Patient, Mr. D., Is a 74-Year-Old Male

Patient, Mr. D., is a 74-year-old male Caucasian, married and retired. Mr. D. complains of dizziness and weakness. Type-2 diabetes was diagnosed in 1994, hypertension in 2002, and arthritis in 2007. Mr. D. is currently taking 20mg Lipitor/daily; 81 mg Aspirin/daily; 333mg Calcium/daily; 5mg zinc/daily, and 500mg Vitamin C/3X day. He denies any drug or herbal use, and uses 650 mg of Tylenol for pain as needed. He has no known food allergies, does not use tobacco or illicit drugs, but has a family history of diabetes and heart disease with both mother and father. His general health acuity is strong (bowels, urinary, etc.), but has occasional slurred speech, weakness in right lower limb, syncope, vertigo, and vision fluctuations. Mr. D. reports that his wife complains he asks the same question repeatedly within a short time period.

Areas for Focused Assessment- The combination of syncope, vertigo, vision, and memory issues combined with the patient's history suggest insulin reaction or possible stroke. His other medical history, level of education, lack of substance abuse and communication skills preclude other possibilities, as do a lack of nausea or vomiting.

Client's Strengths -- Mr. D. is coherent, verbal, has a strong sense of self and family, an excellent vocabulary, and is able to express his symptoms and concerns in an educated and tangible manner. He has strong motivation to stay healthy and watch his grandchildren grow, seems reasonably happy and secure in his life, and is secure in his marriage. He is financially stable, and appears to be truthful in his responses and his own view of his personal healthcare responsibilities.

Areas of Concern- Primary concerns are the symptoms that indicate blood sugar (diabetes issues) or potential stroke event. Because of the history, medications, and frequency of issues, first steps would be to evaluate Mr. D. with a fasting glucose test and other indicators of diabetic concern. Nurse/Physician should probe more to get a better longitudinal understanding of the fainting, vertigo, dizzy or memory spells and try to match with certain times of day, length of time from eating, eating diary, and overall longer term testing of blood sugar levels. Mr. D's weight and BMI are not indicated, so we are unsure based on the data if obesity is an issue.

Health Teaching Topics -- Symptoms of diabetes, differentiation between diabetes and stroke issues, ways to mitigate blood sugar issues, clues about sweet food weaknesses. It appears that Mr. D. does not get enough exercise for fear of aggravating his arthritis. For teaching purposes, lack of proper diet, fast foods, sweet foods high in sugars and carbohydrates without adequate fruits and vegetables contribute to the potential of diabetic issues, particularly as a patient ages (Madden and Loeb, 2009).

Nursing Care Plan

Diagnosis- Because the symptoms are temporary and occasional, it is more likely that there is an issue with proper blood sugar maintenance. Because Mr. D. was already diagnosed with Type 2 diabetes, it is possible that as he aged, the issue has become more severe. Based on Mr. D's symptoms, it is possible that his blood sugar level has plummeted below 70 mg/dl. Low blood sugar can case sweating, confusion, hunger, headaches, fatigue, fainting, seizures, and memory loss. We need to probe more to find out the length of Mr. D's symptoms and what he does to mitigate them (Hypoglycemia, 2012). There are three possibilities for Mr. D.: 1) Extension and aggravation of Type-2 diabetes based on lack of exercise, age, and improper diet; 2) Extension of Type-2 diabetes to Type-1 diabetes and resulting blood-sugar imbalances, or; 3) Potential stroke that may or may not be combined with blood sugar issues. We will assume #3 is unlikely because of history, but the weakness in right lower limb might indicate either a loss of blood flow or other issues that may predicate stroke. To be safe and thorough, all potentials will be dealt with in nursing plan.

Plan -- The first step in the plan will be to identify conclusively the source of Mr. D's symptoms; 1, 2 or 3 above. To do this, we will begin with test A and proceed as needed:

A. Fasting Plasma Glucose Test, possible oral glucose tolerance test

B. Glycated hemoglobin (A1C) test

C. Cholesterol, Thyroid, Liver Function, Kidney Function, Electrolytes, Clotting time tests

D. Potential CT brain scan

E. Potential MRI scan

F. Electrocardiogram

In this case, we will assume the most optimistic diagnosis for Mr. D. -- Type-2 diabetes that is somewhat out of control. The plan would then be to place Mr. D. On a regime that will control his diabetes issues without severe or intrusive medication, and monitor in 14 days, then 30 days thereafter to evaluate whether symptoms have been alleviated.

Intervention -- Depending on the severity of the glucose imbalance, Mr. D's weight, and ability to exercise, we would place him on a plan that would be multidimensional in its approach to blood sugar management. The research shows that exercise for the management of type-2 diabetes, combined with nutritional strategies, when used with culturally appropriate education and training have the best chances for long-term success (Zanuso, 2010). Management for Type-2 diabetes focuses on lifestyle intervention, lowering cardiovascular risk factors, losing weight and maintain blood glucose levels. For Mr. D., we would recommend the following:

1. Regular, non-impact exercise due to his arthritis issues. This could include water aerobics, riding a stationary bicycle, or careful use of a home treadmill. Mr. D's goal should be 30-60 minutes per day of some type of aerobic exercise.