case study

CASE STUDY XIII

Nancy Halpert (N. H.) is a 75-year-old African American female who lives in a one-bedroom apartment in Washington D.C. She is widowed. She had a daughter who passed away at the age of 40 due to breast cancer. Her remaining two children live in different states, one in Ohio and the other in California. Her 25-year old granddaughter stays with her on the weekends when she is not working. Nancy’s children call her every week to see how she is doing. She has a neighbor who checks on her daily to see if she needs anything. Nancy visits the senior citizen center located one block from her apartment once per week.

N. H. was diagnosed as a Type 2 diabetes five years ago. Her last physical exam was two years ago. She doesn’t like to go to the doctor because she is afraid she will need insulin. She takes glyburide daily and “tries to watch what I eat.” Her blood glucose has been consistent with an average AM reading of 180 mg/dl. She eats fast food from nearby restaurants frequently because she doesn’t feel like cooking for just herself and she likes to have her meals delivered. She often says, “I like to get visitors. I enjoy the company.” She sleeps only 3-4 hours per night, and sleep is often interrupted. She reports having difficulty sleeping ever since she turned 70. She complains of feeling tired most days. She has frequent periods of restlessness at night and must urinate frequently. She does not have difficulty with hygiene activities but states, most days she doesn’t feel like grooming herself since she doesn’t go anywhere. N. H. is 35 pounds overweight and reports she would like to lose some weight but doesn’t know what to do.

For the past five days, N. H. has been feeling “dizzy and more tired than usual.” She has been unable to keep any food down and reports nausea, vomiting, and abdominal pain. She noticed a fruity odor to her breath. When she checked her glucose this morning, it was

690 mg/dl. Also, she has been experiencing headaches, frequent urination, and increased thirst. When her neighbor came to check on her, she noticed N. H. was confused and had trouble concentrating. Her neighbor bought her to the to the E.R. immediately. Her blood pressure was 135/80. Lungs were clear upon auscultation. Her face was flushed, and she was restless and having some difficulty breathing. Lab tests revealed a blood glucose level of 750 mg/dl and a hemoglobin A1c of 8%. N. H. was treated with intravenous fluids, electrolyte replacement and insulin. After she was stabilized, she was admitted for two days for observation, and then released.

On discharge, the medical diagnoses were as follows:

1. Uncontrolled diabetes mellitus

2. Diabetic ketoacidosis

3. Obesity

4. Possible depression

Her discharge orders were as follows:

1. Metformin 500 mg po bid

2. 2000 calories ADA diet

3. Diabetic teaching classes

4. Follow up with primary provider within two weeks for physical exam and depression screening

You are the nurse working in the primary care office. Since N. H.’s last physical exam was one year ago, a complete health history and physical exam is indicated at the next scheduled visit.

When N. H. arrives for her exam, she denies any headaches, nausea, vomiting, but still has frequent urination. She reports since being in the hospital she has tried to cook just for herself but has had to eat fast foods for at least one meal a day. On the day of her physical, N. H.’s weight is 235 pounds, height 5’2”, which calculates to a BMI of 43 indicating obesity. She is talkative during the assessment, answers questions politely and appropriately, and makes frequent eye contact. She is alert and oriented x 4, speech is clear and not pressured, and thoughts are logical.

As you begin taking her health history, N. H. admits she is “worried” and nervous about having to need insulin. She wants to change her diet so that she can live a healthier lifestyle. You explain to N. H. the role of insulin in her body and the benefits of adding an insulin sliding scale to the treatment plan to control her glucose and prevent the complications of hyperglycemia. You also teach her how to self-administer insulin and provide her with the opportunity to return the demonstration. You also include the manifestations of hypoglycemia and how to prevent it from occurring.

You see a patient who is eager to learn and willing to make changes. You decide to use this healthcare opportunity to provide education and health promotion.