Clinical Reasoning Cycle: Managing Peter Mitchell's Diabetes & Obesity

This case study focuses on Peter Mitchell, a 52-year-old male with poorly managed type 2 diabetes, obesity, ventilation syndrome, and sleep apnea. The analysis employs Levett-Jones' clinical reasoning cycle to prioritize nursing care, addressing his prolonged diabetes and associated hypertension, as well as his overweight condition due to lack of physical activity and improper diet. The assessment involves collecting cues related to his medical history, current symptoms, and social factors, leading to the identification of key nursing priorities. Interventions include medication management, dietary adjustments, and lifestyle modifications, with the aim of improving his blood glucose levels, blood pressure, and overall well-being. The study also emphasizes the importance of addressing Peter's depression and social isolation through counseling and motivational therapies. The effectiveness of the interventions is evaluated through monitoring anthropometric measurements, blood glucose levels, and other relevant health indicators.

Running head: CASE STUDY ON PETER MITCHELL
Case Study on Peter Mitchell
Name of the Student
Name of the University
Author Note

1CASE STUDY ON PETER MITCHELL
Prioritization of care in severe patient healthcare conditions is the effective
mean using which healthcare professionals could understand the patient situations
which should be targeted to provide them with rapid and effective treatment (Morley
et al., 2014). In this aspect, the Levett- Jones clinical reasoning cycle helps to identify
the patient crucial conditions and then by collecting the cues identifies the priority
areas upon which action plan related interventions should be applied (Giger, 2016). In
this essay, the prioritisation of nursing care for Peter Mitchell has been discussed
with the application of clinical reasoning cycle of Levett Jones. It is identified that
Peter is suffering from poorly managed diabetes (since last 9 years) and extreme
overweight due to which secondary health complications such as depression, social
isolation, sleep apnoea has been acquired. Hence, the primary aim of the essay would
be using the clinical reasoning cycle and its steps to target two nursing priorities for
the patient such as his prolonged diabetes and associated hypertension and his
overweight condition due to lack of physical activities and improper diet.
Assessing the condition of patient is the primary steps of the Levett Jones
clinical reasoning cycle, as through this the healthcare professional would be able to
identify the current or past patient condition that could lead to present healthcare
complication. From the case scenario, it is observed that, Peter Mitchell is 52 year old
male and he is suffering from diabetes type 2, obesity ventilation syndrome and sleep
apnoea. Peter was admitted to the medical ward along with symptoms like increased
hunger, shakiness, diaphoresis, high blood glucose level and difficulty in breathing. From the
information it is also observed that, he is regular smoker for last 30 years. As he is obese, in
his previous admission he was suggested high protein diet for reducing his weight. However,
he never wanted to do any exercises as he thinks it is very difficult for him. A physiotherapist
also instructed him to do light exercises which he had to perform continuously in his house.
From the social history of Peter, it was noted that, he was jobless and after losing his jobs,
he had gained more weight. Due to his weight, he also faced difficulties to find a new job.
Therefore, he lived alone in his house as his two sons seldom visited their father.
The second step of clinical reasoning cycle is to collect important cues from
the provided patient considerations so that using those cues healthcare professionals
could easily process them to develop healthcare priority for the patient. After
assessing the Peter’s case study, it can be said that, the community nurse should work
along with a dietician, diabetes specialist and with a doctor specialized in respiratory
problems (Atlantis, Fahey & Foster, 2014). As he was facing breathing difficulties, the
community nurse should also collect information about the medicines that Peter was taking.
Along with this, it is the duty of the community nurse to collect information about the blood

