TRODUCTION: Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the

insulin that is produced, so that gluco se in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includ es changes in diet, oral medications, and in some cases, daily injections of ins ulin. The most common form of diabetes is Type II, It is sometimes called 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 seve ral years) and because it usually can be controlled with diet and oral medicatio n. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-de pendent diabetes, a term that is somewhat misleading. Many people with Type II d iabetes can control the condition with diet and oral medications, however, insul in injections are sometimes necessary if treatment with diet and oral medication is not working. The causes of diabetes mellitus are unclear, however, there seem to be both here ditary (genetic factors passed on in families) and environmental factors involve d. Research has shown that some people who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the bodys defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, o besity, and family history of diabetes play a role. In Type II diabetes, the pancreas may produce enough insulin, however, cells hav e become resistant to the insulin produced and it may not work as effectively. S ymptoms of Type II diabetes can begin so gradually that a person may not know th at he or she has it. Early signs are lethargy, extreme thirst, and frequent urin ation. Other symptoms may include sudden weight loss, slow wound healing, urinar y tract infections, gum disease, or blurred vision. It is not unusual for Type I I diabetes to be detected while a patient is seeing a doctor about another healt h concern that is actually being caused by the yet undiagnosed diabetes. Individuals who are at high risk of developing Type II diabetes mellitus include people who: are obese (more than 20% above their ideal body weight) have a relative with diabetes mellitus belong to a high-risk ethnic population (African-American, Native American, Hisp anic, or Native Hawaiian) have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg) have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL have had impaired glucose tolerance or impaired fasting glucose on previous test ing Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle changes. It is best managed with a team approach to empower the client to successfully manage the disease. As part of the team the, the nurse plans, o rganizes, and coordinates care among the various health disciplines involved; pr ovides care and education and promotes the clients health and well being. Diabete s is a major public health worldwide. Its complications cause many devastating h ealth problems. ANATOMY AND PHYSIOLOGY: Every cell in the human body needs energy in order to function. The bodys primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food c irculates in the blood as a ready energy source for any cells that need it. Insu lin 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 glyco gen or fatty acids and saved for later use. When there is not enough insulin pro duced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells. PATHOPHYSIOLOGY: Image Source: www.caninsulin.com/Pathophysiology-algorithm.htm DIAGNOSTIC TEST: Several blood tests are used to measure blood glucose levels, the primary test f or diagnosing diabetes. Additional tests can determine the type of diabetes and its severity. Random blood glucose test for a random blood glucose test, blood can be drawn at any time throughout the day, regardless of when the person last ate. A random b lood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symp toms of high blood glucose (see Symptoms above) suggests a diagnosis of diabetes. Fasting blood glucose test fasting blood glucose testing involves measuring bloo d glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose level is less than 100 mg/dL. A fasting blood gluco se of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by t aking a small sample of blood from a vein or fingertip. It must be repeated on a nother day to confirm that it remains abnormally high (see Criteria for diagnosis below). Hemoglobin A1C test (A1C) The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose c ontrol in people with known diabetes, but is not normally used to diagnose diabe tes. Normal values for A1C are 4 to 6 percent (show figure 3). The test is done by taking a small sample of blood from a vein or fingertip. Oral glucose tolerance test Oral glucose tolerance testing (OGTT) is the most se nsitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended because it is inconvenient compared to a fasting blood glu cose test. The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two hours later, a second blood glucose level is measured. Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregn ancy to screen for gestational diabetes; this requires drinking a 50 gram glucos e solution with a blood glucose level drawn one hour later. For women who have a n abnormally elevated blood glucose level, a second OGTT is performed on another day after drinking a 100 gram glucose solution. The blood glucose level is meas ured before, and at one, two, and three hours after drinking the solution. MEDICATIONS: When diet, exercise and maintaining a healthy weight arent enough, you may need t he help of medication. Medications used to treat diabetes include insulin. Every one with type 1 diabetes and some people with type 2 diabetes must take insulin every day to replace what their pancreas is unable to produce. Unfortunately, in sulin cant be taken in pill form because enzymes in your stomach break it down so that it becomes ineffective. For that reason, many people inject themselves wit h insulin using a syringe or an insulin pen injector,a device that looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump , which provides a continuous supply of insulin, eliminating the need for daily shots. The most widely used form of insulin is synthetic human insulin, which is chemic ally identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isnt perfect. One of its chief failings is that it doesnt mimic the way natural insulin is secreted. But newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin acts in your bod y. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lant us).

