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Clinical Case Study Assignment: Nursing Diagnosis & Inter-Professional Plan of Care


Task: Clinical Case Study Assignment Scenario:
As the community nurse for the Aged Care Assessment Team, you have been asked to conduct a home visit to assess Mrs Jane Summers.

Mrs Jane Summers is a 64-year-old newly retired office worker, who has recently been diagnosed with diabetic retinopathy and is legally blind in her left eye. Mrs Summers has a medical history which includes type 2 diabetes mellitus (diagnosed five years ago) and hypertension (diagnosed 7 years ago). Mrs Summers' doctor has prescribed Metformin 500mg twice daily and Metoprolol 50mg twice daily.

Mrs Summers lives alone, in her own home. She is a self-described single woman, but has a daughter who lives interstate, and a son who lives locally, both from a previous marriage.

The referral from the General Practitioner (GP) indicates that Mrs Summers has suboptimal blood pressure and diabetes control, despite medication management and recommended dietary control. The last blood pressure recorded was 159mmHg/96mmHg and her glycated haemoglobin (HbA1C) has never been less than 8%.

Mrs Summers lives in a two-story terrace home, with a sunken living room and an outdoor veranda leading to a courtyard garden. The paving on the surrounding brick paths is in poor repair and the garden could do with some maintenance. Several rooms of the home appear cluttered, with ‘keepsakes’ from overseas travels and old magazines stacked in piles around the home.

On general appearance, Mrs Summers appears moderately overweight and has a flushed facial appearance. She wears glasses for reading and driving her motor car and says that she loves to read but has been having trouble recently and describes her vision as ‘patchy and blurred’. On questioning, she does admit to often feeling ‘fuzzy in the head’ if she forgets to take her tablets, but otherwise feels that she is in good general health. Mrs Summers states that she is "doing well" and only retired because she was finding the work on the computer in her job a bit difficult and it was tiring looking at a screen all day, due to her impaired vision. Mrs Summers does not routinely test her blood glucose levels at home as often as she should, and expresses doubt that this would help her, saying: "the doctor knows of my condition, he can sort me out." Mrs Summers has been trying to lose weight for the past 6 months, without success; but feels that she has more time for exercise now that she is retired, and not stuck behind a desk all day.

Mrs Summers wants to remain in her own home, that she has lived in all her adult life, and takes pride in her cooking, entertaining friends and making her own apple cider. Mrs Summers will require an inter-professional community plan of care. Based upon the clinical scenario provided, construct a case report which is a detailed report of the client’s clinical presentation, nursing diagnosis and inter-professional plan of care. The case report will draw upon your knowledge of pathophysiology, pharmacology and relevant academic literature to support an evidence-based plan of care.


ISBAR clinical handover framework explored herein clinical case study assignment has been recognized by the World Health Organization in order to provide a standardized approach in the field of health care to better communicate with any critical situation (Burgesset al. 2020).

Introduction: a 64 years old lady named Mrs. Jane Summers has been assisted at her residence with a complaint of blindness. She is a newly retired personal who worked in an office. The assessment will thus focus on her case study in order to evaluate the issues

Situation: she tends to live alone in her own apartment as her son and daughter live away from her. She is been diagnosed with diabetic retinopathy and blindness and is also overweight.

Background: she has a medical history of diabetes and hypertension as well as difficulty in vision she has been on medication such as Metformin500mg and Metoprolol 50mg twice a day for her condition of diabetes and hypertension.

Assessment: the condition of diabetic retinopathy has been diagnosed in her condition which is stated to be occurring due to the increase in blood sugar level as it has been found that she does not routinely measure her blood sugar level as well as doesn’t follows the medication dosageand routine diet provided to her.

Recommendation: thus, focusing on her condition, it is necessary to develop an inter-professional care plan for her with the involvement of a person-centered approach in order to assister her with her co-morbidities.

The assessment will thus focus on assessing the primary medical diagnosis as well as the medication she has been prescribed with regarding her health conditions. It will also assess the nursing problems related to medical condition as well as medication management along with development of an interprofessional plan of care for her diagnosed health issues.

Primary medical diagnosis:
Diabetes retinopathy:

From the case study analysis, it was found that Mrs. Jane Summers has been diagnosed with diabetic retinopathy which is known to be a complex condition of the eye that tends to develop loss of vision as well as blindness in the case of the patient. it was due to her past medical history of type 2 diabetes. The condition of vision loss and blindness was common in the case of Mrs. Jane Summers as she was blind in her left eye. The condition of diabetic retinopathy is found to occur in the patient suffering from diabetes where it impacts the blood vessels present in the retina which especially indicates the light-sensitive tissue layer present in the back portion of the eye (Duh, Sun and Stitt 2017).

