Case Study Report: Managing Mr. Brown's Diabetes and Cardiac Issues

This case study presents a detailed analysis of Mr. Brown, a 70-year-old retired man with a 20-year history of type 2 diabetes, who presented to the hospital with chest pain, weight gain, and poor diabetic control. The case study covers his medical history, physical examination findings (including BMI, blood pressure, and blood glucose levels), and psychosocial aspects. The core of the report focuses on a comprehensive care plan that prioritizes alleviating chest pain (potential myocardial infarction), managing his diabetes (high blood glucose levels and related cardiovascular risks), and addressing his weight management issues. Evidence-based nursing interventions are proposed for each care priority, including monitoring vital signs, administering medications, patient education, and dietary modifications. The evaluation section outlines how the effectiveness of these interventions would be assessed, focusing on pain reduction, blood glucose control, and weight management. The case study highlights the importance of critical thinking, individualized care, and the application of theoretical knowledge in a clinical setting.

Running head: NURSING
NURSING
Name of the Student
Name of the University
Author Note

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Case study
Case study analysis in nursing studies gives an in depth understanding of a particular
patient and improves the problem solving skills of the nurse. Nursing students needs to be
critical thinkers and a growing body of evidence have suggested that development of critical
thinkers are necessary to solve complex medical problem or to provide prompt care as and
when required (Dutra, 2013). During my clinical placement, I was allotted to care for Mr.
Brown, who was a retired 70 years old man with a 20 years history of type 2 diabetes. As
reported by Mr. Brown, his mother also suffered from type II diabetes. He had reported to
have some past records of nocturia. His current weight is 170 lb. When the first time he was
diagnosed with T2D, he was asked to lose weight, but no action has been taken. Mr. Brown
smokes 1-3 packet of cigarettes a day and consumes the 1-2 cocktails per night. He says it
“settles his nerves”.
Mr. Brown had been presented to the hospital with the recent weight gain, nil diabetic
control and a pain on the chest. Mr Brown described the pain to be chest tightedness. As per
his subjective records- “It is in my breast bone and it is not radiating”. He had also informed
that he often feels burning sensation in his chest. Mr. Brown had been taking glyburide
Diabeta) every morning, but had stopped them recently as he had been feeling dizzy followed
by sweating with a feeling of the agitation, sometimes in the late afternoon. Mr. Brown also
takes Atorvastatin (Lipitor, 10 mg daily) for his hypercholesterolemia (Elevated LDL
cholesterol). For the past 6 months he had also been taking gymnema sylvestre and a
pancreatic elixier for improving his diabetes control. Mr. Brown does not monitor his blood
glucose level regularly and does not know to use the normal glucometers. The diet history of
the Mr. Brown signifies excessive intake of carbohydrates in the form of pasta and breads.
For dinner he takes about two cups of pasta and 3-4 slices of Italian bread.

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Physical examination
 Weight: 170 lb; height: 5′″; body mass index (BMI): 31.6 kg/m2
 Fasting capillary glucose: 165 mg/dl
 Blood pressure: BP right arm 162/94; left arm 160/92
 Respiratory rate is- 16/minute
 Temperature- 98.4 degree F
 Haemoglobin = 15.2g/dL
 Blood Urea Nitrogen (BUN) 11mg/dL
 Lungs are clear to percussion and auscultation.
 Heart: 86/minute, S1 is heard best at the apex, S4 is also heard at the base of the apex
absence of any peripheral oedema.
Describing about the psychosocial aspect, Mr. Brown had lost his wife there years back and
since them, he cannot manage cooking alone and hence consumes read made pasta which are
easy to make. As he is retired, his movements have also become restricted which is also
increasing his body mass index. Mr. Brown stays in a small household with almost no space
where he can do exercise, which had been worsening his cardiac health.
Care Plan
Care priority/Objective 1
One of most important care priority for Mr. Brown would be to alleviate his chest pain, for
which he had been admitted in to the hospital. Typical chest pain or angina are often
described as “ pressure like” Older patients are more likely to have a clinical presentation of a
chest pain. Half of the patients who had been admitted with a chest pain, was diagnosed with
myocardial infarction. Hence, it can be possible that Mr. Brown might have contracted with