A number of drug options exist for treating type 2 diabetes, including: Sulfonylurea drugs. These medications stimulate your pancreas to produce and rel ease more insulin. For them to be effective, your pancreas must produce some ins ulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol, G lucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (A maryl) are prescribed most often. The most common side effect of sulfonylureas i s low blood sugar, especially during the first four months of therapy. Youre at m uch greater risk of low blood sugar if you have impaired liver or kidney functio n. Meglitinides. These medications, such as repaglinide (Prandin), have effects sim ilar to sulfonylureas, but youre not as likely to develop low blood sugar. Meglit inides work quickly, and the results fade rapidly. Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available in the United States. It works by inhibiting the production and relea se of glucose from your liver, which means you need less insulin to transport bl ood sugar into your cells. One advantage of metformin is that is tends to cause less weight gain than do other diabetes medications. Possible side effects inclu de a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdomin al bloating, or pain, gas and diarrhea. These effects usually decrease over time and are less likely to occur if you take the medication with food. A rare but s erious side effect is lactic acidosis, which results when lactic acid builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur if you mix this medica tion with alcohol or have impaired kidney function. Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your di gestive tract that break down carbohydrates. That means sugar is absorbed into y our bloodstream more slowly, which helps prevent the rapid rise in blood sugar t hat usually occurs right after a meal. Drugs in this class include acarbose (Pre cose) and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhi bitors can cause abdominal bloating, gas and diarrhea. If taken in high doses, t hey may also cause reversible liver damage. Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and keep your liver from overproducing glucose. Side effects of thiazolidinedio nes, such as rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), inc lude swelling, weight gain and fatigue. A far more serious potential side effect is liver damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor prescribes these drugs, its important to have your liver checked every two months during th e first year of therapy. Contact your doctor immediately if you experience any o f the signs and symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be related to diabetes medications, but your doctor will need to investigate all possible causes. Drug combinations. By combining drugs from different classes, you may be able to control your blood sugar in several different ways. Each class of oral medicati on can be combined with drugs from any other class. Most doctors prescribe two d rugs in combination, although sometimes three drugs may be prescribed. Newer med ications, such as Glucovance, which contains both glyburide and metformin, combi ne different oral drugs in a single tablet. NURSING INTERVENTIONS: Advice patient about the importance of an individualized meal plan in meeting we ekly weight loss goals and assist with compliance. Assess patients for cognitive or sensory impairments, which may interfere with t he ability to accurately administer insulin. Demonstrate and explain thoroughly the procedure for insulin self-injection. Hel p patient to achieve mastery of technique by taking step by step approach. Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen. Instruct patient in the importance of accuracy of insulin preparation and meal t iming to avoid hypoglycemia.

Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to ea t carbohydrate snack before exercising to avoid hypoglycemia. Assess feet and legs for skin temperature, sensation, soft tissues injuries, cor ns, calluses, dryness, hair distribution, pulses and deep tendon reflexes. Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoc onstriction and enhance peripheral flow.

INTRODUCTION Pneumonia is an inflammation of the lungs caused by an infection. It is also cal led Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our he alth. Although pneumonia is a special concern for older adults and those with ch ronic illnesses, it can also strike young, healthy people as well. It is a comm on illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are many kinds of pneumonia that range in seriousness from mild to life-th reatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumo nia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. Its best to do everything we can to prevent pneumonia, but if one do get sick, reco gnizing and treating the disease early offers the best chance for a full recover y. A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an appropriate car e has to be done to make the patients recovery faster. Treating patients with pne umonia is necessary to prevent its spread to others and make them as another vic tim of this illness. ANATOMY AND PHYSIOLOGY The lungs constitute the largest organ in the respiratory system. They play an i mportant role in respiration, or the process of providing the body with oxygen a nd releasing carbon dioxide. The lungs expand and contract up to 20 times per mi nute taking in and disposing of those gases. Air that is breathed in is filled with oxygen and goes to the trachea, which bra nches off into one of two bronchi. Each bronchus enters a lung. There are two lu

ngs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two l obes in the left one. The lungs are cone shaped and made of elastic, spongy tiss ue. Within the lungs, the bronchi branch out into minute pathways that go throug h the lung tissue. The pathways are called bronchioles, and they end at microsco pic air sacs called alveoli. The alveoli are surrounded by capillaries and provi de oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which i s then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs . Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a ver y, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

PATHOPHYSIOLOGY Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood . If there is too little oxygen in your blood, your body cells cant work properly . Because of this and spreading infection through the body pneumonia can cause d eath. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a sectio n (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches th roughout both lungs. Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumon iae is the most common. Other pathogens include anaerobic bacteria, Staphylococc us aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachom atis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pn eumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher bacteria including Noca rdia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and P neumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever). The usual mechanisms of spread are inhaling droplets small enough to reach the a lveoli and aspirating secretions from the upper airways. Other means include hem atogenous or lymphatic dissemination and direct spread from contiguous infection s. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airw ay disease, age extremes, debility, immunocompromise (as in diabetes mellitus an d chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents. Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detec t tachypnea and signs of consolidation, such as crackles with bronchial breath s ounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H . influenzae.

