NRSG366 Individual Case Study

This assignment discusses the case scenario for a patient Peter Mitchell, following the clinical reasoning cycle. It focuses on his health problems, comorbid conditions, and the necessary action plans for managing his clinical manifestation and weight problems.

Running head: ESSAY
NRSG366 Individual Case Study
Name of the Student
Name of the University
Author note

1ESSAY
Community health nurses have the duty of using their nursing skills, with the aim of
providing care services to patients, while directing the latter to necessary healthcare
amenities that is beyond the basic scope of practice (Stanhope & Lancaster, 2015).
According to Levett-Jones (2010) nurses having adequate skills of clinical reasoning are
able to bring about a positive impact on the health outcome of the patients, who manifest the
presence of complex health problems. This assignment will discuss the case scenario for a
patient Peter Mitchell, following the clinical reasoning cycle.
The first step is consideration of the patient Peter Mitchell is a 52 year old male who
has been admitted to the medical ward, following poor glycemic control, and upon reporting
signs and symptoms of increased hunger, shakiness, and sleep apnoea. During previous
episodes of admission, he had been advised to follow a LEHP diet for reducing weight,
owing to the fact that he is obese. In addition, he is an active smoker and has been smoking
for the past 30 years. The current scenario involves referral post-discharge, with the aim of
managing his clinical manifestation and weight problems.
The second phase of the cycle involves collection of information and cues from the
patient. An analysis of the results from his investigation suggests that his weight is 145 kg,
thus confirming obesity. In addition, he also suffer from a range of comorbid conditions
namely, hypertension, sleep apnoea, type 2 diabetes, and GERD (gastro-oesophageal reflux
disease). He is also under several medications namely, lisinopril, metformin, insulin novomix,
pregabalin, metoprolol, and nexium. The prevalence of a high body weight can be accredited
to the production of ghrelin and leptin that control the appetite of a person by exerting their
actions on the central nervous system, which in turn affects the amount of energy
expenditure and food intake (Khodabakhshi et al., 2015). His smoking habits can be allied
with the presence of type 2 diabetes and sleep apnoea. The chemicals present in tobacco
damage the arterial wall linings, thus leading to narrowing of the arteries and subsequently
increasing the blood pressure (Leone, 2015). Furthermore, nicotine present in tobacco also
works by relaxing the muscle rings located in lower oesophagus, According to Kohata et al.
(2016) relaxation of the ring often results in trickle of the stomach acids, and leads to a
burning sensation. In addition, it was also found that losing a secure employment as a fork
lift driver, and separation from spouse and kids, created a substantial impact on Peter’s
health, which in turn made him socially isolated. Furthermore, his current condition also
makes it difficult for him to conduct activities of daily living, thus worsening the scenario.
While processing information in the third phase, it must be taken into consideration
that smoking results in inflammation in the body that causes swelling and interferes with the
cell function of the body, thus increasing the risks of diabetes (Pan, Wang, Talaei, Hu & Wu,

2ESSAY
2015). Presence of type 2 diabetes indicates a blood glucose levels higher than 125 mg/dL.
Sleep apnoea also indicates that Peter manifests episodes of shallow breathing and pauses
in breathing, while he is sleeping. This can be accredited to the build-up of carbon dioxide in
the bloodstream that are detected by chemoreceptors located in the blood (Krishnan, Dixon-
Williams & Thornton, 2014). Furthermore, his smoking habit can also be associated with
sleep apnoea due to the fact that inflammation of the upper airways due to the stimulant
impacts of nicotine on the airway muscles. Furthermore, being obese or overweight has
been identified as a major risk factor that contributes to abnormal levels of sugar in the
bloodstream. Peter’s social isolation can also be associated with the fact that being
overweight increases the likelihood of a person to suffer from depressive symptoms.
In the fourth phase that involves synthesis of inferences and facts, it can be
suggested that the major problems manifested by Peter that need immediate attention are
high blood glucose levels, and obese. Taking into consideration the fact that people suffering
from diabetes report presence of one or more comorbidities such as, hyperlipidaemia,
cardiovascular complications, non-alcoholic fatty liver disease, obesity, renal disease, and
obstructive sleep apnoea, there is a need to take immediate actions for restoring the amount
of glucose in bloodstream to normal levels (Schram et al., 2014). Another issue that must be
immediately addressed is the increased body weight due to its association with stroke,
osteoarthritis, gallbladder disease, hyperuricemia, hypertension, and other comorbid medical
problems (Castro, Kolka, Kim & Bergman, 2014).
The following phase involves establishment of goals for the patient. The two care
priorities that are in accordance to the care priorities identified above are namely, (i) lowering
the blood glucose levels of Peter within 100-125 mg/dL, and (ii) reducing the body weight of
Peter to an extent that the BMI is within 22-24.9.
The course of action for the pre-defined goals will form the next phase of the clinical
reasoning cycle. Owing to the fact that sustained hyperglycaemia creates a negative impact
on almost all cells and tissues located in the body, and is also related with complications of
the kidneys, blood vessels, nerves, and eyes, the nursing care action plan for Peter would
encompass effective pharmacological and non-pharmacological strategies for normalising
the levels of blood glucose, while reducing the likelihood of associated complications. In
addition to his current medication regimen, Peter will be administered sulfonylureas such as,
glimepiride and glyburide in order to stimulate secretion of insulin from the pancreas
(Weissman et al., 2014). These will also enhance the sensitivity of the cell receptors to the
insulin hormone, thereby decreasing the synthesis of glucose from stored glycogen and
amino acids. Peter will also be instructed to take rapid-acting insulin such as, Humalog,