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myocardial infarction. It has already been stated that he often felt nauseated. Treatment delay
might increase the chance of mortality. For adults above the age of 65, ischemic heart attack
accounts for about 81 % of mortality and needs to be diagnosed first when any older person
presents to the care with a chest pain. Some of the complications of heart disease might
include heart failure, which occurs when heart cannot pump enough blood to meet the
requirements of the body. Some of the other complications might involve aneurysm and
peripheral artery diseases. If prompt action is not taken. Then it can lead to cardiac arrest
casing death.
Clinical priority 2
Managing diabetic health
It is evident from the case study that the blood glucose level of the patients is quite
higher than the standard value. The normal blood glucose level of a patient is about 72to
99mg/dL while fasting and about 140mg/dL, after eating. A large number of literary sources
have indicated diabetes to be the major risk factor for coronary heart disease. As per the
studies, it has been found that about 68 % of the people older than 65years with diabetes die
from cardiovascular diseases (Currie & Delles, 2014). Studies have reported a positive
association between the insulin resistance and hypertension (Currie & Delles, 2014). The
likelihood of cardiovascular disease doubles, if an individual has a combination of diabetes
and hypertension. Patients having T2D, often have high LDL cholesterol levels and high
triglycerides that is an important risk factor for the development of cardiovascular diseases.
Diabetes affects the heat muscle and can cause both systolic and the diastolic heart failure
(Currie & Delles, 2014). According to Jia, DeMarco and Sowers, (2016) diabetic
cardiomyopathy occurring in patients increases the chance of heart failure in the patients.
Diabetes has been found to be related to micro vascular diseases, causing endothelial

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dysfunction. Diabetes has been also found to be associated with diastolic dysfunction in
presence of a poor metabolic control (Peters, Huxley & Woodward, 2014). Due to this
association of diabetes with several comorbidities, it is better that diabetes should be
controlled at their earliest. The case study reveals that Mr. Brown does not know glucose
monitoring. Regular monitoring of glucose is required for an optimal blood glucose control.
Clinical priority 3
The third care priority for Mr. Brown is weight management. As per the case study,
the weight of the patient is quite higher than the standard weight, which would have been as
per the height of the patient. Being obese or overweight increases the risk of T2D and
cardiovascular diseases. It is evident from the case study that the Mr. Brown mainly stays on
minute made pasta. The carbohydrate content and the glycaemic index of the pasta is quite
high. A simple healthy eating plan will not only help Mr. Brown in maintaining diabetes but
will also help patients to manage weight. Although the exact relationship between overweight
and diabetes is not well understood. There are studies that has suggested that abdominal fat
causes the adipose tissues to secrete inflammatory chemicals, which cause the body cells to
be less sensitive to insulin, by disrupting the function of the insulin responsive cells and their
ability to respond to insulin (Bastien, Poirier, Lemieux & Després, 2014). Obesity and
overweight has also been found to be causing some unwanted metabolic changes (Gray,
Picone, Sloan & Yashkin, 2015). These metabolic changes causes the adipose tissue to
release fat molecules in the blood, which can affect the insulin responsive cells leading to
lessened insulin sensitivity (Bjerregaard et al., 2017). Obese individuals have free fat mass
that increases the chance of cardiovascular accidents (De Schutter, Lavie, & Milani, 2014).
Hence, the symptoms of chest pain experienced by Mr. Brown was due to any cardiovascular
condition, whose predisposing factors can be diabetes and overweight.

