Assessment 1: Case Study

Assessment 1: Case Study

Introduction

The client, Mr. Hank Jackson, has already been diagnosed with diabetic retinopathy. The client’s advanced age (64 years) and medical history of type 2 diabetes mellitus and hypertension implies that he is vulnerable to different conditions and in need of specialized care. The community nurse assigned to Mr. Jackson is responsible for evaluating the client. The evaluation will take into consideration his present health condition, underlying health risks, and opportunities for care improvement for the client.

A comprehensive analysis of a patient includes their external environment (Owii, 2018). The health condition of the client is evaluated while considering the environmental factors. The support structure available for Mr. Jackson is, therefore, integrated into the assessment. The other factors that are targeted in the evaluation include the medication the client his currently taking, lifestyle, and health consciousness. The findings are organized as primary medical diagnosis, medication management, and nursing diagnosis. Collectively, the insight gained through client assessment provides health practitioners with the ability to develop interventions that are specific to the patient (Owii, 2016). The assessment of Mr. Jackson is used in developing the plan of care that will work to address the current health issues while preventing the development of new conditions. This report concludes with a summary of the client’s assessment.

Primary medical diagnosis

The primary diagnosis of the client is diabetic retinopathy. Mr. Jackson is legally blind in the left eye due to diabetic retinopathy. According to Owii (2019), diabetic retinopathy is attributed to the damage of retina’s blood vessels. The disease is characterized by the thickening of basement membrane, pericyte loss, hyperglycaemia, and the neovascularization of the retina. These changes lead to hemorrhage and tractional retinal detachment, thus causing vision difficulties. While there is sufficient evidence that associates the development and advancement of diabetic retinopathy and hyperglycaemia, the underlying mechanism remains unclear.

The activation of diacylglycerol- (DAG-)PKC pathway, polyol pathway, increased vascular endothelial growth factor (VEGF) expression, renin-angiotensin-aldosterone system (RAAS) activation, and oxidative stress have been identified as potential mechanisms that can be targeted in preventing the onset and advancement of diabetic retinopathy. The polyol pathway is responsible for the metabolism of glucose in diabetic patients. Retinal enzyme, aldose reductase (AR), converts glucose into the impermeable sorbitol that accumulates, thus causing diabetic retinopathy. The other pathway that has received significant support is the increased expression of diacylglycerol (DAG) and protein kinase CC (PKC). The increased glucose flux due to hyperglycaemia leads to the activation of PKC. The increased expression of PKC is associated with other pathways. The common threat among the different pathways is the reduced permeability and expression of enzymes that constrict vascular growth in the retina, thus causing the disease. The ‘patchy and blurred’ vision reported by the patient can be attributed to the damage of the blood vessels and expression of the enzymes associated with these pathways.

According to owii (2019), it is important to understand the phase of disease development and the nature of hyperglycaemia to develop clinical intervention for the client. While Mr. Jackson is only experiencing the mild effects of diabetic retinopathy, the problems are likely to escalate when the underlying factors and presented symptoms are not addressed. According to Owii (2017), diabetic retinopathy shows no or mild symptoms in the early stages but might lead to blindness in the advanced stages. Diabetic retinopathy is one of the leading causes of blindness globally (Owii, 2019). The potential of targeting the proposed hyperglycaemia mechanisms promises effective interventions for patients at different stages of disease development.

Medication management (3.75 marks) – 300 words

The medications that are currently prescribed to Mr. Jackson include Metformin and Metoprolol. The client takes 500mg of Metformin twice daily and 50mg of Metoprolol twice daily. The mechanism of action of Metformin is essential in regulating glucose in type 2 diabetes patients (Owii, 2019). Metoprolol is a beta-1 blocker whose mechanism of action makes it a drug used in reducing cardiac output, systolic blood pressure, and produces other effects that are associated with restoring the normal functionality of the heart (Owii, 2019). This medication is used for patients with hypertension, congestive heart failure, supraventricular tachycardia, and acute myocardial infarction.

