International Journal of Molecular Sciences

Running Head: EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Name of the Student:
Name of the University:
Author Note:

1EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Introduction:
The complexities of the medical care environment and the proliferation of chronic illness events
(van Dongen et al, 2016), as well as other difficult health problems, demand that person-centered patient
services be delivered by a team of qualified clinicians to deliver the best treatment in the correct setting
around the services spectrum. Interprofessional treatment is the delivery model of preference, treating the
individual as a valued member of the team, with enhanced use of nursing services within the broad scope
of their function. Registered nurses are important staff leaders and have excellent experience in
communicating and show successful sharing of information with patients and other team members. In
fact, nurses serving as part of interprofessional teams, in partnership with employers, are willing to carry
on constructive leadership positions including accountability for case selection and treatment planning.
Nurses promote person-centered health provision by participating in the key client-centered care
processes: recognizing issues and desires, facilitating collective decision-making, delivering treatment
and health, and determining results. The paper below discusses the case report of a patient named Mr.
Hank Jackson, a 64 year old newly retired truck driver who had just been diagnosed with diabetic
retinopathy and was observed to be blind by his left eye. The case study shows that he was chronically
suffering from uncontrolled and unchecked diabetes mellitus for the past five years and was on
medication for that. The paper helps in understanding the primary diagnosis and discusses the
administration of the medication of Mr. Jackson as well. The paper further allows the nurses to state about
their nursing diagnosis for the said case study along with creating interprofessional care plan for Mr.
Jackson. The main aim of the paper is to establish that importance of interprofessional approach while
managing a patient.

2EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Discussion:
Primary Medical Diagnosis:
Mr. Hank Jackson complained of being unable to see and was facing huge difficulty to read. The
primary diagnosis performed on the patient included the initial assessment of the patient. On speaking to
the patient it was revealed that, he lived alone and that for the past few days he was suffering from fuzzy
and blurred vision and was unable to read anything. Moreover, he revealed that if there was any
occurrence of him forgetting to take his medication for Diabetes Mellitus, he would start feeling fuzzy in
his head. The referral from the general practitioner stated that he had been suffering from high blood
pressure and was in need of immediate diabetes control. Moreover, looking at the patient’s medical chart,
it was revealed that he was recently been diagnosed of diabetes retinopathy and that was suffering from
Type II diabetes mellitus since five years and was an active patient of hypertension for the last seven
years. On further investigation it was also stated that his last recorded blood pressure was
159mmHg/96mmHg and that his glycated haemoglobin (HbA1C) has never been below 8 %.
Additionally, speaking to the patient it was understood that the patient had very least knowledge about his
condition and also had a vague idea of maintaining and checking blood sugar levels for according to him,
the blood sugar levels being high is already a known fact to the medical team.
Clinical symptoms of structural defects in the retina influence the treatment of Diabetes
Retinopathy (DR) (Gargeya and Leng, 2017). Clinically, DR is classified into two stages: non-
proliferative retinopathy diabetic (NPDR) and proliferative retinopathy diabetic (PDR). NPDR reflects
the early stage of DR, in which decreased vascular permeability and capillary occlusion are two major
retinal vasculature findings. At this point, fundus photography may diagnose retinal pathologies including
microaneurysms, hemorrhages, and rough exudates while the patients may be asymptomatic.
Neovascularisation is characterized by PDR, a more advanced stage of DR. The patients may suffer
significant vision loss at this point as the fresh dysfunctional vessels leak into the vitreous (vitreous

3EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
hemorrhage) or when tractional retinal detachment happens. DME is marked by swelling or macula
thickening due to sub-and intra-retinal fluid deposition in the macula caused by blood-retinal barrier
breakdown (BRB). DME may occur at any DR level, triggering visible image distortion and a loss in
visual acuity. This exact situation could be observed for Mr. Jackson, as he started facing reading
problems and stayed fuzzy in his brain. The retinal blood vessels ' initial reactions to hyperglycemia
involve dilatation of the blood vessels and shifts in blood flow. Such modifications are called a metabolic
self-regulation to improve the metabolism of retinal subjects in diabetics. Pericyte disruption is another
characteristic of early DR cases. Both in vitro and in vivo experiments have provided signs of apoptosis
of pericytes caused by high glucose. Because pericytes are responsible for supplying the capillaries with
structural reinforcement, their absence contributes to localize outpouching of capillary walls. This cycle is
associated with the development of microaneurysm, which is the first clinical symptom of DR. Aside
from pericyte destruction, apoptosis of endothelial cells and inflammation of the basement membrane was
also observed during DR pathogenesis, which leads collectively to BRB deficiency.
Medical Management:
Reviewing the medication chart, it was observed that Mr. Jackson was prescribed and an active
taker of the medications that included twice daily intake of Metformin 500 mg and Metoprolol 50mg.
Metformin (Tanet al,. 2016) is an antihyperglycemic agent that increases glucose control in Type II
diabetes patients, raising both basal and postprandial plasma glucose. The pharmacologic action
mechanisms vary from certain types of oral antihyperglycemic agents. Metformin reduces the
development of hepatic glucose, increases the absorption of glucose in the intestines and enhances the
responsiveness of insulin by increasing the peripheral absorption and consumption. Apart from
sulfonylureas, in either patients with type II diabetes or regular subjects metformin doesn't quite induce
hypoglycemia, and does not cause hyperinsulinemia. With metformin treatment, insulin production stays
constant although fasting insulin rates and the insulin reaction of day-long plasma will potentially
decrease. Extended release tablets of metformin are suggested as an alternative to nutrition and exercise

4EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
to improve glycemic regulation in adult patients with type 2 diabetes (aged 18 and older). They can be
used simultaneously with a sulfonylurea or insulin to enhance adult glycemic regulation. Adverse effects
can involve physical fatigue (asthenia), vomiting, upper respiratory tract infection, stomach discomfort,
lactic acidosis (rare), nausea, low blood sugar (hypoglycemia), exhaustion signs, body pain, low blood
vitamin B-12. Monitoring the renal activity, metformin is greatly excreted by the kidney, and the
likelihood of development of metformin and lactic acidosis decreases with the degree of renal activity
deficiency. Thus patients with serum creatinine rates above the usual upper limit do not get metformin for
their age. Renal function should be observed frequently in elderly patients, particularly those under 80
years of age, and Metformin should usually not be titrated to the full dosage. Renal function should be
tested and checked as usual before starting Metformin treatment and at least periodically afterwards.
The Metoprolol (Nassiri et al., 2015) can be however, described as a adrenergic hormone
antagonist beta-1-selective (cardioselective). However, this beneficial influence is not total, as Metoprolol
often stimulates beta-2-adrenoreceptors at higher plasma concentrations, primarily in the bronchial as
vascular musculature. Metoprolol's beta-blocking action tends to lower heart rate and cardiac production
at rest and exercise, suppress isoproterenol-induced tachycardia, decrease reflex orthostatic tachycardia
and decrease systolic blood pressure while exercising. Tartrate tablets with metoprolol are recommended
for hypertension management. They can be used alone or with other antihypertensive agents. The adverse
effects of taking this drug include dizziness, chest pain or nausea, blurry vision, uncertainty,
lightheadedness, or exhaustion where a sluggish or erratic pulse sweating excessive fatigue or weakening
occurs unexpectedly from a lying or sitting position. Avoiding alcohol is a must while being under
medication with Metoprolol as the medicine increases the dizziness. It is very important to follow proper
diet and be under weight control while administering the said medicines.

5EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Nursing Diagnosis:
I. Nursing Problem related to Medical Diagnosis:
While the precise process by which diabetes triggers retinopathy is uncertain and many hypotheses
have been suggested, it is generally accepted that when the capillaries are blocked or leaked, or develop
haphazardly (a microvascular characteristic correlated with diabetes), the retina is weakened in a variety
of ways. Mr. Jackson is found to have already lost his vision in his left eye after the case report. The
greatest challenge the nurses can face, though, is the deterioration of the disease. Since the occlusion of
the retinal capillaries, proliferative retinopathy occurs, leading to retinal ischaemia. This facilitates the
production of neovascularization due to the release of vascular endothelial growth factors, a mechanism
that proliferates on the surface of the retina via fresh blood vessels. These tubes, though, are weak, simple
to hemorrhage, and the resultant blood concentration in the vitreous cavity severely impairs vision. This
could be lasting due to other problems, such as retinal detachment by pressure, contributing to reported
blindness.
II. Nursing Problem related Medication Management:
It can be observed from the medical case history that Mr. Jackson had been an active user of
Metoprolol and Metformin to treat his Type II diabetes mellitus and hypertension. Although, it has been
observed that Metformin had been actively successful to prevent the active advances to Diabetic
Retinopathy, the prolonged use of Metoprolol has adverse side effects (Liu et al., 2014) on patients
specifically with older age. Relevant trials (Stafford, 2018) undertaken to date have demonstrated no
geriatric-specific issues that would hinder the effectiveness of Metoprolol in older persons. Elderly
people, though, are more likely to have liver, renal, or cardiac issues due to age, and could need vigilance
and dosage change for patients taking Metoprolol.

6EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Nursing Role and Inter-professional Plan of Care:
Understanding the nursing problems that had been stated previously in the paper, Mr. Jackson is
observed to be obese living with an unhealthy lifestyle. Moreover, he had no knowledge of how to self
manage his diabetes and neither had any regulation of checking his blood sugar level regularly. The risks
that prevail in the case study include the advancement of the diagnosed condition. As per nursing
management, the adverse conditions can be avoided with the application of panretinal laser
photocoagulation (PRP) (Chen et al., 2015), which was correlated with a 50 per cent decrease in
incidence of mild to serious vision impairment in patients with extreme nonproliferative to proliferative
retinopathy. For eyes with macular edema, focal laser photocoagulation has been correlated with a drop in
the likelihood of mild vision impairment of 50 to 70 per cent. In patients with proliferative retinopathy
and serious vitreous hemorrhage, early vitrectomy was linked with enhancement of the visual recovery.
For eyes with chronic vision impairment, intravitreal corticosteroid injections can be an alternative where
traditional therapy has failed. Reports show that glycemic regulation, any decrease in hemoglobin A1C
(HbA 1c) rates, is helpful in minimizing the production of new DR or preventing the growth of current
DR. In fact, the treatment package often requires a decrease in systolic and/or diastolic BP. It has been
seen to be effective in that the production of new DR or restricting the advancement of current DR. In
addition, teams are structured to meet common programmatic aims. Primary health care professionals
should collaborate alongside patients / clients, relatives, organizations, partners and others to accomplish
quality outcomes for patients and/or the community. To order for an interprofessional primary health care
team (Regan, Laschinger and Wong, 2016) to work efficiently, all participants can fully recognize the
intent and priorities of the team and collaborate on them. Chronic suffering from conditions such as
diabetes hypertension contributes to a major decline of health leading to heightened requests for
treatment. Chronically sick people frequently see 4 − 9 separate health-care providers. Administrations
plan to move coverage of sick patients from acute services to primary care and maintain an increased cost
of health care under track. Therefore, the primary care environment would see a significant increase in

7EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
workload, especially with respect to patients with complicated issues. Accordingly, productive and
efficient interprofessional cooperation is required in chronic care, especially in the primary care
environment. Collaboration between roles may have beneficial impacts on the systems and results of
health care. Furthermore, interprofessional cooperation appears to be a requirement for making a move
from disease-oriented to patient-oriented treatment simpler. This is utilized by health care providers to
create their own discipline-specific treatment programs. Nevertheless, despite the growing complexities
of caring for individuals with numerous chronic conditions, synchronizing all discipline-specific
treatment arrangements into one interprofessional collaborative caring strategy appears important.
Interprofessional cooperation will contribute to improved performance and increased patient health if
performed correctly. The strategy helps registered nurses to benefit not just from their own knowledge
and experience but also from the resources of each healthcare professional. Since nurses (Price, Doucet
and Hall, 2014) typically spend much of their time with patients, they will discuss with physicians what
they have experienced, and create the best treatment plan for each particular patient. As nurses and
physicians operate together as partners, establishing a linked, welcoming healthcare environment is
simpler. The introduction of anti-VEGF Diabetic Retinopathy (DR) treatments has increased the threshold
for visual outcomes. However, there are still multiple barriers stopping patients from understanding the
advantages of individualized collection of effective anti-VEGF medication. Coordinated management is
critical for DR patients, who often have many different care and management providers involved,
including endocrinologists, ophthalmologists, optometrists and primary care providers. Panretinal laser
photocoagulation (PRP) was linked with a 50 per cent decrease in incidence of mild to serious vision
impairment in patients with extreme nonproliferative to proliferative retinopathy. For eyes with macular
edema, focusing laser photocoagulation has been correlated with a drop in the likelihood of mild vision
impairment of 50 to 70 per cent. In patients with proliferative retinopathy and serious vitreous
hemorrhage, early vitrectomy was linked with enhancement of the visual rehabilitation. For eyes with
chronic vision impairment, intravitreal corticosteroid injections can be an alternative where traditional
therapy has failed.

8EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Conclusion:
Traditionally a healthcare system has developed between top physicians and lower ranking staff.
Therefore, instituting a paradigm change where nurses are at the same level as doctors can be challenging,
particularly for physicians who have been practicing for many years. A collaborative approach to diabetes
treatment will help patients deal successfully with the overwhelming amount of problems that can arise
from diabetes. People with diabetes may lower their risk for microvascular complications, such as eye and
kidney disease; macrovascular complications, such as cardiac disease and stroke; and other complications
of diabetes. Although each healthcare provider holds discipline-specific training courses, nurses will
make an attempt to sit in on the classes in other staff so that they can gain additional input into certain
hospital positions. It will also allow nurses to empathize more with the struggles encountered by their
peers in other professions, and will deepen the connections between caregivers. Being active in assessing
a scenario from several points of view helps patients to make informed treatment choices. Nevertheless,
the primary goal of a doctor is to provide their patients the highest possible treatment, so that is supported
through interprofessional cooperation. The article above outlines Mr. Jackson's case analysis and deals
with the implementation of interprofessional treatment strategy to explain proper control of the chronic
disease.
References:
Abràmoff, M.D., Lavin, P.T., Birch, M., Shah, N. and Folk, J.C., 2018. Pivotal trial of an autonomous AI-
based diagnostic system for detection of diabetic retinopathy in primary care offices. NPJ digital
medicine, 1(1), pp.1-8.

9EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Chen, Y.W., Wang, Y.Y., Zhao, D., Yu, C.G., Xin, Z., Cao, X., Shi, J., Yang, G.R., Yuan, M.X. and
Yang, J.K., 2015. High prevalence of lower extremity peripheral artery disease in type 2 diabetes patients
with proliferative diabetic retinopathy. PloS one, 10(3).
Crossland, L., Askew, D., Ware, R., Cranstoun, P., Mitchell, P., Bryett, A. and Jackson, C., 2016.
Diabetic retinopathy screening and monitoring of early stage disease in Australian general practice:
tackling preventable blindness within a chronic care model. Journal of diabetes research, 2016.
Gargeya, R. and Leng, T., 2017. Automated identification of diabetic retinopathy using deep
learning. Ophthalmology, 124(7), pp.962-969.
Gucciardi, E., Espin, S., Morganti, A. and Dorado, L., 2016. Exploring interprofessional collaboration
during the integration of diabetes teams into primary care. BMC family practice, 17(1), p.12.
Jusufbegovic, D., Mugavin, M.O. and Schaal, S., 2015. Evolution of controlling diabetic retinopathy:
changing trends in the management of diabetic macular edema at a single institution over the past
decade. Retina, 35(5), pp.929-934.
Kanagasingam, Y., Xiao, D., Vignarajan, J., Preetham, A., Tay-Kearney, M.L. and Mehrotra, A., 2018.
Evaluation of artificial intelligence–based grading of diabetic retinopathy in primary care. JAMA network
open, 1(5), pp.e182665-e182665.
Liu, X., Zhong, C., Zhao, P., Zhang, Z., Jia, N., Su, S.O., Zou, B. and Song, Y., 2014. Analysis of
therapeutic effect and safety of target-dose metoprolol in the treatment of patients with diabetes mellitus
with chronic heart failure. Pakistan journal of medical sciences, 30(1), p.7.
McGill, M., Blonde, L., Chan, J.C., Khunti, K., Lavalle, F.J. and Bailey, C.J., 2017. The interdisciplinary
team in type 2 diabetes management: Challenges and best practice solutions from real-world
scenarios. Journal of clinical & translational endocrinology, 7, pp.21-27.

10EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
Nagelkerk, J., Thompson, M.E., Bouthillier, M., Tompkins, A., Baer, L.J., Trytko, J., Booth, A., Stevens,
A. and Groeneveld, K., 2018. Improving outcomes in adults with diabetes through an interprofessional
collaborative practice program. Journal of interprofessional care, 32(1), pp.4-13.
Nassiri, M., Babina, M., Dölle, S., Edenharter, G., Ruëff, F. and Worm, M., 2015. Ramipril and
metoprolol intake aggravate human and murine anaphylaxis: evidence for direct mast cell
priming. Journal of Allergy and Clinical Immunology, 135(2), pp.491-499.
Price, S., Doucet, S. and Hall, L.M., 2014. The historical social positioning of nursing and medicine:
Implications for career choice, early socialization and interprofessional collaboration. Journal of
Interprofessional Care, 28(2), pp.103-109.
Regan, S., Laschinger, H.K. and Wong, C.A., 2016. The influence of empowerment, authentic leadership,
and professional practice environments on nurses’ perceived interprofessional collaboration. Journal of
nursing management, 24(1), pp.E54-E61.
Scanlon, P.H., Aldington, S.J. and Stratton, I.M., 2014. Delay in diabetic retinopathy screening increases
the rate of detection of referable diabetic retinopathy. Diabetic medicine, 31(4), pp.439-442.
Stafford, A., 2018. CPD: Chronic disease management: Diabetes update. Australian Pharmacist, 37(11),
p.40.
Tan, M.H., Alquraini, H., Mizokami-Stout, K. and MacEachern, M., 2016. Metformin: from research to
clinical practice. Endocrinology and Metabolism Clinics, 45(4), pp.819-843.
Ting, D.S.W., Cheung, G.C.M. and Wong, T.Y., 2016. Diabetic retinopathy: global prevalence, major
risk factors, screening practices and public health challenges: a review. Clinical & experimental
ophthalmology, 44(4), pp.260-277.

11EVIDENCE BASED PERSON CENTRED CARE: CASE REPORT
van Dongen, J.J.J., van Bokhoven, M.A., Daniëls, R., van der Weijden, T., Emonts, W.W.G.P. and
Beurskens, A., 2016. Developing interprofessional care plans in chronic care: a scoping review. BMC
family practice, 17(1), p.137.
Wang, W. and Lo, A.C., 2018. Diabetic retinopathy: pathophysiology and treatments. International
journal of molecular sciences, 19(6), p.1816.