Case Study for Care Plan  Assignment:

A retired 69-year-old man “Mr. Casey” with a 5-year history of type 2 diabetes. Although he was diagnosed 5 years ago he had symptoms indicating hyperglycemia for 2 years before diagnosis. His fasting blood glucose values of 118–127 mg/dl, which was explained to him as “borderline diabetes.” He also states he has had past episodes of nocturia with large pasta meals and Italian pastries. At the time of diagnosis, he was advised to lose 10 lbs.

Referred by his family physician to the diabetes clinic, Mr. Casey presented with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

Mr. Casey also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia. He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken OTC medications to try to control his diabetes. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control.

Mr. Casey states that he has “never been sick a day in his life.” He is retired and volunteers locally. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, Mr. Casey has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, Mr. Casey has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose.

Mr. Casey’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago.

The medical documents that Mr. Casey brings to his appointment indicate that his hemoglobin A1c(A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health.

Mr. Casey has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

• Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m2
• Fasting capillary glucose: 166 mg/dl
• Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg
• Pulse: 88 bpm; respirations 20 per minute
• Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy
• Thyroid: nonpalpable
• Lungs: clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops
• Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally
• Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

• Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
• Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
• Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
• Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
• Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
• Lipid panel
  • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
  • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)
  • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)
  • Triglycerides: 177 mg/dl (normal: <150 mg/dl)
  • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)
• AST: 14 IU/l (normal: 0–40 IU/l)
• ALT: 19 IU/l (normal: 5–40 IU/l)
• Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)
• A1C: 8.1% (normal: 4–6%)
• Urine microalbumin: 45 mg (normal: <30 mg)

Please use the attached Care Plan outline for this assignment and post in the “Drop Box” under “Instructional”.

Credit of care study to: Geralyn Spollett, MSN, C-ANP, CDE

Reference: 

American Diabetes Association. (2003, January 1). Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Retrieved from http://spectrum.diabetesjournals.org/content/16/1/32 

AFRICAN AMERICAN CASE STUDY #2 

Mr. and Mrs. Evans are an African American couple who retired from the school system last year. Both are 65 years of age and reside on 20 acres of land in a large rural community approximately 5 miles from a Superfund site and 20 miles from two chemical plants. Their household consists of their two daughters, Anna, aged 40 years, and Dorothy, aged 42 years; their grandchildren, aged 25, 20, 19, and 18; and their 2- year-old great-grandson. Anna and Dorothy and their children all attended the university. Mr. Evans’s mother and three of his nieces and nephews live next door. Mr. Evans’s mother has brothers, sisters, other sons and daughters, grandchildren, and great-grandchildren who live across the road on 10 acres of land. Other immediate and extended family live on the 80 acres adjacent to Mr. Evans’s mother. All members of the Evans family own the land on which they live. Mrs. Evans has siblings and extended family living on 70 acres of land adjacent to Mr. Evans’s family, who live across the road. Mr. and Mrs. Evans also have family living in Chicago, Detroit, New York, San Francisco, and Houston. Once a year, the families come together for a reunion. Every other month, local family members come together for a social hour. The family believes in strict discipline with lots of love. It is common to see adult members of the family discipline the younger children, regardless of who the parents are. Mr. Evans has hypertension and diabetes. Mrs. Evans has hypertension. Both are on medication. Their daughter Dorothy is bipolar and is on medication. Within the last 5 years, Mr. Evans has had several relatives diagnosed with lung cancer and colon cancer. One of his maternal uncles died last year from lung cancer. Mrs. Evans has indicated on her driver’s license that she is an organ donor. Sources of income for Mr. and Mrs. Evans are their pensions from the school system and Social Security. Dorothy receives SSI because she is unable to work any longer. Mr. Evans and his brothers must assume responsibility for their mother’s medical bills and medication. Although she has Medicare parts A and B, many of her expenses are not covered. Mr. and Mrs. Evans, all members of their household, and all other extended family in the community attend a large Baptist church in the city. Several family members, including Mr. and Mrs. Evans, sing in the choir, are members of the usher board, teach Bible classes, and do community ministry. 

Study Questions 

1. Describe the organizational structure of this family and identify strengths and limitations of this family structure. 

2. Describe and give examples of what you believe to be the family’s values about education. 

3. Discuss this family’s views about child rearing.

4. Discuss the role that spirituality plays in this family. 

5. Identify two religious or spiritual practices in which members of the Evans family may engage for treating hypertension, diabetes, and mental illness. 

