Case Study
Case Study-A 48 year old man with morbid obesity, poorly controlled diabetes type 2, sleep apnoea and obesity ventilation syndrome
Multiple factors influence the care of patients with chronic conditions. As a Primary Heath Care nurse, it is important that care given is prioritised based on clinical and patient needs. Prioritisation of the patient needs for care is integral to daily nursing practice. This requires integrating and collaborating different aspects of patient needs in order to maximise care activities and the effectiveness of nursing interventions.
This case study is designed to demonstrate the integration of various principles of managing care of patients with chronic conditions. Students will be expected to analyse the case scenario, identify the care needs and from the list of identified needs discuss two COMPLEX care priorities. Please refer to the subject outline and marking rubric when answering this question.
The case scenario
Michael Anderson is a 48 year old male with morbid obesity and type 2 diabetes who was admitted to the medical ward with poorly controlled diabetes, obesity ventilation syndrome and sleep apnoea. Michael was referred by his GP after he presented with symptoms of shakiness, diaphoresis, increased hunger, high BGL levels and finding it difficult to breathe when he sleeps.
On the previous admission, Michael was seen by the dietician and was commenced on low energy, high protein diet (LEHP) to help him reduce weight. His GP had previously mentioned weight loss however he had never wanted to do anything about it as it ‘seemed too hard'. Michael had also been seen by the physiotherapist and was commenced on light exercises which he was to continue at home on discharge.
Michael has been discharged home, with referral to community care unit for ongoing support and follow up, after three weeks in the medical ward to manage his weight and clinical comorbidities.
Past medical history
- Obesity (weight165kgs with a BMI of 57.09m2).
- Type 2 diabetes ( diagnosed 9 years ago)
- Hypertension, (HTN)
- Depression (Diagnosed three months ago y GP).
- Sleep apnoea
- Gastro oesophageal disease reflux disease
Social History
Michael is an unemployed male who is on financial benefits. Michael lost his job three years ago as a fork lift driver at the Moranbah coal mine in far North Queensland. Michael states that he has always been a 'biggish guy' with his ‘normal weight' sitting at around 95kg but since starting insulin and losing his job he has gained a significant amount of weight. Consequently, because of his weight issues Michael has difficulty finding work due to fatigue and feeling generally ‘uncomfortable' about his size. Michael is a divorcee who lives alone, his daughter and son live in the same state but live in different cities and rarely visit him. He is socially isolated because he is embarrassed by his size and he rarely goes out. Michael is also finding it increasingly hard to perform activities of daily living (ADL). Michael realises that he is in the prime of his middle age life and he wants to lose weight.
Current Medication
- Insulin novamix 30/70 DB (20 units mane and 10 units nocte)
- Novarapid sliding scale
- Metformin 500mg BD
- Lisinopril 10mg daily
- Nexium 20mg daily
- Metoprolol 50mg BD
- Pregabalin (Lyrica) 50mg nocte
Last observation on discharge
- Weight 165kgs
- BP 180/92
- RR 23
- HR 102
- Sp02 RA 95% on Room Air (R/A)
Part -2
Case Study-Parkinson's disease
Case scenario: Diana Harrison is a 64 year old female newly diagnosed Parkinson's patient who you have been asked to visit.
Multiple factors influence the care of patients with chronic conditions. As a Primary Heath Care nurse, it is important that care given is prioritised based on clinical and patient needs. Prioritisation of the patient needs for care is integral to daily nursing practice. This requires integrating and collaborating different aspects of patient needs in order to maximise care activities and the effectiveness of nursing interventions.
This case study is designed to demonstrate the integration of various principles of managing care of patients with chronic conditions. Students will be expected to analyse the case scenario, identify the care needs and from the list of identified needs discuss two COMPLEX care priorities. Please refer to the subject outline and marking rubric when answering this question.
The history you have been provided is as follows:
Diana is an active semi-retired part time as a relief high school science teacher. She is married to Oliver with three adult children, all of whom live out of home and have done so for a period of time-Vanessa 35 years old-3 children under 10, Adam 33 years old-new born baby and Anton 30 years old-1 year old. Each of the adult children is located interstate and has young family as indicated. Diana had previously participated in many outdoor activities with her husband and her hobbies include bushwalking, cryptic crosswords and gardening.
Shortly after returning to relief work after the Christmas period Diana noticed that the fingers on her right hand began to shake with a very slight tremor and her gait became very unsteady. The tremor in her hand seemed to be worse when she sat down at night and in bed when she was resting. Leading up to and over the Christmas period Diana began to notice that she was very fatigued and increasingly forgetful. This was becoming more noticeable and problematic as the tremor did not subside and Diana felt she was becoming clumsier. Diana spoke with her husband and they concluded it was probably due to a very busy and stressful time over the recent Christmas period with all her adult children and grandchildren staying for the week between Christmas and New Year's. Diana nevertheless made an appointment with her GP for the following week to discuss her ‘odd' symptoms with her GP.
During her first week back at work in late January Diana felt so fatigued that she was concerned she would ‘go to sleep in class!' and the tremor in her right hand persisted. Diana was watching TV after a busy day at work and when she went to stand up she found herself falling back onto the couch and she felt as if the ‘world was spinning', both her hands felt numb and she could not stop shaking. Diana became extremely emotional and could not speak properly. Diana's husband called an ambulance as he was concerned perhaps she was having a stroke. Diana was seen by a medical officer, admitted and referred to a neurologist for assessment.
Diana spent three weeks in hospital and a provisional diagnosis of Parkinson's disease was made. To rule out any other neurological conditions a series of investigations was conducted including an MRI and PET scan was conducted. Both imaging investigations returned a normal result. Following this and based on the neurological physical exam and symptom history a firm diagnosis of Idiopathic Parkinson's disease was made.
Diana was discharged into the care of her husband with two months of sick leave from her job. Diana found that once the provisional diagnosis was made previous symptoms that she had concluded were due to stress or fatigue began to make sense.
Symptoms experienced
- Fatigue for 12/12 -Diana was increasingly fatigued at work struggling to make it through the day
- Bradykinesia 6/12-She would find that setting up her science classroom she would drop things and her hands felt ‘stiff'
- Tremor 6/12-Increasing tremor in her left hand that she noticed mainly at rest
- Emotional outbursts 12/12 intermittently-Diana would become overly emotional at forgetting things or dropping items at work and at home
- Unsteady gait 6/12-Tripping and stumbling with no obvious cause
Discharge Summary
- Diana Harrison is a 64 year old female
- Admitted via A&E with a history of:
o Pronounced tremor in left hand-patient describes worse when sitting
o Global bradykinesia-shaking and slow response to requests
o C/O increasing fatigue and ‘sleepy' episodes during the day when working
o Feeling ‘blue' and sad on and off for the past 12 months
Medical history
- High cholesterol-Lipitor
Surgical history
- 1 caesarean birth 1980
- Tonsillectomy as a child
Other
- Fit and healthy, works as relief high school science teacher
- Admitted 14/01/2016
- Neurological, muscloskeletal, cardiovascular assessment
- Excluded neuro pathology-CT and PET scan clear Provisional diagnosis: Parkinson's disease
Discharged 03/02/2016
Primary diagnosis of Parkinson's disease
Medications
- Lipitor 25mg mane
- Dopamine releaser-Amatadine HCL-5 mg daily
- Dopamine agonists-Carbergoline- 0.25mg BD
- Dopamine replacement- Levodopa 10mg TDS
- MAO-B inhibitors-Selegiline -25mg patch changed daily
- Maxolon for nausea 10mg prior to meals