Case Study: Prioritizing Care in Diabetes and Hypertension

This case study examines a 52-year-old patient, Peter, diagnosed with type 2 diabetes and hypertension, highlighting the application of the clinical reasoning cycle in community health nursing. The case study prioritizes care for diabetes and hypertension, detailing the collection of patient data, interpretation of information, identification of nursing diagnoses (unstable blood glucose and decreased cardiac output), goal setting (blood glucose and weight reduction, blood pressure management), and intervention strategies, including diet, exercise, medication adherence, and smoking cessation. It emphasizes the importance of patient education, monitoring, and evaluation to achieve desired outcomes, referencing the patient's comorbidities, lifestyle factors, and the nurse's role in providing comprehensive care and support. The case study also involves the application of the clinical reasoning cycle for each priority of care, including assessment, diagnosis, planning, implementation, and evaluation. The references are also provided to support the content.

CASE STUDY 1
CASE STUDY INVOLVING USE OF CLINICAL REASONING CYCLE
Name:
Institutional affiliation:

CASE STUDY 2
DIABETES; FIRST PRIORITY OF CARE
Clinical reasoning cycle has been defined as the ability to have critical skills as a
community health nurse to identify a patient who is deteriorating and evaluating the outcomes of
the goal set for the patient (Hunter & Arthur,2016). Nurses with good clinical reasoning skills
have better judgement skills and are able to assess and plan for an emergency patient
promptly. Diabetes is an endocrine condition which refers to high blood sugar levels as a result
of low insulin levels or tissue resistance to insulin. Diabetes type two is whereby the islets of
Langerhans in the pancreas produce insulin but the tissues are resistant. The first step in
clinical reasoning cycle is considering the client’s situation. Peter is 52 was diagnosed with
diabetes type two which is poorly controlled nine years ago. He was admitted with high blood
glucose levels and increased hunger. He is on insulin novomix and metformin an oral
antidiabetic.
The second step is to collect patient data regarding the clinical condition. Peter is obese
and currently weighs 145kgs an increase from 105 kgs. According to Czech (2017) obesity has
been linked to insulin resistance causing diabetes type two. This calls for weight management
and reduction to reduce chances of complications. Peter commenced on a diet to help him
reduce weight and also light exercises. He is meant to continue with exercises after discharge.
Peter also feels isolated as he is unable to manage his weight therefore, he needs counselling
and motivation by the community health nurse. He also thinks weight loss is too difficult to be
implemented.
Diabetes type two is mainly has late onset although it is also affects adolescents. The
pathophysiology manifests by insulin resistance in the tissues which results in high blood
glucose levels. This causes infections, glycosuria and constant fatigue. Complications of
diabetes include nephropathy, visual impairment, delayed wound healing which may lead to
gangrene, neuropathy and hyperosmolar hyperglycemic state. Also, the patient may be
hypoglycemic if he administers excess insulin. Sleep apnea has been associated with the
development of diabetes type two (Doumit & Prasad, 2016). Peter is on insulin novomix which
converts blood glucose to glycogen while metformin is a biguanide which enhances the action of
insulin on tissue. Pregabalin is used to manage the neuropathic pain caused by diabetes.
The third step is to interpret the information and predict an outcome that is expected
after community health nurse’s intervention. Peter requires constant follow up which ensures
that he is involved in his on care and the diabetes is under management. The nurse will work

CASE STUDY 3
with Peter to form exercise plan and adhere to it. It is necessary for him to administer insulin
and note any signs of hypoglycemia that may occur. The desired outcome is a reduction in
Peter’s weight and decrease in blood glucose levels in random blood glucose tests and glycated
hemoglobin test which is done after three months.
The fourth step is identifying the major problem and deduce a nursing diagnosis. Since
Peter has high blood glucose levels which is the main clinical morbidity the nursing diagnosis
will be unstable blood glucose related to insulin resistance. Peter presents with multiple
comorbidities such as hypertension and gastroesophageal reflux disease hence requires
multidimensional care. It is also important to advise Peter to seize smoking as this complicates
his management due to vascular compromise and increased hypertension.
The fifth step is to establish the goal and outcome criteria which will determine the level
of success attained by Peter. The major goal is to maintain Peter’s blood glucose within the
normal range which will be assessed by random blood sugar tests, fasting blood glucose and
glycated hemoglobin tests. The second goal is to ensure weight reduction from 145kgs.
The sixth step is to take action. The community health nurse helps to Peter to formulate
an eating plan in accordance to the dietician low energy high protein diet low salt diet. This is
tailored to meet Peters budget considering that he is unemployed and he relies on government
benefits. He agrees to what works best for him as it will determine the success. The nurse also
assists Peter in formulating an exercise plan as reviewed by the physiotherapist and
emphasizes on the need to lose weight to Peter. The nurse should follow up if he is adhering to
the plan which may involve various activities such as walking. The nurse encourages Peter on
the need to meet the set goal everyday such as 1000 steps a day. Most importantly the nurse
educates Peter on how to administer insulin on the subcutaneous tissue; the right amount to
prevent hypoglycemia and what to do in case of hypoglycemia such as taking juice. The nurse
also teaches Peter on conducting random blood sugar tests using a kit and how to interpret the
results. Peter should also be aware of signs of diabetic complications.
The seventh and last step involves evaluation and reflection. This involves check listing
whether Peter’s blood glucose is within the normal range using the record of random blood
glucose levels and if he can administer the insulin appropriately. Peter should have a daily
record of his exercise activities and the number of steps he has attained. This will go a notch
higher to running and gym activities depending on his commitment levels.

