Setting the scene
Michael’s holistic assessment by the General Practitioner (GP) today indicates:
• Weight 140kg (up from 135kg six months ago)
• Height 176 cm
• BP 160/70; HR 88
• Temp 37.7
• BGL: 9.0mmol
• Pain in his knees and ankles (rated as 4/10 on pain scale) – patient states this makes it difficult to do any exercise
• Laboratory testing indicated that chemistries, Blood Urea Nitrogen, creatinine, liver function tests, thyroid function tests and urine microalbumin are all normal
• Glycated Haemoglobin (HBA1c) was 7% for one year but is now 9%
• LDL: 2.2 mmol/L
• HDL: 1.6mmol/L

Previous history:
• 9-year history of diabetes
• Obesity
• Depression
• Hypertension
• Arthritis
Surgical history:
• Trans-urethral resection prostrate
• Cholecystectomy
Nurofen, Metformin, Coversyl, Atorvastatin, Celexa

Michael lives on his own after losing his wife five years ago. He has learned some cooking skills and prepares most of his meals although takeaways are an easy option for him during his work day as a taxi driver. He has good family support from one daughter, one son and two grandchildren who live close. Michael has little social engagement other than his children and often chooses not to leave the house.
Epidemiology / pathophysiology of disease processes
The National Health Priority Areas of Diabetes Mellitus, Obesity and Mental Health were established with the aim of improving health outcomes in these areas. Review your modules, references and extended reading regarding these National Priority areas.
Diabetes is a chronic condition marked by high levels of glucose in the blood caused by either the inability to produce insulin or by the body not being able to use insulin effectively. The main types of diabetes are Type 1, Type 2 or Gestational. In 2014-2015 approximately 1.2 million people (6% of Australian adults) had diabetes, based on self-reported data. This is a growing issue with increasing hospitalisations due to diabetes and one in ten Australian deaths having diabetes as an underlying and/or associated death.
In 2011-2012, almost 2 in 3 (63%) of Australian adults are overweight or obese. Obesity is a major risk factor for cardiovascular disease, Type 2 diabetes, some musculoskeletal conditions and some cancers, while making the management of and controlling of chronic disorders difficult.
Mental health and behavioural disorders describe a wide spectrum of disorders which can vary in both severity and duration. The most common disorders are depression, anxiety and substance use disorders and are important drivers of disability and morbidity. There is also an association between diagnosis of mental health disorders and a physical disorder with 1 in 8 (12%) of people with a 12-month mental disorder also reporting a physical condition and 1 in 20 (5%) reporting two or more physical conditions.
There is a clear bidirectional association between diabetes and mental illness. Statistics show that Australians with diabetes have a higher prevalence of poor mental health than those without diabetes. People with diabetes are more than twice as likely to have mental or behavioural problems as those without diabetes.

Your Task:

Use the Clinical Reasoning Cycle on the following pages to review the nursing priorities in relation to the care of Michael.

Gain an initial impression of your patient
Question 1:

a. What is Michael’s BMI and how is this calculated?

b. Discuss what this BMI means for Michael?

Gain an initial impression of your patient.

Question 2:

Review the anatomy and physiology of the three types of diabetes (Type 1, Type 2 and Gestational).

a. What type of diabetes do you think that Michael has? Justify the reason for your answer

Gain an initial impression of your patient.

Question 3:

Review and recall your knowledge of diabetes and the possible adverse complications that may occur.

a. List four signs and symptoms of hyperglycaemia that Michael might experience

b. Using your knowledge of anatomy and pathophysiology, explain in detail why one of these signs and symptoms could occur.

(a) Review current information
(b) Gather new information
(c) Recall knowledge (A&P, ethics, law, cultural safety)

Question 4:
Review current information: review and think about Michael’s presentation, the observations that have been carried out and what further assessment you would want to carry out now.

a. Celexa is a commonly used medication to treat anxiety and depression in adults. Describe the mode of action of this medication for Michael.

b. What should you be aware of with this medication?

c. List two side effects of the medication.

(a) Review current information
(b) Gather new information
(c) Recall knowledge (A&P, ethics, law, cultural safety)

Question 5:
A normal BGL for an adult is:

a) 2.5-3.5mmol
b) 4.0-8.0mmol
c) 5.0-10.0mmol
d) > 10.0mmol

(a) Review current information
(b) Gather new information
(c) Recall knowledge (A&P, ethics, law, cultural safety)

Question 6:

Michael has indicated that he does not follow any specific diet and takeaways are an easy option. What allied health professional would you consider referring Michael to?
Give a rationale for your answer.

 Interpret data – what does it all mean?
 It is important to consider the potential inter-relationships between diabetes, obesity and mental health issues

Question 7:

Obesity puts Michael at risk of developing what four conditions?

 Interpret data – what does it all mean?

Question 8:

Of the physical assessment on Michael – what finding is of most concern?

a. BGL
b. BP
c. Temperature
d. Pain

Discuss why this is of most concern.

Your Answer:

Synthesise all information that has been collected and processed.

Question 9:

List the three highest priority relevant nursing diagnoses for Michael. Justify your answers.

Your Answer:

What should happen to improve problems/issues and by when?

Question 10:

What are the three most important short-term goals and justify the importance for Michael’s management currently:

Your Answer:

What action/interventions will you do?

Question 11:

The GP suggests to Michael that he might need to commence insulin. List two strategies that you would suggest and educate Michael on to avoid becoming an insulin dependent diabetic.

Justify these strategies.
Your Answer:

What action/interventions will you do?

Question 12:

Being diabetic puts Michael at higher risk of healthcare associated infections and diabetic foot ulcers. Explain why this is the case?
Your Answer:

What action/interventions will you do?
 Who should be notified?

Question 13:

For Michael’s ankle and knee pain from osteoarthritis, in addition to taking the prescribed Non-Steroidal Anti-Inflammatory Drug, as a nurse you should also instruct him to:

a. Start a regular exercise program
b. Avoid all fatty foods
c. Ensure eight hours sleep each night
d. Rest the ankles and knees as much as possible to decrease inflammation.

Your Answer:

What action/interventions will you do?
Who should be notified?

Question 14:

Give a rationale for your answer to Q13?
Your Answer:

Assess the effectiveness of actions

Question 15:

List three signs and symptoms that would indicate Michael’s goals are being achieved.
Your Answer:
ssess the effectiveness of actions

Question 16:

It is important for Michael to ensure that his feet are examined regularly. Why is this?
Your Answer:

What have you learned from this experience?

Question 17:

Long-term complications of diabetes include:

a) Increased risk for high blood pressure and atherosclerosis
b) Impaired sensation in the hands and feet
c) Increased risk for heart failure
d) All the complications listed above.

Justify your answer.

Your Answer:

What have you learned from this experience?

Question 18:

Waist circumference can also be used to determine obesity. Why might this be a better measurement of obesity than BMI?
Your Answer:

What have you learned from this experience?
Question 19:

Why are patients with mental illness at risk of patient safety?
Your Answer:


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