2CASE STUDY ON PETER MITCHELL
pressure, blood glucose level, height, weight of Peter. Along with this, in order to assess the
respiratory system of Peter, the nurse should collect information about the nicotine
dependency by using the test for Nicotine dependence (Grant et al., 2014). For assessing
the sleep apnea condition of the patient, the nurses can perform specific tests for it. As the
patient is obese in nature, cardiovascular assessment is required as obesity is related to the
cardiovascular problems.
Processing the collected cues to determine nursing priority for the specific
patient is the next step of the Levett- Jones clinical reasoning cycle and application of
these ensures that healthcare professionals would chose care priorities depending on
the patient concerns and their needs. After collecting cues of Peter’s healthcare
condition, it was seen that his one healthcare complication is connected to another
complication. Peter is suffering from diabetes since 9 years and due to his prolonged
healthcare complication he has lost all his hope from the care process and it has
increased his mental illness, depression and stress. Further he is observed affected
with social illness due to his increased depression and hypertension. As Peter has
symptoms of hypertension the nurse would continue the process of treating diabetes as
diabetes induced insulin resistance can cause aggravation of blood glucose level and also
promote the accumulation of lipid into the endothelial layer of the blood vessels which can
promote the hypertension (Blum et al., 2014). The overweight condition of Peter indicated
that, he had high BMI level than normal and this is also another promoting factor of
cardiovascular disease and diabetes. Therefore, the Fagerström Test will help the
community nurse to understand the present attempts of Peter for smoking cessation as
smoking is one of the key factors of enhancing the risk of hypertension and cardiovascular
disease and it should be looked after in an urgent manner. The diabetes assessment will
allow the community nurses to examine the obesity and diabetes management status of
Peter and in various studies; it is observed that obesity can alter the breathing pattern,
insulin resistance and alteration in sleeping habits (Hakim, Kheirandish-Gozal & Gozal,
2015). A dietary assessment will help the community nurses to fix the dietary pattern of
Peter and it will also help in managing diabetes and cardiovascular disease of Peter.
The community nurse then identify the Peter’s problem that are high level of blood
glucose levels, hypertension, hyperglycaemia, hyperlipidaemia. The high of BMI of Peter will
encourage to start the diagnosis of obesity and this abnormal condition will indicating more
complicated situation of cardiovascular disease and hypertension. Along with this, the
abnormal nursing diagnosis of cardiovascular disease will promote the risks of cardiac
arrhythmia and tachycardia.

3CASE STUDY ON PETER MITCHELL
Then the nurse will establish the goals for the management of Peter’s
condition based on the priority of care as Levett- Jones clinical reasoning cycle helps
the nursing professionals to work on the found nursing priorities so that effective
care could be provided to the patient. The primary concern of Peter is the obesity and
diabetic condition of Peter. Moreover, due to his obesity, he also has the risks
metabolic and cardiovascular complication (Bastien et al., 2014). Therefore it would
one of the nursing goals or priorities of the patient’s healthcare. Further, his
increased hypertension leads to specific healthcare complication. Therefore, the
second nursing goals should include the management of diabetes and the associated
hypertension. All the goals should be achieved within 2 weeks of implementing the
plans.
The first priority of care is the management of diabetes and hypertension and
as a part of this, the nurse should continue the current medicines that are metformin,
novomix insulin. Metformin is used for the management of hyperglycaemia by reducing the
hepatic glucose production. On the other hand Novomix is the external insulin that helps in
combating against the insulin resistance. On the other hand lisinopril is used as an effective
medicine for treating hypertension and other cardiovascular disorders by restricting the
angiostenin-converting enzyeme (ACE) activity (Dworacki et al., 2015). Peter is also given
Nexum that is a proton pump inhibitor and it can reduce the gastric acid production. The
nurse also should monitor the blood pressure and blood sugar level in a regular manner in
order to identify the progress of the disease management (American Diabetes Association,
2015). In addition, the nurse may work cooperatively with a cardiologists, diabetes
specialists so that additional assessments for cardiovascular problems and diabetes can be
managed accordingly. Therefore the community nurse can take opinion from the
gastroenterologists to manage the metabolic problems of Peter.
The second priority of care is the management of obesity and as a part of this,
the community nurse may work along with the dietician whop will fix the diet of Peter and
that should be comprised of low in sugars and high protein. Along with this, the diet must
contain high fibres carbohydrate and antioxidants as these diet practice can improve the
insulin sensitivity and stabilize the blood glucose level (Tangvarasittichai, 2015). In addition,
the nurse may have to work with a fitness experts in order to achieve the goal of fitness for
Peter. The fitness expert can recommend few mild exercises and other physical activities so
that the joint flexibility of Peter will improve and along with this his glucose metabolism will
improve due to increased muscle activity. In order to assess the physical health condition of
Peter, the nurse may use anthropometric measurements. Therefore, in order to manage the

