NURSING 7 Case Study: Managing a Hypertensive Diabetic Patient's Care

This case study examines the condition of a 75-year-old male, Bill McDonald, diagnosed with type 2 diabetes and hypertension. The essay explores his symptoms, including fluctuating blood glucose levels, elevated blood pressure, and lower extremity edema, linking them to the pathophysiology of insulin resistance and the interplay of the nervous system, RAAS, and environmental factors. The assignment emphasizes the need for both pharmacological and lifestyle interventions, prioritizing blood pressure control through ACE inhibitors, ARBs, and loop diuretics, while also stressing lifestyle modifications such as increased physical activity, smoking cessation, alcohol reduction, and dietary changes. Nursing interventions like compression stockings are also discussed to manage edema. The conclusion highlights the importance of managing hypertension in diabetic patients and suggests regular monitoring and tailored interventions to prevent complications.

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Type 2 diabetes (T2D) is a chronic health condition, whose prevalence is increasing
globally. According to the data by Australian Bureau of Health Statistics (2018), one in twenty
Australians had diabetes in 2017-2018. With the increase in risk of diabetes, the rate of other
chronic health issue such as hypertension and heart disease has increased too. Research literature
has established correlation between diabetes and hypertension as both the condition exists
together and worsens clinical outcomes in patients. Hypertension in diabetes patient can further
increase the risk of cardiovascular disease and nephropathy (Khangura et al., 2018). Thus,
paying attention to hypertensive diabetic patient is important to reduce the burden of
cardiovascular disease. This essay will look into the case scenario of a patient who has similar
issue of hypertension and diabetes. The case study is about Bill McDonald, a 75 year old male
patient diagnosed with T2D. The essay will examine the symptoms and diagnostic test results of
the patient and link it to the pathophysiology of T2D. The essay will also examine the potential
management approaches for a hypertensive diabetic patient.
Bill McDonald is a patient with diagnosis of diabetes. He has a history of smoking
cigarettes for 35 years and a history of alcohol consumption. His blood glucose level had been
fluctuating over the past 3 months. His risk of diabetes was linked to family history as his mother
had diabetes and diet of heart failure at the age of 65 years. Recently, Mr. Bill was found to have
high blood pressure, when he presented for a regular GP visit. His blood pressure was found to
be 170/100 mmHg. To understand the events that lead to his diabetes and his current chronic
symptoms, looking at the pathophysiology behind the condition is important.
The pathophysiology of T2D involves peripheral insulin resistance and declining of beta
cell function leading to beta cell failure. The primary event for all patients with diabetes is the
initial deficit in insulin secretion and initiation of insulin resistance. Insulin resistance is an

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important factor for the development of T2D. According to Tesauro and Mazzotta (2020), all
patients with T2D suffer from varying degree of insulin resistance and insulin deficiency. Insulin
resistance is a phenomenon that occurs due to presence of excess glucose in the blood and the
reduction in the ability of the blood to use glucose for energy. This is manifested in the form of
high blood glucose level in the blood. Similar issue was found for Mr. Bill as his fasting blood
glucose level ranged from 4.5 to 7 mmol/L. The blood glucose of 7mmol/L or higher is seen in
patient with diabetes and blood glucose between 5.6 to 6.9mmol/L is seen in prediabetes patient.
Hence, Mr. Bill’s FPG value shows that he is suffering from moderate blood glucose control
issues as his FPG test is fluctuating.
There are many driving forces behind insulin resistance in any individual. This is
influenced by various factors such as obesity, smoking, genetics and ageing. Obesity can be
linked to Mr. Bill’s diagnosis as his weight was 123 kg. Obesity is a condition that is highly
associated with developing insulin resistance and T2D. This is because obese individuals have
adipose tissues which release large amount of non-esterified fatty acids and pro-inflammatory
cytokines. These cytokines can cause insulin resistance in adipose tissue and liver. The initiation
of the inflammation occurs in obese individuals, when adipose tissues lead to adipocyte
hypertrophy and local oxygen supply is disrupted by the adipocytes leading to activation of
cellular stress pathways. This mechanism results in autonomous inflammation and release of
cytokines and other pro-inflammatory signals (Kang et al., 2016). Thus, localized insulin
resistance takes place leading to abnormal metabolic state. Mr. Bill is an active smoker and his
smoking habit can be one of the reasons behind his T2D.
In addition to obesity, Mr. Bill’s high blood pressure is because of the effect of diabetes.
The main pathophysiology behind hypertension in diabetic patient involves the interaction

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between the nervous system, rennin-angiotensin-adolesterone system (RAAS) and the influence
of individuals and environmental factors (Henson et al., 2018). Mr. Bill had a sedentary lifestyle
and the study by Khangura et al. (2018) suggests that sedentary behaviour increases the adiposity
level and consequently insulin resistance. This is followed by increase in vascular adhesion,
inflammation and decreased nitric oxide levels in the vascular sections. All these changes
together promote vascular stiffness and lead to hypertension. RAAS is also an important factor
behind the pathogenesis of hypertension in diabetic patients like Mr. Bill. RAAS is a factor that
has direct effects on angiotensin II and aldosterone. Obesity and insulin resistance together lead
to activation of RAAS and increased adiposity level inhibits insulin metabolic signalling by
angiotension II and aldosterone. This induces endothelial-mediated vascular relaxation and
development of hypertension (Khangura et al., 2018). Based on the review of the
pathophysiology of T2D and its link with symptoms of Bill, it can be said that he is in need of
both pharmacological and life style intervention for the management of his symptoms.
Before prioritizing best intervention for the management of Mr. Bill’s condition, finding
out his abnormal symptom is important. The first care priority will be to control and reduce
blood pressure of Mr. Bill. The target should be to keep blood pressure less than 130/80 mm Hg
in Mr. Bill and this will be done by pharmacological intervention. The second priority will be to
improve his lifestyle. This is important as currently he leads a sedentary lifestyle and eating
bananas, both of which can be detrimental to his diabetic outcomes. During presentation to the
GP, he was asymptomatic, however he suffered from symptoms of dizziness or blurred vision
and he had pitting oedema in both his lower legs. Lower extremity oedema is a sign of fluid
retention issue. This symptom should be taken seriously as such oedema is a sign of poor
prognosis in patients (Tesfaye & Wu, 2018).

