = 10 – 190 mg/dL

Increased LDL Levels =228 mg/dL

Normal = <178 mg/ dL

Formation of blood clot

Thrombosis

Occlusion of major blood vessels

Vascular wall becomes weakened and fragile

Blood leaks from the weakened and fragile blood vessel

Cerebral Hemorrhage Headache Nausea and vomiting

Dizziness Visual Disturbances

Thrombus becomes mass of blood and increases in size

Vasopspasm of tissue and ateries

Cerebral Hypoperfusion

Cellular starvation and tissue hypoxia Alteration in mental status Disorientaion

Cerebral Ischemia

Blood flow decreases to <25mg/100 g. of blood flow per minute

Neurons are no longer able to maintain aerobic respiration

Initiates a complex series of cellular metabolic events

The “Ischemic Cascade” begins

Mitochondria switches to anaerobic respiration

Generates large amount of lactic acid

Results in a change in pH

Respiratory Alkalosis

Normal Result

pH 7.35 – 7.45 7.610 Respiratory

Alkalosis

Partially

Compensated

PCO2 35 – 45 mmHg 15.1

HCO3 22 – 26 mEq/L 14.9

Neurons are incapable of producing suffi cient

quantities of ATP

Failure of energy dependent process (ion pumping)

Can no longer fuel the depolarization process

Increase in intracellular calcium Release of excitatory neurotransmitter glutamate

Cell membranes and protein breakdown

Protein production decreases

Production of oxygen free radicals

Damage to the blood vessels

Failure of mitochondria

Brain sustains an irreversible cerebral damage

Brain sustains an irreversible cerebral damage

Structural integrity loss of brain tissue and cerebral blood vessels

Breakdown of the blood brain barrier

Cerebral edema

Vascular congestion Hypertension = 160/100 mmHg

Compression of tissue

Increased Intracranial Pressure

Impaired tissue perfusion and function

Affects the POSTERIOR CEREBRAL ARTERY

Disruption of cerebral blood flow

LEFT POSTERIOR CEREBRAL ARTERY INFARCTION Occipital lobe, anterior and medial portion

temporal lobe

Diffuse sensory loss

Slurred speech Poor skin turgor

Hemiparesis ; Right side of the body

Speech abnormalities Edema

Altered mental status

Confusion Disorientation

Affects the POSTERIOR CEREBRAL ARTERY

Disruption of cerebral blood flow

LEFT POSTERIOR CEREBRAL ARTERY INFARCTION Occipital lobe, anterior and medial portion

temporal lobe

Diffuse sensory loss

Slurred speech Poor skin turgor

Hemiparesis ; Right side of the body

Speech abnormalities Edema

Altered mental status

Confusion Disorientation

Comparative of the Disease

NCP

Diagnostic Procedure

MEDICATIONS

SOAPIE

Health Teaching Plan

Conclusion

Implication

Recommendation