6. Identify and discuss cultural views that Dorothy and her parents may have about mental illness and medication. 

7. To what extent are members of the Evans family at risk for illnesses associated with environmental hazards? 

8. Susan has decided to become an organ donor. Describe how you think the Evans family will respond to her decision. 

9. Discuss views that African Americans have about advanced directives. 

10. Name two dietary health risks for African Americans. 

11. Identify five characteristics to consider when assessing the skin of African Americans. 

12. Describe two taboo views that African Americans may have about pregnancy. 

APPALACHIAN CASE STUDY #1 

William Kapp, aged 55 years, and his wife, Gloria, aged 37, have recently moved from an isolated rural area of northern Appalachia to Denver, Colorado, because of Gloria’s failing health. Mrs. Kapp has had pulmonary tuberculosis for several years. They decided to move to New Mexico because they heard that the climate was better for Mrs. Kapp’s pulmonary condition. For an unknown reason, they stayed in Denver, where William obtained employment making machine parts. The Kapp’s oldest daughter, Ruth, aged 20, Ruth’s husband, Roy, aged 24, and their daughter, Rebecca, aged 17 months, moved with them so Ruth could help care for her ailing mother. After 2 months, Roy returned to northern Appalachia because he was unable to find work in Denver. Ruth is 3 months’ pregnant. Because Mrs. Kapp has been feeling “more poorly” in the last few days, she has come to the clinic and is accompanied by her husband, William, her daughter Ruth, and her granddaughter, Rebecca. On admission, Gloria is expectorating greenish sputum, which her husband estimates to be about a teacupful each day. Gloria is 5 ft 5 in. tall and weighs 92 pounds. Her temperature is 101.4°F, her pulse is regular at 96 beats per minute, and her respirations are 30 per minute and labored. Her skin is dry and scaly with poor turgor. While the physician is examining Mrs. Kapp, the nurse is taking additional historical and demographic data from Mr. Kapp and Ruth. The nurse finds that Ruth has had no prenatal care and that her first child, Rebecca, was delivered at home with the assistance of a neighbor. Rebecca is pale and suffers from frequent bouts of diarrhea and colicky symptoms. Mr. Kapp declines to offer information regarding his health status and states that he takes care of himself. This is the first time Mrs. Kapp has seen a health-care provider since their relocation. Mr. Kapp has been treating his wife with a blood tonic he makes from soaking nails in water; a poultice he makes from turpentine and lard, which he applies to her chest each morning; and a cough medicine he makes from rock candy, whiskey, and honey, which he has her take a tablespoon of four times a day. He feels this has been more beneficial than the prescription medication given to them before they relocated. The child, Rebecca, has been taking a cup of ginseng tea for her colicky symptoms each night and a cup of red bark tea each morning for her diarrhea. Ruth’s only complaint is the “sick headache” she gets three to four times a week. She takes ginseng tea and Epsom salts for the headache. Mrs. Kapp is discharged with prescriptions for isoniazid, rifampin, and an antibiotic and with instructions to return in 1 week for follow-up based on the results of blood tests, chest radiograph, and sputum cultures. She is also told to return to the clinic or emergency department if her symptoms worsen before then. The nurse gives Ruth directions for making appointments with the prenatal clinic for herself and the pediatric well-child clinic for Rebecca. 

Study Questions 

1. Describe the migration patterns of Appalachians over the last 50 years. 

2. Discuss issues related to autonomy in the workforce for Appalachians. 

3. Identify high-risk behaviors common in the Appalachian region. 

4. Describe barriers to health care for people living in Appalachia. 

5. What might the nurse or physician do to encourage Mrs. Kapp to comply with her prescription regimen? 

6. What would your advice be regarding each of the home remedies that Mrs. Kapp is taking? Would you encourage or discourage her from continuing them? 

7. What might the nurse have done to help ensure that Ruth would make the appointments for herself and her daughter? 

8. What advice would you give Ruth regarding the home remedies that she and her daughter are currently taking? Would you encourage or discourage their use? 

9. Do you think Mrs. Kapp will return for her appointment next week? Why? What would you do if she did not return for her appointment? 

10. Do you think that Ruth will make and keep appointments for herself and her daughter?

11. What would you do to encourage Mr. Kapp to consent to a health assessment? 

12. What additional services could you suggest to assist the Kapp family at this time? 

13. What additional follow-up do you consider essential for the Kapp family? 

14. What advice would you give Ruth regarding her daughter’s frequent bouts of diarrhea?