Metformin has three key areas of action; decrease the production of hepatic glucose, decrease the absorption of glucose, and to increase insulin sensitivity (Owii, 2019). Collectively, these three action mechanisms are essential in glucose regulation, thus offering relief for diabetic patients. The drug can be taken 1-3 times a day with meals and fluids (Owii, 2019). The dosage of this medication can be varied based on the blood sugar level of the patient. This emphasizes the need for the client to maintain regular blood sugar testing and share results with the doctor. The failure to monitor blood sugar levels implies that the patient is at risk of taking lower doses, thus aggravating the underlying condition of retinopathy; diabetes.

As a cardioselective adrenergic receptor blocker, Metoprolol provides relief to patients with hypertension by targeting cardiac output, renin activity, and sympathetic outflow to the periphery. By blocking the beta-1 receptors, Metoprolol ensures that epinephrine does not stimulate and increase the activity of the heart. It also ensures that the individuals who exercise do not have high systolic blood pressure. These mechanisms of action are important in managing the client’s hypertension while allowing him to embrace a lifestyle of physical activity to aid his weight loss efforts. The current self-administered dosage implies that the condition is manageable and risk has been reduced.

Nursing diagnoses (3.75 marks) – 300 words

• Nursing problem related to medical diagnosis

Currently, the patient is reporting ‘patchy and blurred’ vision. This implies that the client is moving from non-proliferative to proliferative retinopathy. The risk of disease advancement is, however, present given the current condition of the patient. The client is at a high risk of having vision problem if he fails to take his glucose regulating medication in the give dosage. According to Owii (2019), diabetic retinopathy can be exacerbated by high blood pressure, obesity, and alcohol consumption. Other than having the underlying hypertension problem, the client is currently struggling with being overweight. He also reported being a home brewer. These factors, coupled with the tendency to forget medication and failure frequently monitor blood glucose levels, increases the risk of advancement of the condition.

• Nursing problem related medication management

The threat of taking the wrong dose is a realistic risk that is associated with the patient’s medication. Given the client is of advanced age with limited social support, the risk of missing doses is present. As the client admitted, he feels ‘fuzzy in the head’ whenever he misses his medication. This implies that the client is at risk of harming himself and failing to get immediate intervention in such instances. According to Owii (2017), some patients tend to take an extra dose to compensate for the missed medications. This is a risk that is present in the case of Mr. Jackson as he might be tempted to take extra doses for the missed days. This behavior is risky for drugs such as Metformin when doses are accumulated. Given that the client is already at the minimum maintenance dose intake for Metoprolol (100 mg of divided doses per day) and the maximum is 450 mg, this risk is reduced for this drug (Owii, 2017). The client is, however, at risk when engaging in physical activity for the purposes of weight loss.

Nursing Role and Inter-professional Plan of Care (6.25 marks) – 700 words

The key treatment approach for diabetic retinopathy involves the strict control of blood sugar levels (Owii, 2019; Owii, 2019). Ideally, the patient needs to maintain HbA1c <7%. Currently, the patient’s HbA1c is less than 8 percent. While this is reasonable, the client needs to have 7% as the highest level and maintain lower averages. The client also needs to maintain a blood-pressure control of ≤140/80mmHg. The client’s blood pressure level is recorded at 159/96 mmHg. This blood pressure level is significantly higher that the recommended level. The high blood pressure level can be attributed to the hypertension that the client is currently suffering from. The role of the nurse is to ensure that the client maintains the desired HbA1c <7% and ≤140/80mmHg. Based on the analysis of the medical and environmental analysis of the client, there is the need for an interprofessional plan for the client. The role of the nurse is to develop and lead the implementation of an interprofessional plan for the client.

