Nursing Case Study: Peter Mitchell and Chronic Illness Management

This essay presents a nursing case study of Peter Mitchell, a 52-year-old patient admitted with poorly controlled diabetes, obesity, sleep apnea, hypertension, and depression. The essay utilizes the clinical reasoning cycle to analyze the patient's situation, including his medical history, vital signs, and social factors. The analysis identifies obesity and uncontrolled diabetes as the primary health issues, leading to the establishment of two care priorities: weight reduction and blood glucose control. The essay proposes both pharmacological interventions, such as orlistat, metformin, and anti-hypertensive medications, and non-pharmacological interventions, including lifestyle modifications like diet and exercise, and psychological support for depression. The importance of regular monitoring and reflection on the care process is also highlighted, emphasizing the need for a patient-centered approach to improve Peter's health-related quality of life.

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Case Study-Peter Mitchell
Nursing care for chronic illnesses involves influence from multiple factors. In order to
ensure safe and high quality care the nurse must ensure that the patient needs and the clinical
needs are met. It can be ensured by the prioritisation of care and it is considered to be the integral
part of the daily nursing practice (Harrison et al., 2017). The essay deals with Peter Mitchell
presented with the uncontrolled diabetes and obesity. The aim of the essay is to manage the chronic
illness integrating various principles. Applying the clinical reasoning cycle the main health issues of
Peter will be identified, and two priorities of care will be discussed. According to Levett-Jones,
clinical reasoning involves collection of cues, followed by information processing, understanding the
health problems of the patient, implementing the interventions, evaluating the outcomes and
reflecting on learning process (Barker, Linsley & Trueman, 2016).
The first step in clinical reasoning process is taking into consideration the patient’s
situation and it involves listing of facts, objects or people (Dalton et al., 2015). Peter Michell, (52
years) is presented to medical ward with poorly controlled diabetes. He is troubled with sleep
apnoea and obesity ventilation syndrome. For cues and information, the nurse must review the
current information from the exiting handover, and asses for collecting new information (Barker,
Linsley & Trueman, 2016). On obtaining information from the clinical handover, it was found
that patient has history of diabetes since 9 years; he has morbid obesity, hypertension, depression
since three months, apnoea and Gastro oesophageal disease reflux disease. The patient is
smoking since last 30 years. Social appears to be poor as he lives alone and his children rarely
visit him. He is unable to cope up with his weight gain. His diabetes intervention, insulin led
him to leave job. He is surviving only on government benefits. He avoids socialization owing to
his illness. He appears to be motivated to lose weight and is currently under medication. As per

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the previous assessment the Peter has HR 102 Bpm, BP 180/92mmHg, RR 23 Bpm, and Sp02 95%,
Obesity, blood pressure, hypertension, and diabetes may be interrelated as per knowledge
pathophysiology. The vital signs and symptoms demonstrated the risk of heart diseases
(Koolhaas et al., 2017).
Processing the collected information is important to identify the main heath issue of the
patient. This part of the clinical reasoning involves analysing the data to understand the signs and
symptoms of the patients and relate with the cues to identify the relationships (Barker, Linsley &
Trueman, 2016). It will help predict the necessary clinical outcomes in Peter. The patient has
weight 145kgs and height 170cms, that can be calculated to have BMI around 50.2. A BMI of 30
or less than 30 is normal and above this range is considered obesity. The patient presenting
ventilation syndrome and apnoea may be related to obesity. According to Castro-Añón et al.
(2015) obesity disturbs the breathing process resulting low blood oxygen level and buildup of
carbon di-oxide. It may have caused the ventilation syndrome. It affects sleeping process due to
episodes of shallow breathing causing apnoea. People with excess weight have soft tissues in
mouth and throat that may cause obstruction of airway during sleep. Smoking also causes apnoea
through airway obstruction (Kent et al., 2015). It requires immediate intervention to prevent
further deterioration.
Patient history of hypertension is due to both obesity and diabetes. Hypertension is
known as high blood pressure. The normal BP should be 120/80 and the patient has 180/92.
Increase in fatty tissues in the body with weight gain increases vascular resistance and pressure
on arteries. It causes the heart to pump more blood. Obesity is known as the major cause of type
2 diabetes. Obesity increases the insulin production to compensate the blood sugar level. It
results in diabetes. Diabetes causes arthrosclerosis, thereby increasing blood pressure. It is the

