Tomas Del Rosario College

Balanga 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 its 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 patients 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 worlds 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-insulindependent 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 occluded oCommonly due to thrombosis or embolism Thrombotic (large vessel) stroke The most common cause of ischemic stroke Atherosclerosis is the primary cause Fatty materials deposit on large vessel walls (especially at arterial bifurcations) and eventually these plaques causes stenosis of the artery Blood swirls around the irregular surface of the plaques causing platelets to adhere and the vessel becomes obstructed These causes infarcts usually affecting the cortex Most 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

Patient Centered:
To alleviate the signs and symptoms of the patients disease To render a comfortable environment to the patient To provide health teachings for the patients condition and to his family as well To identify risks and measures for the patients family to minimize occurrence of the disease To develop the familys support system and involve them in promoting in the health care of the patient

Student Centered:
To know more about the development of the disease To identify the signs and symptoms of the patients 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, hes a good provider and a loving husband, father and grandfather. Hes 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 doesnt 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, thats 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 Js 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 (Deceased)

unknown (Deceased)

(Deceased)

abdominal pain (Deceased)

Hypertension CVA (deceased)

(deceased) old age

Patient

hypertension DM type II

(deceased) Colon cancer

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

Legend:

Patients mother

Paternal grandfather

maternal grandfather

patient
maternal grandmother

Paternal grandmother

Patients Father

Patients Paternal Uncle

Patient Brother

Patient Sister

Maternal Aunt

Maternal Uncle

Review of Systems

Integumentary
The skin texture is dry. Poor capillary refill (>3 seconds) Impaired wound healing on both feet. Poor skin turgor Equal skin distribution.

Eyes/Ears/Nose/Mouth/Throat
With blurring of vision Hearing range below normal Decreased smelling condition. Impaired swallowing due to right sided hemiparesis

Cardiovascular Normal heart rate but increased blood pressure. Pulses are thready
Respiratory With crackles upon auscultation Gastrointestinal Normal bowel habits

Genitourinary
Voiding pattern is normal and there is no alteration

Musculoskeletal Right sided hemiparesis Body weakness Neurologic/Psychiatric

Disoriented to time, place and person, semi-conscious Allergic/Immunologic/Lymphatic/Endocrine

No allergies to food, drugs, insects and flowers.

PHYSICAL ASSESSMENT

Functional
Health Pattern

Developmental

Task

THEORIES Generativity vs Stagnation Adulthood (25-65yrs old)

Normal Eric Erickson- Psychosocial The desire to expand ones influence and commitment to family, society, and future generations. The middle adult is concerned with forming and guiding the next generation.

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

Havighurts 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 ones 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.

Kohlbergs 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 And physiology

Pathophysiology

NON INSULIN DEPENDENT DIABETES MELLITUS (DM TYPE II)

Modifiable Factors Sedentary lifestyle Diet Hypertension

Non Modifiable Factors Age Family History Race

Decreased tissue sensitivity to Insulin

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

Weight Loss

Muscle wasting

Hunge r

Body malaise

Polyphagia

Nerve demyelization

Extracellular hyperglycemia

Increased serum glucose level

Neuropathy Increased blood viscosity Hyper osmotic plasma Impaired kidney filtration mechanism

Hyperglycemia

Parest hesias and numbness

Glucose (RBS) = mmol/L 19.635

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

= -6.1 Normal3.3 mmol/L

Delayed wound Edema Healing

Occlusion of plaque

Polydipsia

Sodium Ion Loss

Potassium Ion Loss

Blood flow is blocked Non healing in the ulcers feet Increased BP

Hyponatremia + Na = 127.8 mEq/L Normal = 134 mEq/L -148

Hypokalemia K = 2.25 mmol/L Normal 3.6 mmol/L 5.4

Hypertension

16 mmHg 0/100

Contributes to the occurrence of Cerebrovascular accident

CEREBROVASCULAR ACCIDENT
Modifiable Factors Non - Modifiable Factors Age Diabetes Mellitus Hyperlipidemia Excessive Alcohol Consumption Sedentary Lifestyle Family History Gender (Men)

Hypertension

Constant exposure to offending agents

Artery wall thickens from the accumulation of fatty materials

Atherosclerosis

Increased Triglycerides = 215 mg/dL Normal = 10 190 mg/dL Increased LDL Levels =228 mg/dL Normal = <178 mg/ dL

Hyperlipidemia

Increased Cholesterol Levels = 321 mg/dL Normal = 140 250 mg/dL

Formation of plaque deposits

Blood flow is obstructed

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

Headache Cerebral Hemorrhage Dizziness

Nausea and vomiting Visual Disturbances

Thrombus becomes mass of blood and increases in size

Vasopspasm of tissue and ateries

Cerebral Hypoperfusion

Disorientaion

Cellular starvation and tissue hypoxia

Alteration in mental status

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

Neurons are incapable of producing sufficient quantities of ATP

Production of oxygen free radicals

Generates large amount of lactic acid Failure of energy dependent process (ion pumping) Results in a change in pH Can no longer fuel the depolarization process

Damage to the blood vessels

Respiratory Alkalosis Normal Result Increase in intracellular calcium Respiratory Alkalosis Partially Compensated Cell membranes and protein breakdown Release of excitatory neurotransmitter glutamate

pH PCO2 HCO3

7.35 7.45

7.610

35 45 mmHg 15.1 22 26 mEq/L 14.9

Protein production decreases

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

Hemiparesis ; Right side of the body

Altered mental status

Edema

Speech abnormalities Confusion Disorientation

Poor skin turgor

Slurred speech

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

Hemiparesis ; Right side of the body

Altered mental status

Edema

Speech abnormalities Confusion Disorientation

Poor skin turgor

Slurred speech

Comparative of the Disease

NCP

Diagnostic Procedure

MEDICATIONS

SOAPIE

Health Teaching Plan

Conclusion

Implication

Recommendation