Clinical Reasoning Cycle for Peter Mitchell: Case Scenario

This essay elaborates on the case scenario for Peter Mitchell, following the stages of the clinical reasoning cycle. It discusses the patient's background, presenting complaints, assessment results, pathophysiology, priority issues, and proposed action plan for effective management.

Running head: CASE SCENARIO
Peter Mitchell case study
Name of the Student
Name of the University
Author note

1CASE SCENARIO
Community health nursing focuses on the fact that nurses must be able to completely utilise
their knowledge, skills, and capabilities, in order to deliver healthcare services to the patients, with
the aim of enhancing their health and wellbeing. Clinical reasoning is defined as the procedure by
which nursing professionals collect cues, process information, understand the patient problem,
implement a care plan, evaluate the outcomes and reflect on their learning from the procedure. This
essay will elaborate on the case scenario for Peter Mitchell, by following the stages of the clinical
reasoning cycle.
The first step involves consideration of the patient. Peter Mitchell is aged 52 years old and
had been admitted to the medical ward due to high blood glucose levels. His presenting complaints
also included signs of shakiness, increased hunger, and sleep apnoea. During his previous admission,
he was recommended to show adherence to LEHP diet, with the aim of reducing his body weight
since he has been diagnosed as obese. Furthermore, he has been actively smoking an estimated 20
cigarettes each day for the last 30 years. He is currently unemployed and separated from his wife
and sons. The case scenario encompasses his referral after discharge, and focuses on management
of the priority issues that have been identified.
Collecting information cues is the second step of the reasoning cycle. Upon analysing the
results from the patient assessment, it can be suggested that the high body weight of Peter (145 kg)
is responsible for the manifestation of signs and symptoms of obesity ventilation syndrome (OHS).
Furthermore, his excess body weight is also responsible for obstructive sleep apnoea that is one
primary reason for admission of the patient in the medical ward. Some other health abnormalities
that Peter is currently suffering from includes high glucose levels in the bloodstream, hypertension,
and GERD (gastro-oesophageal reflux disease). The current medications that have been prescribed
to the patient include metformin, lisinopril, insulin novomix, metoprolol, pregabalin, and nexium.
Peter had also been separated from his wife and sons and lived in isolation.
Processing patient information in the third stage will take into account the pathophysiology
of the presenting complaints. There is mounting evidence for the fact that obese patients
demonstrate signs of sleep disorder breathing, which in turn is associated with a reduction in the
sensitivity to increasing amount of PaCO2 (Castro-Añón et al., 2015). Furthermore, obesity has also
been allied with leptin resistance. In addition, obesity and overweight results in several pulmonary
and extrapulmonary ailments that bring about respiratory failure. Elevated levels of levels of
inflammatory and pro-inflammatory markers such as, tumor necrosis factor alpha (TNF alpha),
interleukin-6 (IL-6), interleukin-1 (IL-1), prostaglandin E2 (PGE2), and interleukin-18 (IL-18) trigger
chronic inflammation of the peripheral tissue pathway, thereby causing insulin resistance, and

2CASE SCENARIO
hypofunctioning of the hypothalamic C releasing hormone, subsequently leading to OHS (Shetty &
Parthasarathy, 2015). Hence, the complications observed in Peter were all interrelated. In addition,
hypertension can be associated with his smoking habits since extracts of tobacco are responsible for
damaging the linings of the arterial blood vessels, thus causing artery constriction and elevating the
pressure of blood flow. According to Chang and Friedenberg (2014) there is an increased risk for
GERD with extra abdominal fat that exerts pressure on the stomach and causes backflow of the
gastric acid. Diagnosis of type 2 diabetes suggests that Peter has blood glucose levels greater than
6.9 mmol/L, which in turn can be accredited to his body mass. An increase in weight adds pressure
on the insulin hormone to keep a check on the amount of glucose present in bloodstream (Gallagher
& LeRoith, 2015). This in turn increases resistance of the tissues and muscles to insulin hormone,
thus causing diabetes. Furthermore, the release of non-esterified fatty acids (NEFAs) from adipose
cells and tissues in obese people also supports the association between β-cell dysfunction and
insulin resistance (Pickens et al., 2015). In addition, it has also been found that smoking weakens the
muscles of the airways, thereby causing sleep apnea and increasing the likelihood of suffering from
cardiovascular complications, heart attack, and stroke.
The following stage involves synthesising information from the facts presented in the case
scenario. It can be deduced from the case that two major issues that are faced by Peter are the
presence of obesity ventilation syndrome and type 2 diabetes. Owing to the fact that severely obese
people suffering from OHS report a failure to breath deep enough or rapidly enough that
subsequently leads to a reduction in the oxygen levels in blood, concomitant with the amount of
carbon dioxide, immediate care must be given to address this concern (Hollier et al., 2014). Low
levels of oxygen due to OHS will also result in physiologic narrowing of the pulmonary arteries for
rectifying the ventilation-perfusion matching, thereby putting excessive strain on the right portion of
the heart, referred to as cor pulmonale. Lowering the high blood glucose levels is also crucial for
managing Peter’s health condition since poor glycaemic control might result in possible renal
impairment, neuropathy, cardiovascular damage, limb amputation, and retinopathy (Danziger et al.,
2016).
Establishment of goals for the identified priority problems form the succeeding phase. The
goals developed for Peter’s health management are namely, (i) decreasing the blood sugar levels
within 5.6 to 6.9 mmol/L and (ii) improving symptoms of OHS.
The next stage of the reasoning cycle involves formulating the course of nursing action that
will be adopted for effective management of the health ailments. Peter will be assessed for signs and
symptoms of hyperglycaemia that generally occurs when an insufficient amount of insulin hormone

