NURSING 6: Case Study of a 75-Year-Old Hypertensive Diabetic Patient

This essay presents a comprehensive analysis of a nursing case study involving a 75-year-old man, Bill McDonald, diagnosed with type 2 diabetes and hypertension. The essay delves into the pathophysiology of type 2 diabetes, exploring the roles of insulin resistance, beta-cell dysfunction, and genetic and environmental risk factors, including obesity, poor nutrition, and smoking. The analysis examines the patient's symptoms and vital signs, linking them to the underlying mechanisms of the disease. Based on the assessment, the essay outlines crucial nursing and clinical management strategies, including pharmacological interventions like metformin and ACE inhibitors, alongside lifestyle modifications such as diet, exercise, and smoking cessation. The importance of regular blood pressure monitoring and the implementation of evidence-based guidelines are also emphasized to stabilize the patient's condition, reduce complications, and promote long-term health outcomes. The essay highlights the interconnectedness of diabetes and hypertension, underscoring the need for a holistic approach in patient care.

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Introduction:
The purpose of this essay is to review the case study of Bill McDonald, a 75 year old man
who has been diagnosed with type 2 diabetes (T2D) and suffering from high BP. During
presentation to the GP for a normal visit, he was found to have high blood pressure. Many
additional test and vital sign examination was done for Bill. The essay will examine the
symptoms and discuss its relation to the pathophysiology of T2D. In addition, based on the
analysis of immediate and long-term health care needs of patient, the essay will give insight into
potential management and nursing approaches that is necessary for managing a hypertensive
diabetes patient.
Pathophysiology of diabetes:
Mr. Bill is a patient with a previous diagnosis of T2D. Diabetes is a complex chronic
disease that is associated with impaired insulin secretion or impaired insulin function and poor
glucose control. In case of type 1 diabetes, the immune cells attack the insulin producing cells
leading to poor production of insulin, whereas in T2D, the cells fail to respond to insulin (known
as insulin resistance) and beta cells of the pancreas fail to produce enough insulin to meet the
needs of the human body. This results in poor opening of glucose channels and building up of
glucose into the blood instead of getting absorbed in the cells for the generation of energy (Better
Health Channel, 2020). Hence, high blood glucose level is the main indicator of T2D and this is
mainly diagnosed or regularly monitored by fasting blood glucose (FPG) test and HbA1c level.
The HbA1c level and FPG test was done for Mr. Bill too and the impact of insulin resistance on
blood glucose level was evident from the results obtained from this test. HbA1c level is useful
for assessment of average glycemic status over the course of 2 to 3 months. Mr. Bill’s HbA1c

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level was 7.2%. The value of 6.5% or higher suggest that the person have diabetes. Moreover,
his FPG value ranged from 4.5 to 7 mmol, which is an indication that condition is fluctuating
between pre-diabetes and diabetes stage (Wang,, 2017).
According to Zaccardi et al. (2016), peripheral insulin resistance, poor hepatic glucose
production and decline in beta cell function is involved in the pathophysiology of T2D. Beta cell
dysfunction means impairment in the insulin secretion during glucose stimulation process. Two
factors namely reduced insulin production from pancreatic beta cells and peripheral insulin
resistance contributed to T2D. Hepatic glucose production increases due to the elevation of the
fatty acids in the plasma and decrease in the glucose transport into the muscle cells. Hence,
insulin resistance and beta cell dysfunction together plays a role in the pathophysiology of
diabetes (Al-Goblan, Al-Alfi & Khan, 2014). There are various factors that predispose people to
risk of T2D. This includes combination of genetic factors as well as environmental factors such
as obesity, poor nutrition, aging, physical inactivity and stress. The genetic factor contributes to
insulin secretion and insulin resistance due to the genetic abnormality in the molecules involved
in the regulation of glucose metabolism (Kohei, 2010). The genetic risk of diabetes is seen in Mr.
Bill as her mother also had diabetes and she died of heart failure at the age of 65 years. In
addition, risk of poor nutrition was evidenced by his Mr. Bill’s love for fresh fruit specially
banana. Increase in the consumption of sugar can deteriorate blood glucose level of client.
The effect of environmental factor on risk of T2D is seen for Mr. Bill too as he was
leading a sedentary lifestyle and was suffering from obesity too. His weight was 123 kg which
can be one of the causes behind diabetes. The role of obesity in the pathophysiology of T2D is
that obesity is associated with decrease in muscle mass and promotion of insulin resistance. Even
mild obesity increases the risk of T2D by 4-5 times (Kohei, 2010). Moreover, Al-Goblan, Al-

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Alfi and Khan (2014) mentions that anyone with obesity or overweight issues suffer from insulin
resistance and they may develop diabetes due to poor production of insulin. Insulin resistance
along with thrombotic abnormalities like family history, smoking and hypertension increase risk
of cardiovascular risk for diabetic patient too. Mr. Bill is also vulnerable to risk of cardiovascular
disease as he is current suffering from hypertension evidenced by his BP value of 170/100 and he
is an active smoker since the past 25 years (Al-Goblan, Al-Alfi & Khan, 2014). Smoking is a
condition that increases the likelihood of insulin resistance and it is identified as the modifiable
risk factor for T2D. Continued exposure to cigarette smoke leads to vascular damage and
endothelial dysfunction. This effect of smoking combined with elevated blood glucose can
accelerate vascular damage in Mr. Bill and increase risk of micro and macrovascular
complications (Campagna et al., 2019). Symptoms edema in the lower legs of Mr. Bill is a sign
of macrovascular complications. In addition, blood pressure level of Mr. Bill has increased
because of the effect of diabetes too. This is said because patient with diabetes suffer from
peripheral artery resistance and increased body fluid volume; both these pathophysiological
changes can contributed to T2D (Ohishi, 2018).
Nursing and clinical management of hypertensive diabetes patient
Based on the review of Mr. Bill current symptoms, vital signs and current clinical test
results, it has been found that he is a hypertensive diabetic patient. Hence, while planning clinical
treatment and nursing management of Mr. Bill, targeting both blood pressure control and blood
sugar control will be important. The first care priority will be to stabilize Mr. Bill’s blood
glucose level as his blood glucose level is fluctuating over the last 3 months and diabetes is one
of the reason behind his hypertension too. The treatment should start with the initiation of
pharmacological intervention for Mr. Bill. According to evidence based research, metformin is