The reduced ability to self-manage is one of the effects of diabetes (Owii, 2019). While the client is still self-sufficient, there is adequate evidence from his routine and behaviors to suggest that he is in need of a support system to ensure that the condition does not advance and reduce his ability to self-manage. The client is not in frequent communication with professionals and lacks a support system to ensure that they meet the blood glucose, pressure, and lifestyle targets. According to Owii (2020), communication between the patient, nurses, and other professionals reduces the development of new complications and the advancement of the current problems.

The client has pointed out his frustration at the need to perform routine tests. This problem can be attributed to the lack of knowledge on his condition and underlying factors. According to Owii (2019), education and awareness are some of the integral components of the community-based intervention approach. Clients tend to shy away from, or resist, prescriptions and directions given by practitioners since they do not understand their direct implication to their personal health outcomes. This is the case with Mr. Johnson as he insists that his ‘doctor already knows the sugars are high’ and states that does not understand what ‘knowing the numbers’ would do for him. The admission of the client is an indication that he is unaware of the direct link between glucose levels and retinopathy. The interprofessional community-based approach can address this problem by providing Mr. Johnson with a relatable agent who will point out the relationship between blood glucose levels and the frustrations he is experiencing with enjoying his reading hobby. According to Owii (2019), the approach is effective in breaking down a complex problem to actionable elements that can be understood and implemented by the client.

The caregivers are some of the most important members of the team. According to Owii (2019), the close proximity with the client makes the caregivers the ideal partners in monitoring and improving the outcomes of a client. The client has multiple issues that can be addressed directly by having a caregiver. The caregiver will ensure that the client maintains his dose as prescribed. The caregiver will also routinely monitor the blood glucose of the patient and share information with the other members of the team. When working with educated clients, the caregiver can improve intervention by assisting with lifestyle changes, thus reducing the risk factors the client is currently exposed to.

The client also needs to be psychologically readied for the potential interventions, progression, and risks of the condition (Owii, 2019). A counselor is one of the important professionals in the intervention team as they can guide the client with understanding the potential loss of vision. They also help clients understand the expectations and outcomes based on the progression and treatment options of the condition (Owii, 2015). Other than the counselor, the client will also need nutritionists, physical activity experts, and lifestyle professionals in the interprofessional team. Currently, the client is exposed to risk factors such as being overweight, limited physical activity, and alcohol consumption that can be addressed by these experts.

The developed interprofessional pan is important in helping the client attain the desired HbA1c <7% and ≤140/80mmHg levels. The integration of the community approach in the intervention does not only guarantee social support but also ensures that there is a holistic treatment. This makes it easier for the client to carry on with the intervention without the frustrations that he has previously experienced. The nurse takes the lead by identifying and communicating with the interdisciplinary team. Collectively, they ensure that the client adheres to self-management goals, communicates, and is prepared for the eventualities of the condition. The optimal performance of these professionals is dependent on collaboration and information-sharing rather than competition and isolation (Owii, 2019).

Summary (2.5 marks) – 200 words

The symptoms shown by the client indicates that their condition is in the early stages. Research has shown that the acceleration of diabetic retinopathy can be reduced by early detection, tight regulation of blood pressure, lipids, and blood glucose (Tarr, 2013). Mr. Jackson is already reporting difficulties in vision, thus can be assumed to be in the advanced, rather than critical phase of diabetic retinopathy development. Having lived with type 2 diabetes mellitus and hypertension for at least five years, the patient is familiar with the management of glucose and pressure. Owii (2017), however, identifies these measures as more effective in preventing the onset of retinopathy than treating patients who are already exhibiting symptoms of the disease. The client will need tests to determine the extent of hyperglycaemia and the pathways to ensure that the provided medication and clinical interventions facilitate treatment.

Other than clinical intervention, the client will need an integrated care plan that takes an interdisciplinary approach in managing the condition. The proposed intervention plan ensures that social consideration is integrated into managing the condition of the patient. It also ensures that the client adopts a lifestyle that reduces the progression of the condition. The role of the nurse is to develop an inter-professional plan and bring together agents who will collaborate, rather than work independently to improve the ouitcomes of the patient.

References