3CASE SCENARIO
has been released from the pancreatic cells. Excess glucose might create an osmotic impact that will
increase his hunger, urination, and thirst. Peter will be administered meglitinides that will stimulate
secretion of insulin from the pancreas (J Meneses et al., 2015). In addition to his current
medications, he will also be subjected to the action of alpha-glucosidase inhibitor drugs likes miglitol
and acarbose that will delay the absorption of sugar into bloodstream from the intestine, thus
keeping a check on sugar levels (Nakamura et al., 2014). Insulin resistance in the peripheral tissues
will also be decreased through the administration of thiazolidinedione drugs like rosiglitazone and
pioglitazone. Peter will also be educated on correct insulin injection procedures since absorption is
typically the fastest when administered to the abdomen, followed by thighs and arms. Patient
education would also focus on storage and rotation of insulin injection to prevent lipoatrophy and
lipohypertrophy (Kadiyala, Walton & Sathyapalan, 2014). Taking into consideration that the most
essential management strategy for OHS is weight reduction, Peter will be subjected to dietary
modifications, physical exercise, and medications. Increasing the amount of whole grains and fiber in
the diet, while lowering sugar and calorie intake. In addition, OHS treatment would also encompass
making Peter participate in physical exercise, with the aim of managing his BMI that would
subsequently reduce OHS (Mandal et al., 2018).
Continuous positive airway pressure (CPAP) will form an essential aspect of the action plan
since it will successfully deliver positive pressure to the inflamed airways, thereby averting the
collapse of soft tissues located in the throat at the time of breathing (McMillan et al., 2014).
Furthermore, the subsequent accumulation of carbon dioxide will also be removed from the
bloodstream, thus improving the obstructive symptoms. Necessary education will be provided to
Peter on habits of binge eating, while ensuring that he shows adherence to the recommended
interventions. Period assessment of his BMI and glucose levels and will help in determining the
efficacy of the treatment plans. Peter will also be referred to a counselling service for lowering
symptoms of persistent low mood and social isolation. Further action plans would also encompass
providing employment opportunities owing to the fact that loss of a secure employment has
contributed to the onset of depressed mood in the patient. He will also be referred to community
services that will help in interact with other members of the community, notwithstanding issues
related to his body image, thereby enhancing his psychosocial health.
Evaluating the consequences of the proposed action plan will form the next phase of the
reasoning cycle. Successful management of diabetes will be observed by a significant reduction in
blood glucose levels within normal limits. Outcome evaluation would also encompass demonstration
of adequate knowledge and awareness of Peter on his health condition and the risk factors that
might increase his likelihood of suffering from comorbid conditions. In addition, he also needs to

4CASE SCENARIO
manifest proper compliance to the medications that have been prescribed. Regular monitoring of his
food and liquid consumption, frequency of eating meals, exercise regimen, insulin administration
regimen are imperative for health outcome evaluation (Haak et al., 2017). Vital signs measurement
will also be crucial to determine the normalisation of breathing patterns with proper rate and depth.
Peter will also be engaged in a discussion, with the aim of assessing his current thoughts on body
image, obesity, and social life.
The last phase involves a reflection process. Upon reflection I realised that health and
wellbeing of an individual is multifaceted and involves the complex interaction of different
physiological systems. Furthermore, I also understood that the environment and social
circumstances exert an influence on health outcomes of all people. The reasoning cycle facilitating
gaining an insight into several physiological abnormalities namely, sleep apnoea, OHS, type 2
diabetes, hypertension, GERD, and obesity. It also assisted me to understand the exact roles and
responsibilities of a community health nurse, in relation to providing patient education. However,
there was a need of placing focus on sleep apnoea, and social isolation as two major priority health
concerns.
To conclude, community health encompasses environmental, social, and economic
resources that are domineering for supporting the emotional and physical health and wellbeing amid
individuals such that the care services provided are in alignment with the values and preferences of
the patients. The case scenario of Peter Mitchell discussed above elaborated on the signs and
symptoms for which he had been admitted to the medical ward and the action plans that need to be
implemented for helping him recover.

5CASE SCENARIO
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