NURSING PROFILE a. Patients Profile Name: Patient X Age: 1 yr,1 mo. Weight:10 kgs Religion: Roman Catholic b. Chief Complaint: Fever Date of Admission: 1st admission Hospital Number: 060000086199 c. History of Present Illness 2 days PTA (+) cough (+) nasal congestion, watery to greenish (+) nasal discharge Tx: Disudrin OD Loviscol OD Few hrs PTA - (+) fever, Tmax= 39.3 C (+) difficulty of breathing (+) vomiting, 1 episode Tx: Paracetamol Sought consultation at ER: Rx=BPN, Salbutamol neb. IE: T = 38.3C, CR= 122s, RR= 30s (+) TPC SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema d. Past Illness (-) asthma (-) allergies e. Family History PMHx: (+) asthma (mother) f. Activities of Daily Living Sleeping mostly at night and during afternoon Usually wakes up early in the morning (5AM) to be milkfed. Eats a lot (hotdogs, chicken, crackers, any food given to her) Active, responsive BM (1-2 times a day) Urinates in her diaper (more than 4 times a day) Likes to play with those around her g. Review of Systems Neuromuscular: weakness of muscles Integumentary: (-) cyanosis Respiratory: tavhypnea; (+) DOB; (+) coarse crackles, (+) wheezes, Digestive: food aversion, vomits ingested milk DRUG STUDY View NCP NURSING ACTIONS INDEPENDENT positioning of the patient with head on mid line, with slight flexion rationale: to provide patent, unobstructed airway , maximum lung excursion auscultating patients chest rationale: to monitor for the presence of abnormal breath sounds provide chest and back clapping with vibration rationale: chest physiotheraphy facilitates the loosening of secretions considering that the patient is an infant, and has developed a strong stranger a nxiety

as manifested by white coat syndrome , it is a nursing action to play with the pa tient. rationale: to establish rapport, and gain the patients trust DEPENDENT administer due medications as ordered by the physician, bronchodilators, anti py retics and anti biotics rationale: bronchodilators decrease airway resistance, secondary to bronchocons triction, anti pyretics alleviate fever, antibiotics fight infection placing patient on TPN prn rationale: to compensate for fluid and nutritional losses during vomiting COLLABORATIVE assist respiratory therapist in performing nebulization of the patient rationale: nebulization is a favourable route of administering bronchodilators and aid in expectorating secretions, hence patients breathing PHYSICIANS ORDER SHEET 11/19/06 Admit patient to ROC under the service of Dr. Vitan secure consent for admissio n and management, TPR every shift then record. May have diet for age with strict aspiration precaution, IVF D5 0.3NaCl 500cc to run at 62-63mgtts/min.May give p aracetamol 125mg 1supp/rectum if oral paracetamol is not tolerated. 11/20/06 For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use zinacef bra nd of cefuroxine 750mg- given vial 375mg every 8hours, nebulize (Ventolin 1 n ebule) every 6 hours, paracetamol drugs prn every 4hours (Temp 37.8). 11/21/06 Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF, revise Ce furoxine IV to Cefuroxine 500mg via deep Intramuscular BID,continue management. 11/22/06 Continue management and refer. DISCHARGE PLANNING Take the entire course of any prescribed medications. After a patients temperatur e returns to normal, medication must be continued according to the doctors instru ctions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack. Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs. Keep all of follow-up appointments. Even though the patient feels better, his lu ngs may still be infected. Its important to have the doctor monitor his progress. Encourage the guardians to wash patients hands. The hands come in daily contact w ith germs that can cause pneumonia. These germs enter ones body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the ri sk. Tell guardians to avoid exposing the patient to an environment with too much pol lution (e.g. smoke). Smoking damages ones lungs natural defenses against respirato ry infections. Give supportive treatment. Proper diet and oxygen to increase oxygen in the bloo d when needed. Protect others from infection. Try to stay away from anyone with a compromised i mmune system. When that isnt possible, a person can help protect others by wearin g a face mask and always coughing into a tissue.