Mrs. Jones, 55 Years Old Patient, Case Study Example

Analysis Using ‘ADPIE’

A case analysis using ‘ADPIE’ involves the sequential steps of assessment, diagnosis, planning, implementation and evaluation which are the essential parts of a wholesome nursing process which can be applied universally to patients exhibiting similar symptoms and laboratory findings. In case of our current patient, Mrs. Jones we can apply the process in the following manner:

Assessment

The initial assessment is done by the clinical observation on presentation where the patient’s existing ailments are identified. History taking which includes family history as well the sequence of events leading to the presented symptoms are observed and noted down. A paper based and appropriately sorted database of the patient’s medical history and the current symptoms needs to be prepared immediately as a part of the documentation process (www.crnbc.ca). Mrs. Jones has come to the hospital with the primary complaint of blurred vision which is not amenable to relief by wearing glasses. Her disclosure of being hypertensive as well as diabetic serves to induce the immediate suspicion of diabetic retinopathy (www.nei.nih.gov).

The vital aspects about Mrs. Jones can be enumerated as follows

1. A middle aged (55 years), 5’ 2’ tall hypertensive, diabetic female with obvious obesity suggested by her currently observable 170 lbs body weight.
2. Family history of early deaths of her father and brother due to heart attack are suggestive of genetic predisposition to hypertension and obesity. Her mother’s diabetic status also suggests a genetic link for diabetes.
3. The high blood pressure and blood glucose levels upon presentation at the clinic are suggestive of the chronic nature of her condition. Besides her history reveals a positive diagnosis of hypertension as well as type 2 Diabetes in the past.
4. She is already on an antihypertensive regimen which includes the diuretic, Lasix, The ACE inhibitor Captopril in addition to the oral hypoglycemic drug Glucotrol for controlling blood sugar.

The suggested tests for Mrs. Jones include the following:

1. Examination of the eye with an ophthalmoscope for any abnormal lesions in the retina suggestive of diabetic retinopathy and further examination by angiography if recommended.
2. A fasting plasma glucose level and a glucose tolerance test are recommended.
3. Evaluation of her diet habits for investigating the role of high calorie foods.

Diagnosis

The suggestive diagnosis for Mrs. Jones is that of diabetic retinopathy due to the immediate problem of blurred vision which has persisted in the recent past. History of long standing hypertension, diabetes and her obese condition are suggestive of this diagnosis. Further confirmation can be obtained after evaluating the results obtained from retinal examination and other eye tests if recommended. The major changes in type II diabetes are the development of erratic blood glucose varying from hypo to hyperglycemia, increased predisposition for infections, peripheral nephropathy/retinopathy sometimes leading to blurred vision as well as blindness (Votey, 2008)

Planning

Based upon a confirmatory diagnosis diabetic retinopathy, Mrs., Jones needs to be put on a diet regimen which includes only the recommended calorific intake and her diabetes needs to be controlled in order to keep her plasma sugar levels at an optimum level of 80-120 mg/dL. If any abnormal changes in her retina are detected, it needs an immediate surgical intervention to prevent further damage. She needs to follow a more controlled lifestyle after the intervention which should include appropriate control of diet, incorporation of a light exercise regimen to bring down her weight and religious intake of antihypertensive and anti diabetic drugs.

Implementation

After the appropriate surgical intervention and hospital stay, Mrs. Jones needs to be put on a strict diet regimen and light exercise program to control her diabetes as well obesity to prevent further deterioration in health as she is still capable of leading a normal life. She needs to be made aware of the precarious health condition she is presently in to ensure compliance with the prescribed medication and lifestyle after discharge.

Evaluation

Mrs. Jones case is a prime example of negligence of health probably due to the fact that she lives alone and there is nobody to take care of her. She needs to be advised and trained to modify her lifestyle as well as ensure compliance with the recommended medications prescribed for her condition. Under a strict regimen she still has the chance to lead a healthy life in future. She needs to visit the hospital for periodic examination of her blood pressure and plasma sugar levels to make any necessary changes in medication as and when required.

Analysis using ‘SOAP’

While using this problem oriented method of documentation, the following components are pertinent to Mrs. Jones’ case (www.nurses.ab.ca):

Subjective: According to Mrs. Jones own observations, her immediate problem is that of blurred vision which is affecting her lifestyle in a negative manner. Otherwise she is well aware of her condition and duly complies with the intake of medications prescribed for her. Her mental alertness is impressive as she is worried about the additional cost involved in going to a specialist ophthalmologist.

Objective: The perusal of her family history and presented condition in the clinical setting suggest mismanagement of her diabetes and antihypertensive control regimens which have not been reevaluated in the recent past. She needs expert examination by an ophthalmologist to evaluate the damage to her eye, especially due to the suspicion of diabetic retinopathy which is suspected due to the presented symptoms.

Assessment: Her eyes need expert examination with the aid of an ophthalmoscope and possibly retinal angiography. Her diabetes needs to be evaluated by glucose tolerance test and it needs to be ascertained whether the present medication is effective in achieving optimum blood sugar levels for 24 hour or not. Besides this her normal blood profile needs to be evaluated for any discrepancies.

Plan: In order to tackle type II diabetes in the elderly as well as other patients, the major approach is diet restriction coupled with exercise with least reliance on pharmacological approaches as the latter can have more adverse effects in the already physiologically compromised elderly patients. Nutritional approaches in the treatment of type II diabetes usually rely on dietary fat reduction (Accurso et al, 2008). Mrs. Jones is in the need of an appropriate therapeutic intervention, surgical if needed to control further damage to her retina. After this she needs to be put on appropriate medication to control her blood sugar and hypertension. She also needs to make lifestyle changes in tune with her ailments to achieve better control of her life. She needs expert nursing as well as psychological counseling to ensure compliance with the recommendations after discharge from the hospital. She needs to visit the medical facility periodically for her health assessment.

References

Accurso, A, Bernstein R K , Dahlqvist A , et al 2008. Review Article: Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal, Accessed online Feb. 23, 2010 at: http://www.nutritionandmetabolism.com/content/5/1/9

Documentation Guidelines for Registered Nurses, online document assessed Feb. 24, 2010 at: http://www.nurses.ab.ca/CarnaAdmin/Uploads/Documentation%20for%20Registered%20Nurses.pdf

Facts about Diabetic Retinopathy, online article assessed Feb. 23, 2010 at: http://www.nei.nih.gov/health/diabetic/retinopathy.asp

Nursing Documentation, online pdf document assessed Feb. 24, 2010 at: https://www.crnbc.ca/downloads/151.pdf

Votey Scott R., 2008, Diabetes Mellitus, Type 2 – A Review,Pgs 1-24, Online article assessed Feb. 24, 2010 at: http://www.emedicine.com/emerg/topic134.htm