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To control hypertension, it will be necessary to implement pharmacological interventions
for Mr. Bill. ACE inhibitors and angiotensin receptor blockers (ARBs) are the preferred drugs
for management of hypertension and diabetes. ACE inhibitors exerts it action by inhibiting the
action of the ACE enzyme and preventing conversion of angiotensin 1 to angiotensin II. This
mechanism of action of the drug leads to decrease in peripheral resistance and antihypertensive
effect. This can further prevent the likelihood of kidney disease and early nephropathy for
hypertensive patient with dibetes. ARBs also have similar effect like that of ACE inhibitor.
However, evidence points out to the side effect of hyperkalemia due to the use of ACE inhibitors
and ARBs (Khangura et al., 2018). This risk can be minimized by if it is combined with other
medications like diuretics. According to Horr and Nissen (2016), thiazide diuretics can be used
as monotherapy or combination therapy in the treatment of hypertension in diabetes patient.
However, this drug is less effective in patients with diminished renal function. One of the marker
of decreased renal function is decrease in glomerular filtrate rate (GFR) values to less than 50
mL per min per 1.73 m2. As Mr. Bill’s blood test revealed decreased GFR rates, he needs to be
provided loop diuretic to control his hypertension. The above pharmacological intervention can
be followed up with regular blood pressure measurement. This will help to track changes in
blood pressure and detect the therapeutic effect of the drugs too. In addition, his renal function
should be regularly assessed by detecting urea and serum creatinine level to prevent the
progression of risk to end stage renal disease (Fukuda et al., 2018).
Lifestyle intervention is most crucial for recovery of Mr. Bill because lifestyle is the
major cause behind his fluctuations in blood glucose level and presence of other complications in
patient. As the pathophysiological discussion identified sedentary behaviour as a major cause
behind insulin resistance and increase in blood glucose level, it is planned to increase Mr. Bill’s

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activity level first. This can be started by encouraging Bill to engage in regular aerobic physical
activity like brisk walking for 30 minutes every day. The benefit of aerobic exercise is that it can
increase cardiorespiratory fitness of patient, reduce insulin resistance and reduce blood pressure
and HbA1c level (Horr & Nissen, 2016). Aerobic exercise can have a positive effect on
improving peripheral nerve functions too (Mirtha & Permatahati, 2018). As part of lifestyle
modification, diet modifications, smoking cessation and reduction in alcohol consumption will
be crucial for recovery of Mr. Bill. Currently, Mr. Bill is heavily consuming alcohol and there is
need to limit his alcohol consumption to two drinks per day. He needs to quit smoking to protect
his overall cardiovascular health too (Horr & Nissen, 2016). Beer or any form of alcohol
contains carbohydrate which can further increase blood glucose level of Mr. Bill. Hence,
reducing alcohol intake is necessary to clinically manage diabetes. In addition, the positive
benefit of smoking cessation is that it can alter fat distribution and improve lipid profile of
patient too. In addition, insulin sensitive of Mr. Bill will increase with smoking cessation
intervention too (Hu et al., 2018). In terms of diet modification, a diet chart should be planned
for Mr Bill so that he east four to five servings of fruits per day and takes adequate vegetables
and whole grains too (Gray & Threlkeld, 2019). The above intervention can help in the
management of hypertension too.
For the management of the sign of pitting oedema for Mr. Bill, it will be necessary to
conduct appropriate history checking and physical health assessment of patient. This form of
assessment can help to rule out systematic pathology. After this nursing interventions like
elevation of the foot of Mr. Bill can be considered as it can reduce lower extremity edema.
Another advantage of foot elevation is that it can decrease pedal tissue oxygenation as this
position can increase blood flow within the arterial system. The nurse can consider using mild

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compression stockings too as it can reduce lower leg edema without compromising vascular flow
(Wu et al., 2017). Peripheral edema is common symptom in diabetes patient because of damage
to the capillaries and the leakage of fluid into the surrounding tissues. Any sign of edema should
be taken seriously because it is a sign of peripheral complications and risk of diabetic foot ulcer.
Compression therapy is helpful for patients who suffer from diabetic foot ulcer as it promotes
healing of the ulcer (Tesfaye & Wu, 2018).
From the analysis of the case study of Mr. Bill, it can be concluded that presence of
hypertension is an additional issues for diabetic patient and this should be prioritized as it can
disrupt both blood glucose control and affect renal functions too. Three intervention that was
identified for the management of Mr. Bill included use of pharmacological therapy followed with
blood pressure monitoring, lifestyle intervention, use of compression stockings and diet
modifications. It is critical that while administering drugs to hypertensive patient with diabetes,
the side-effect of drugs and its impact on current health state of patient is monitored. This may
help to identify alternatives drugs just like it was done in the case of Mr. Bill.

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Yamasaki, T. (2018). Relationship between Food-Intake Trends and Estimated
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Adipokines, Proinflammatory Cytokines, and Adipose Tissue Macrophages in Obesity-

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