3ESSAY
owing to the fact that it will have an onset of action within first 10-15 minutes of injection and
the duration of actin will remain for 2-3 hours, and bring about improved glycaemic control
(Flat-Sugar Trial Investigators, 2016). Certain non-pharmacological interventions will also be
implemented in the patient such as, dietary modifications. Other action plans will involve
teaching him that tremors, slurred speech and anxiety are signs of hypoglycaemia, and he
should immediate seek consultation if they appear. Action plans for obesity would include
formulation of a diet plan, providing patient education, and determining his nutritional
knowledge. A diet rich in whole grains and fibre, and having low content of fat and simple
sugar will also be formulated for Peter, with the aim of controlling the level of triglycerides
and cholesterol (Tay et al., 2014). Peter will be advised to follow the diet plan based on three
daily meals and one evening snack. He will also be asked to reduce the intake of complex
carbohydrates like rice, and simple sugars. This will help in lowering blood glucose as well.
Efforts will also be taken to identify his emotions and feelings during eating. Conducting and
reviewing the daily food intake (eating habit, amount and type of food, and caloric intake) will
provide the chance to focus on a realistic depiction of the ingested good, and corresponding
patterns. Emphasis will be given on the importance of preventing fad diets since complete
elimination of necessary nutrients might result in metabolic imbalance in the body
(Nouvenne et al., 2014).
Peter will also be made aware of his binge eating habits, while identifying a realistic
increment goal for weekly reduction in weight. Peter will be periodically weighed and
provided information on the effectiveness of the recommended regimen. Upon determining
his current levels of physical activity, a progressive exercise plan will also be tailored based
on his demands and preferences owing to the fact that physical exercise facilitates weight
loss by lowering the appetite and enhancing cardiac fitness (Krause et al., 2014). This will be
concomitant with administration of orlistat, a lipase inhibitor that will block dietary fat
absorption and facilitate weight loss. In addition, reduction will body weight will also lower the
apnoea frequencies (Kushner, 2014). Peter will also be provided information for employment
opportunities since loss of job created a significant effect on his physical and emotional
wellbeing. Furthermore, efforts will be taken to educate Peter on the signs and symptoms of
depression and its risk factors. Patient education and engagement with the community
members will also help in managing his social isolation.
The succeeding phase of the reasoning cycle comprises of evaluation of outcomes
for the proposed action plan. Effective diabetes management will be evaluated by a
reduction of blood glucose to normal levels within a week. Appropriate adherence to
medication management, increase in knowledge on diabetes management, excess amount
of insulin and regular blood glucose monitoring will help in evaluating patient outcomes.

4ESSAY
Recognition of appropriate behaviours related with food intake, change in dietary patterns,
participation in exercise programs, and manifestation of weight loss will prove efficacy of the
strategies implemented. Maintenance of respiratory status near the baseline parameters,
with proper depth, and rate will also suggest successful management of sleep apnoea. In
addition, elimination of thoughts about disturbed body image, increased social interaction,
and improved health literacy will also suggest efficacy of the action plans.
While reflecting on the reasoning process, which forms the final phase of the cycle, I
can state that I gained a sound understanding of the fact that sleep apnoea, obesity, and
type 2 diabetes are associated health complications, and worsen the physical and emotional
wellbeing of the affected person. I also realised that the duty of a community health nurse is
massive and we have the responsibility of educating our patients about their health
condition. However, I could have provided taken steps to manage the signs and symptoms
of GERD as well, in order to enhance the health outcomes.
To conclude, community health is defined as the social, environmental, and
economic resources that are imperative for sustaining the physical and emotional wellbeing
among people in a manner that satisfies their preferences and demands, and advances their
healthcare needs. The case scenario presented above contained exhaustive information on
the signs and symptoms presented by Peter and the necessary action plans that would help
him regain optimal health.

5ESSAY
References
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6ESSAY
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