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the first drug of choice for patient with T2D. Other medications prescribed to diabetic patient
include sulfonylureas, thiazolidinediones, insulin and meglitinides (Chaudhury et al., 2017)).
Metformin is a class of biagunide drug that is most common prescribed to diabetes patient with
overweight or obesity issue. It controls blood sugar level by controlling body’s response to
insulin (Nasri & Rafieian-Kopaei, 2014). Mr. Bill had started with this drug too. Initially, he
used to take 500 mg orally twice daily and this was increased to 1000 mg oral twice daily.
Despite using the drug, his blood glucose level has not stabilized. This might be due to little
changes in activity and diet patterns. Nasri and Rafieian-Kopaei (2014) acknowledge that
metformin should be taken with diet and exercise change to achieve therapeutic effect. As no
therapeutic effect has been achieved for Mr. Bill using metformin, there is a need to initiate
combination therapy with two oral antidiabetic agents (Chaudhury et al., 2017). Metformin can
be combined with any beta blockers, as it is a useful adjunct when any combination therapy is
recommended to achieve target blood pressure in patients like Bill (Guerrero-García & Rubio-
Guerra, 2018).
The second clinical management that is important for Mr. Bill is to control his blood
pressure and this is important because if it is not controlled, he will be at risk of other ailments
too. The nursing consideration that will be important is to regularly monitor blood pressure level
of patient and make changes in the diet of patient. Evidence based guideline suggest that blood
pressure of diabetic patient should be regularly measured during each clinical visit and
hypertensive diabetic patient should be encouraged to monitor blood pressure at home (De Boer
et al., 2017; Better Health Channel, 2020). In addition, clinical management of hypertension
needs to be done with the implementation of pharmacological drugs like angiotensin converting
enzyme inhibitor (ACE inhibitor), angiotensin receptor blockers and diuretics. According to

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Marín-Peñalver et al. (2016), the advantage of using ACE inhibitor is that it can prevent
progression of diabetic kidney disease. Mr. Bill has been found to show risk of renal impairment
and this is evidenced from his glomerular filtration rate (GFR), urea and serum creatinine value.
Hence, initiatin ACE inhibitor as early as possible can be useful in reducing any risk to kidney
function. GFR is biochemical marker for renal function and disturbance in GFR is seen during
onset of diabetes because of the increase in size of the kidney (Dabla, 2010; Weil et al. 2019).
Hence, initiating the above pharmacological intervention can protect Mr. Bill from future risk of
diabetic nephropathy as well as cardiac disease due to hypertension.
Third most important care priority for Mr. Bill is to implement lifestyle intervention. This
is very important because his detailed clinical history indicates that he is engaged in much
negative health behaviour. Some of the behaviour that is linked to poor lifestyle for Mr. Bill
includes history of daily smoking for 25 years, history of heavy alcohol use, sedentary lifestyle,
obesity and poor diet. The effect of obesity and smoking has been already discussed before. The
adverse effect of alcohol use is that it can further deteriorate blood glucose level of diabetic
patient. Hence, it was good that Mr. Bill quit drinking after 1 year of his diagnosis. In case of
lifestyle intervention, the first step will be to engage in diet modifications so that Mr. Bill gets to
eat health food and maintain a healthy weight (Better Health Channel, 2020). A diet chart can be
planned for Mr. Bill so that he gets to eat adequate amount of fruits, vegetables, whole grains and
saturate fat each day. In addition, sodium restriction will be extremely necessary to control his
blood pressure. Nutriation advice by professional dietician is recommended by evidence based
guidelines too. Diet changes will have positive effect on weight outcome of the client too as
healthy balanced diet would control intake of total calories and carbohydrate. This would
eventually lead to weight loss (Chaudhury et al., 2017). To achieve long term glycemic control,

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it will be important to engage Mr. Bill in exercise too. As he is an elderly client, physical
exercise regimen should be planned as per his age and physical capacity. This is because muscle
mass and strength decrease with age. Mild physical exercise may be appropriate for Mr. Bill. He
needs to be supported in ceasing smoking too to ensure that he leads a healthy life (Marín-
Peñalver et al., 2016).
Conclusion:
From the analysis of clinical management of Mr. Bill, a hypertensive diabetic patient, it
can be concluded that both family history and environmental factors like diet, obesity, physical
inactivity and smoking plays a crucial role in the cause of diabetes. Diabetes is a condition that
leads to beta cell dysfunction and peripheral insulin resistance. The risk of diabetes complication
increases with poor blood glucose control and hypertension. Hence, to reduce complication and
stabilize blood glucose level of Mr. Bill, pharmacological interventions and lifestyle intervention
was considered important to promote his health. All care plans and exercise regimented should
be planned as per the age and medical history of clients too.

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