4CASE STUDY ON PETER MITCHELL
depression and loneliness of Peter, the nurse may consult a counsellor by using motivational
therapies so that Peter can be hopeful about his life.
The nurse can examine the effectiveness of the treatment by monitoring the
anthropometric measurements, blood glucose levels, level of hyperglycemia, status of
hypertension, and body weight of the patients as these are the risk factors of the diabetes.
After that, the nurse can evaluate the smoking behaviour of the patients by using the
Fagerström Test as it will give the opportunity to assess the nicotine dependency of patient
(Niddes et al., 2014). Then the nurse then, should evaluate the sleep apnoea by using the
STOP BANG questionnaire as it is associated with the obesity and smoking. The data of
cardiovascular problems should also be evaluated in a regular manner (Chung, Abdullah &
Liao, 2016)
Hence, in conclusion, it could be said that, I was able to identify the two
nursing priorities which are crucial for healthcare condition of Peter and i was able to
understand the way healthcare complications are associated to each other. I was able
to successfully apply the anthropometric management as a part of the obesity
management. However, I understood the fact that I have lack in knowledge of
association between patient’s disease condition and psychological condition of the
patient. Hence I need acquire more knowledge about the relationship of metabolic
disorders, lifestyles so that in future I can handle such situations in a better manner.

5CASE STUDY ON PETER MITCHELL
References
American Diabetes Association. (2015). Standards of medical care in diabetes—2015
abridged for primary care providers. Clinical diabetes: a publication of the American
Diabetes Association, 33(2), 97.
Atlantis, E., Fahey, P., & Foster, J. (2014). Collaborative care for comorbid depression and
diabetes: a systematic review and meta-analysis. BMJ open, 4(4), e004706.
Bastien, M., Poirier, P., Lemieux, I., & Després, J. P. (2014). Overview of epidemiology and
contribution of obesity to cardiovascular disease. Progress in cardiovascular
diseases, 56(4), 369-381.
Blum, K. S., Karaman, S., Proulx, S. T., Ochsenbein, A. M., Luciani, P., Leroux, J. C., ... &
Detmar, M. (2014). Chronic high-fat diet impairs collecting lymphatic vessel function in
mice. PLoS One, 9(4), e94713.
Chung, F., Abdullah, H. R., & Liao, P. (2016). STOP-Bang questionnaire: a practical
approach to screen for obstructive sleep apnea. Chest, 149(3), 631-638.
Dworacki, G., Urazayev, O., Bekmukhambetov, Y., Iskakova, S., Frycz, B. A., Jagodziński,
P. P., & Dworacka, M. (2015). Thymic emigration patterns in patients with type 2 diabetes
treated with metformin. Immunology, 146(3), 456-469.
Giger, J. N. (2016). Transcultural nursing: Assessment and intervention. Elsevier Health
Sciences.
Grant, J. E., Odlaug, B. L., Chamberlain, S. R., Potenza, M. N., Schreiber, L. R., Donahue,
C. B., & Kim, S. W. (2014). A randomized, placebo-controlled trial of N-acetylcysteine
plus imaginal desensitization for nicotine-dependent pathological gamblers. The Journal
of clinical psychiatry, 75(1), 39-45.
Hakim, F., Kheirandish-Gozal, L., & Gozal, D. (2015, June). Obesity and altered sleep: a
pathway to metabolic derangements in children?. In Seminars in pediatric neurology(Vol.
22, No. 2, pp. 77-85). WB Saunders.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
Clinical educators' perceptions. Nurse education in practice, 18, 73-79.
Messner, B., & Bernhard, D. (2014). Smoking and cardiovascular disease: mechanisms of
endothelial dysfunction and early atherogenesis. Arteriosclerosis, thrombosis, and
vascular biology, 34(3), 509-515.

6CASE STUDY ON PETER MITCHELL
Morley, J. E., Caplan, G., Cesari, M., Dong, B., Flaherty, J. H., Grossberg, G. T., ... & Martin,
F. (2014). International survey of nursing home research priorities. Journal of the
American Medical Directors Association, 15(5), 309-312.
Nides, M. A., Leischow, S. J., Bhatter, M., & Simmons, M. (2014). Nicotine blood levels and
short-term smoking reduction with an electronic nicotine delivery system. American
journal of health behavior, 38(2), 265-274.
Tangvarasittichai, S. (2015). Oxidative stress, insulin resistance, dyslipidemia and type 2
diabetes mellitus. World journal of diabetes, 6(3), 456.