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risk factor for stroke, and kidney damage (Koolhaas et al., 2017).The patient has high heart rate
that is 102 bpm which is greater than the normal 100 bpm. The respiratory rate of the patient is
23 bpm which is greater than the normal 12-20 bpm. The increased respiratory and heart rate
may be due to excess adipose tissues that restricts the movement of chest muscle and diaphragm.
The increase in blood pressure, heart rate and respiratory rate, may lead to heart failure. It is also
the risk factors for collapsibility of pharyngeal tract (Lycett et al., 2015).
Depression in the Peter may be associated with illness and deterioration as well as social
isolation. Stresses due to illness, smoking and social isolation are known to elevate depression
(Snoek et al., 2015). Further, the gastro oesophageal disease reflux in patient is also associated
with obesity. Lower oesophageal sphincter in obese people is displaced due to high intra-
abdominal pressure. It results in increased gastro-oesophageal gradient. Obesity with diabetes
further worsens this disease by damaging the nerves that is neuropathy. It may be improved by
better glycemic control. Diaphoresis is also common to both obesity and diabetes (Punjabi et al.,
2015). It can be concluded that obesity and diabetes are the major health issue of the patient.
In order to establish the nursing goals, it is important to identify the patient problems by
synthesising facts and inferences (Barker, Linsley & Trueman, 2016). Based on the above
analysis, the main issues identified are obesity due to excess weight and diabetes due to poorly
controlled blood glucose level. However, obesity is the root of all the complications. The
symptoms presented by Peter such as diaphoresis, shakiness and other deviation in vitals signs
are all common to obesity and diabetes. These symptoms require immediate intervention as there
is increasing risk of heart failure, liver, kidney damage. Weight gain increases obesity and
diabetes, which increases the appetite and further weight gain. The symptoms of both the
diseases are interrelated like a vicious cycle. Adequate nursing plan will help decrease the

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comorbidities and improve the quality of life. Taking action plan to reduce weight and glucose
control will help Peter improve his social life and overcome depression. It will help him better
participate in his activities of daily living.
Based on the analysis two health priorities are identified to develop appropriate nursing
actions. The two health issues in Peter are obesity due to excess weight gain, and uncontrolled
diabetes. Reducing weight and controlling glucose level will eventually improve all the
associated complications and are two priorities of care. Appropriate nursing action plan is
developed to fulfil the two nursing priorities of care. Actions are based on the evidence and
include both pharmacological and non-pharmacological interventions. The non-pharmacological
interventions are lifestyle interventions.
To fulfil the first priority, the patient may be administered with the orlistat as it
effectively decreases the absorption of dietary fat by 30% (Yanovski & Yanovski, 2014). It also
improves sensitivity to insulin. The patient will be educated to lose weight and engage in
exercises. The benefits and implications will be explained to ensure compliance to the treatment.
It will be followed by collaboration with dietician to develop effective weight reduction and diet
plan for Peter (Sharma & Lau, 2013). The plan will include weight loss protocol with weekly
target. The patient may be recommended to intake high protein diet and low fat food. It will help
decrease cholesterol (Franz et al., 2015). Further, patient will be engaged in weight reduction by
exercise program. It may be aerobics or brisk walking, to help manage the sugar level. Peter can
participate for five days in a week for 30 minutes in swimming (Koolhaas et al., 2017).
To fulfil the second priority, the nurse may administer the glucose lowering tablets such
as metaformin. It is a glycosidase inhibitor. It is also helpful to reduce weight as well. Alongside

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insulin may be administered. The dosage may be adjusted to prevent hyperglycemia. In addition
the patient may be administered with the anti-hypertensive medication to control high blood
pressure such as metaprolol. It will prevent the risk of heart failure (Yang et al., 2018). The nurse
may enhance self care in Peter by educating him about the self care. He may be trained to self
monitor glucose. Educating patient about effect of smoking on diabetes, will motivate Peter to
accept healthy behaviour (Lycett et al., 2015). He will be better able to manage the diabetes and
obesity complications (Franz et al., 2015). Also he has depression, so he will be referred to
psychiatrist. It will help Peter stop smoking, cope with weight loos interventions and overcome
depression (Baumeister et al., 2014).
After action plan, evaluating the efficacy of the clinical outcomes is important part of
nursing care that helps achieve desired goals (Dalton Gee & Levett-Jones, 2015). The patient
may be monitored for any sign of ketoacidosis, as it may lead to death in untreated condition.
Peter’s weight should be monitored regularly along with other vital signs. It includes his blood
pressure, respiratory rate and oxygen saturation. Considering the medication, it may be effective
to monitor hyperglycaemic condition. The patient will be monitored for diet plan adherence and
exercise program to make modifications (American Diabetes Association, 2015). Reflection on
the care process seems that it may be challenging for Peter to follow the dietary
recommendations. I will support him through motivational therapy and involve in group
discussions. It will improve social life and minimise stress (Baumeister, Hutter & Bengel, 2014).
In conclusion, the case study helped understand the clinical reasoning process. It allows
nurses to design goal driven care plan for the chronic condition. Applying clinical reasoning
cycle, the care plan for Peter is designed based on evidence. The essay helped gain valuable
insights into prioritisation of care by analysing the health issues obesity and diabetes. The

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interventions were targeted to two priorities of care that are weight reduction and control glucose
level. The interventions will help improve peter’s health related quality of life.

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