Overview
This case involves the assessment of the client’s problems. The case presents the client’s situations that are relevant to the assessment. In this case, the client’s profile, case study, and pertinent case study questions will be outlined. The following medical terminologies will be employed: alpha-glucosidase inhibitor, Amylin, hyperlipidemia, congestive heart failure, coronary artery disease, hemoglobin A1C level, post-prandial, BMI, diabetic nephropathy, diabetic neuropathy, and diabetic retinopathy. The data obtained from the assessment will help design a care plan for the client.
Ethnicity: Pacific Islander Lifestyle: Sedentary lifestyle and smoking
Language: English/Austronesian language Any existing disabilities: None
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Religious preference: Christianity Residence prior to hospitalization: State of Hawaii
Current medications: alpha-glucosidase inhibitor and Amylin
The client was admitted to the hospital on complain of shortness of breath. The client is currently on alpha-glucosidase inhibitor and Amylin. She is overweight and suffering from hyperlipidemia. She was also recently diagnosed with congestive heart failure. Previously, she had been taking high blood pressure drugs. She also has a history of coronary artery disease and diabetes type 2. On the assessment day, the client reported the following vital signs: blood pressure of 156/92, tachycardia evidenced by heart rate of 100 and oxygen saturation of 94%.
The assessment data revealed the following: hemoglobin A1C level of 6.9%, fasting blood glucose level of 102 mg/dL and blood sugar level of 130 mg/dL post-prandial, and hyperlipidemia evidenced by triglyceride level of 312 mg/dL. The blood test further revealed that the client’s total blood cholesterol level was 220mg/dL. Anthropometric assessment revealed a BMI of 28cm and waist circumference of 85 cm. Dietary assessment revealed that the client’s diet is high in calorie and fats but low in fruits and vegetables. Her lifestyle is also characterized by low physical activity and smoking habit.
Based on the assessment data, the care plan for the patient focused on the following: nutritional counselling to enable the her lower her calorie intake, increase her daily physical activity, and quit smoking; administration of medications for coronary heart failure and diabetes; continued monitoring of blood glucose levels and further assessment for risk or presence of complications associated with diabetes such as diabetic nephropathy, diabetic neuropathy, or diabetic retinopathy. The plan would also involve educating the client on appropriate ways of preventing herself from developing wounds since there is high risk of developing ulcers among people with diabetes (Singh, Armstrong and Lipsky, 2005). Normal BMI should be within the range of 18.5 and 24.9 (Kelly, 2006; Preedy, 2012).
Pertinent Case Study Question
- When did you start experiencing the problem?
- Have you had this problem before?
- Have you ever visited the doctor over the same problem before?
- Are you currently taking any medication?
- Do you smoke?
- What is your occupation?
- Do you visit the gym?
Glossary
Alpha-glucosidase inhibitor: This is a group of orally-ingested drugs that block enzymes that digest dietary starches. They are used to treat type 2 diabetes.
Amylin: This is a hormone that slows the emptying of the stomach. It is synthesized by beta cells in the pancreases.
Hyperlipidemia: This refers to high levels of lipids in the blood.
Congestive heart failure: This is a condition characterized by malfunctioning of the heart in terms of pumping of blood. It leads to poor supply of blood in the various body cells.
Coronary artery disease: This is a condition of the coronary artery in which a plaque grows in the artery and result into flow of blood into the various cells of the heart. It results into death of various cells of the heart.
Hemoglobin A1C level: This refers to the percentage of hemoglobin coated with glucose.
Post-prandial: This means two hours after a meal.
BMI: The abbreviation for Body Mass Index. It refers to the ratio of body weight in Kg to the square of height in meters.
Diabetic nephropathy: A disease of the nervous system caused by damage to the nerves by diabetes.
Diabetic neuropathy: This is a kidney disease caused by damage to the vessels in the kidney caused by diabetes.
Diabetic retinopathy: This is a condition characterized by the damage to the blood vessels in the retina.
References
Kelly, E. B. (2006). Obesity. Westport, Conn: Greenwood Press.Top of Form
Preedy, V. R. (2012). Handbook of Anthropometry: Physical Measures of Human Form in Health and Disease. Boston, MA: Springer US.
Singh, N., Armstrong, D. G., & Lipsky, B. A. (2005). Preventing foot ulcers in patients with diabetes. Jama, 293(2), 217-228.Top of Form