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Evidence based nursing interventions
Care priority 1
The initial goal would be to identify the life threats like myocardial infarction, aortic
dissection. `The vital signs of the patient needs to be monitored. Nurses can perform the bed
side tests like EKG and portable CXR. The arterial blood gas levels has be measured.
Medications like Nitroglycerine and beta blockers can be given to the patient. After the
patient had stabilised and the initial data has been gathered, more detailed history and
physical examination needs to be conducted. It is necessary to assess and the document the
response of the patient towards medicines (Andrikopoulos et al., 2017). Pain and decreased
cardiac output can stimulate the sympathetic nervous system to release an excessive amount
of norepinephrine that increases aggregation of the platelets and the release of the
thromboxane (Andrikopoulos et al., 2017). Nurses should identify the duration, frequency,
location and the intensity of pain. Any reports of pain in neck, jaws, shoulders or hands
should be noted as cardiac pain might radiate to more superficial sites. The edge of the bed
can be elevated if the patient was having shortness of breath. The heart rhythm and the heart
rate has to be monitored, as patients with unstable angina can have an increased risk of life
threatening dysrhythmias, that occurs in response to the ischemic changes or stress (Lewis,
Bucher, Heitkemper, & Dirksen, 2014). It is necessary to maintain a calm and a quite
environment as emotional stress and anxiety has been found to be increasing myocardial
workload. Antianginal medicines like nitro-glycerine and sustained release tablets. Nitro-
glycerine tablets had been the standard medicine for treating angina pain.
Care priority 2
The nursing actions would initially start with a nursing assessment for the signs of
hyperglycemia. The blood sugar level has to be assessed before the meals and at the bed time.

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Furthermore, it is also necessary to assess for the signs of anxiety, any incidence of slurring
of speech or tremors, as these are the acute signs of hyperglycemia (Ley, Hamdy, Mohan &
Hu, 2014). It is evident from the case study that Mr. Brown was reluctant to learn about the
use of the glucometer. The patient should be taught about glucose monitoring at home. It is
necessary to assess, whether the patients is adhering to dosage of medications, as these
medicines stimulates insulin secretion in the pancreas (Evert et al., 2016). Mr. Brown should
be instructed to maintain a diet that would contain nutrient dense food than that of the energy
dense food. Complex sugars, high fibres and whole grains should be consumed in adequate
amount. Additionally, it is also important to notify patients about the importance of
adherence to medicines and teach them about oral hygiene (Evert et al., 2016).
Care priority 3
In order to develop a plan of care for the weight management, it is necessary to
review the actual cause of obesity in Mr. Brown and discuss with him about the events
associated with eating. Nurses would formulate a diet plan with the consent obtained from the
patient itself and using knowledge about the height, weight, age and gender of the patient and
the patterns of eating each patient follows. A good reducing the diet should contain
proportionate amount of calorigenic food, body building food, vitamins and minerals.
Adequate proteinaceous and low fat diet would prevent loss of muscle mass (Ley, Hamdy,
Mohan & Hu, 2014).
Evaluation
Care priority 1
The effectiveness of the interventions would possibly be evidenced by decreased pain
in frequency, severity and duration. Relief of pain will be demonstrated by stable vital signs,

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absence of muscle tension and restlessness. The patient will be restored to the condition,
where he will be able to verbalise about his own condition, such as the severity of the pain or
any form of restlessness. A time line of one hour was chosen, as at least a time period of one
hour was required to see the effectiveness of the interventions. A numeric rating scale was
used to evaluate the intensity of the pain and can be matched with the initial pain. The
patients should be educated about the ill effects of eating fad foods like minute made pastas.
Care priority 2
On effective intervention , Mr. Brown would display a blood glucose reading less
than 180 mg/dL, fasting glucose level would be less than <140mg/dL and the hemoglobin
A1C level would be less than 7 %.
Care priority 3
Appropriate nursing interventions would enable the client to identify inappropriate
behaviours and consequences related to over eating and weight gain (Sackner-Bernstein,
Kanter & Kaul, 2015). On regular follow up, the patient will demonstrate a change in the
eating patterns and involvement in exercise regimen. The timeframe for the evaluation would
be about 2 months.

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