CASE STUDY 4
HYPERTENSION; SECOND PRIORITY OF CARE
Hypertension refers to a systemic disease in which there are raised blood pressure levels
beyond normal. It is classified into essential and non-essential hypertension. In essential
hypertension the cause is unknown while in nonessential hypertension the cause is known.
Hypertension is a common comorbidity with diabetes diagnosis due to vascular effects where
high blood glucose levels destroy the endothelial layer causing increased systemic resistance
(De Boer et.al,2017). Peter has hypertension and is obese with current weight of 145kgs.Peter
has been a smoker for 30 years and smokes at least 20 cigarettes a day. Smoking is a risk
factor in hypertension.
The second step is reviewing Peter’s data. Peter was previously admitted in a medical
ward before discharge with shakiness and difficulty breathing whilst sleeping. He was
discharged with metoprolol and lisinopril antihypertensives. Hypertension is a cardiovascular
disease which occurs due to decreased blood pressure levels as sensed by the juxtaglomerular
cells of the kidney. This triggers as cascade of action as renin is released. It is then converted to
angiotensinogen then angiotensin one and lastly angiotensin two. The latter is a vasoconstrictor,
induces thirst and causes release of aldosterone which causes salt retention and subsequent
rise in blood pressure. Hypertension is described as blood pressure above 140mm/Hg for
systolic and 90mm/Hg for diastolic. Smoking causes damage to the blood vessels increasing
systemic resistance worsening the blood pressure levels. Lisinopril is an angiotensin converting
enzyme inhibitor which is administered as an antihypertensive while metoprolol is a selective
Beta one receptor inhibitor. Complications arising from hypertension include coronary heart
disease which may lead to myocardial infarction, heart failure, nephropathy, retinopathy and life-
threatening aneurysms. Obesity has been implicated on increasing sodium reabsorption in the
renal tubules (Hall et.al,2010). It is important to help Peter control his hypertension by managing
his diabetes, weight reduction and smoking cessation. There is need to involve his immediate
family members with his consent regarding his condition so as to ensure he has support and
caregivers as he is sometimes unable to perform activities of daily living.
The third step is to interpret the hypertension data and infer so as to give Peter the best
outpatient care. So, for Peter to maintain normal blood pressure ranges he needs to have a low
cholesterol diet, fruits and vegetables. Peter also needs to be committed in terms of weight loss
and clean eating. It is also known that diabetes is a highly contributing factor to hypertension

CASE STUDY 5
therefore if the diabetes is well controlled the blood pressure would easily be managed. The
expected outcome management of blood pressure within the normal range.
The fourth step is creating a nursing diagnosis which is decreased cardiac output related
to increased vascular resistance as evidenced by systolic blood pressure of above 140mm/Hg.
The desired goal is a subsequent decrease in obesity which is a contributing factor. The
community health nurse’s role is first and foremost to educate Peter on the effects of smoking
on his hypertensive state. Peter willingness to quit smoking will make the program successful.
Smoking not only exacerbates hypertension and diabetes but also increases the chances of
getting cancer. The nurse will refer Peter to smoking cessation center where he will receive
nicotine replacement patches or bupropion (Cahill, Lindson‐Hawley, Thomas, Fanshawe &
Lancaster,2016).
The second role of the nurse is educating Peter on importance of adherence to the
antihypertensive drugs and side effects. Hypertension is best managed while the patient
adheres to medication as prescribed (Lo, Chau, Woo, Thompson & Choi, 2016). In addition,
Peter should have a low sugar, low cholesterol and high protein diet to help in management.
Drug efficacy is measured by regular blood pressure measurements to ascertain if there
is need to change to other antihypertensives or stick to the current ones. The nurse will
measure Peter’s blood pressure every two weeks and document to deduce any improvement or
deterioration. The nurse further encourages Peter to manage his stress as stress increases
adrenaline levels which then increases heart rate and consequently high blood pressure.
Healthy activities are important as they ensure weight loss and fat metabolism.
Evaluation of the goals and outcome criteria involves Peter’s blood pressure has
successfully decreased and is within normal range. Peter is managing his stress successfully
and seeing a therapist if necessary. Healthy eating especially low salt diet and low cholesterol
diet. Most importantly Peter has quit smoking through the use of nicotine replacement patches
and bupropion. Reflection involves looking back at Peter’s journey and making necessary
adjustments for example involving his sons so that he has a primary caregiver.

CASE STUDY 6
REFERENCES
Cahill, K., Lindson‐Hawley, N., Thomas, K. H., Fanshawe, T. R., & Lancaster, T. (2016).
Nicotine receptor partial agonists for smoking cessation. Cochrane database of
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Czech, M. P. (2017). Insulin action and resistance in obesity and type 2 diabetes. Nature
medicine, 23(7), 804.
De Boer, I. H., Bangalore, S., Benetos, A., Davis, A. M., Michos, E. D., Muntner, P., ... & Bakris,
G. (2017). Diabetes and hypertension: a position statement by the American Diabetes
Association. Diabetes Care, 40(9), 1273-1284.
Doumit, J., & Prasad, B. (2016). Sleep Apnea in type 2 diabetes. Diabetes Spectrum, 29(1), 14-
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Hall, J. E., da Silva, A. A., do Carmo, J. M., Dubinion, J., Hamza, S., Munusamy, S., ... & Stec,
D. E. (2010). Obesity-induced hypertension: role of sympathetic nervous system, leptin,
and melanocortins. Journal of Biological Chemistry, 285(23), 17271-17276.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
Clinical educators' perceptions. Nurse education in practice, 18, 73-79.
Lo, S. H., Chau, J. P., Woo, J., Thompson, D. R., & Choi, K. C. (2016). Adherence to
antihypertensive medication in older adults with hypertension. The Journal of
cardiovascular nursing, 31(4), 296.