As the body witnesses an increase in blood sugar level for a longer duration, the risk of development of the condition of diabetic retinopathy is more. It was found to take place in case of Mrs. Jane Summers as she did not routinely measure her sugar level as well as was had an optimal level of blood sugar despite of diet and medication management. The presence of an excessive amount of sugar in her blood tends to damage the blood vessels which function by supplying a significant amount of blood to the retina. When the blood vessels present in the retina witness severe damage, they tend to witnesses low blood supply as well as a blockage in the retina. Thus, the inhibited supply of blood within the region tends to support the development of weaker and incompetent blood vessels within the retina which when witnesses blood supply, leaks and gets distorted and develops scar tissues. The process of development of scar tissue thus tends to hamper the vision of the patient and cause blindness. It has been found that the longerMrs. Jane Summers will witnesses an increase in blood sugar level the higher the risk, as well as a complicationrelated to damage of blood vessels in the retina will grow. The damage witnesses by the limited supply of oxygen within the retina become complicated if not treated or the blood sugar level is normalized (Wang and Lo2018).

Medication management:

Metformin is used for treating diabetes and cancer and in the case of Mrs. Jane Summers, it was provided against the condition of type 2 diabetes. The mode of action or mechanism under which the drug function explains the process of modification of the energy metabolism carried out within the cell. It tends to function in lowering the glucose level in the body by inhibiting and opposing hepatic gluconeogenesis and glucagon action. Metformin, also known as Glucophage is generally indicated as an assistant in the diet and exercise of the patient suffering from type 2 diabetes in order to improve the control of blood sugar level. It minimizes the production of glucose by the liver, improves insulin sensitivity as well as intestinal glucose absorption. Side effects related to Metformin include muscle pain, irregular heartbeat, dizziness, difficulty in breathing as well as nausea. It is necessary to monitor the blood sugar level routinely as the sugar level may fall to the level of low sugar count in blood and it is also guided not to drive after taking the medication s it sometimes causes dizziness (Rena, Hardie and Pearson 2017).

Metoprolol belongs to the class of drugs known as beta-blockers which functions by affecting the heart as well as the circulatory system of the patient. It functions by decreasing the cardiac output and blood pressure as well as slows down the sinus heart rate in order to avoid heart failure and the condition of hypertension. Metoprolol is general used in order to treat the condition of angina and hypertension and it was prescribed to Mrs. Jane Summers as she has been suffering from hypertension. It is also found to be used in case of heart failure to minimize the risk of mortality as well as hospitalization in critical cases. Side effects that areassociated with the drugs account for depression, dizziness, pain in the chest, slower heartbeat, shortness of breath as well as swelling of legs and arms. While taking the medication it is necessary to monitor blood sugar levels routinely in the case of diabetic patientsas it tends to unstable the condition of diabetes by fluctuating the blood glucose level (Brockeret al. 2020).

Nursing diagnosis:
Nursing problem related to medical diagnosis:

Vitreous hemorrhage is known to be one of the main and crucial nursing problems identified in the case of Mrs. Jane Summers as she has been primarily diagnosed with diabetic retinopathy. The risk of Vitreous hemorrhage is high in case of Mrs. Jane Summers as she does not have a stable blood glucose level and often witnesses elevation in her condition of diabetes. The condition of Vitreous hemorrhage thus tends to occur when the blood glucose level is not maintained to the normal level and the diabetes retinopathy remains untarred, the blood vessels sustained major bleeding the jelly-like structure present in the eye. This will lead to disruption of the vitreous cavity leading to the development of the condition of total vision loss. It is possible that the right eye of the Mrs. Jane Summers might get affected as well if the condition of blood glucose level is not managed (Antoszyket al. 2020).

Nursing problem-related medication management:
As Mrs. Jane Summers has been on medication metformin, it will be necessary to manage her medication dosage significantly as it has a greater risk of developing a condition of renal failure and acute condition of hypoglycemia. Metformin has its negative impact on the kidney condition as well the glucose level of the body if the proper dosage of the medication is not used. It is generally recommended to provide Metformin as a single dose in every patient, but it was found that the Mrs. Jane Summers was prescribed two-dose a day which may develop a condition of hypoglycemia and renal failure. Thus, it will be necessary to regularly monitor the blood glucose level as well as revise the medication dosage provided to the patient (Salvatoreet al. 2019).

Nursing role and inter-professional plan of care:
An interprofessional approach:

The inter-professional care approach is necessary to use in the case of Mrs. Jane Summers as she has been diagnosed with diabetic retinopathy and other complex health risks. The approach will help in addressing every health acre need she might be in need of in order to lead a quality life. An inter-professional collaborative care approach focuses on using different health professionals includes, including nurses, doctors, pathologies, pharmacists, and many more. They work together within the approach as a team in order to assess, evaluate, prepare and deliver best practices for the patient according to the health needs (Maracciniet al. 2018). The approach helps in minimizing the risk of death, medical error, Vitreous hemorrhage, hypoglycaemia, renal failure or deprived health care services as it ensures that every professional according to the needs of the patient involved in the team with a common goal of sustaining better health for Mrs. Jane Summers. Thus, focusing on the issue of Mrs. Jane Summers, an interprofessional collaborative care team must be included which will assist her in her different health complications and needs.

Role of the Registered nurse in the interdisciplinary plan of care:
In the process of facilitation of interprofessional plan of care, the registered nurses play a major role as they serve as the connection between the care planning and delivery of the services. The registered nurses possess the role of identifying the case as well as issues of the patient which is necessary for the development of the inter-professional care plan. They function in conducting health assessment, diagnosis as well as identification of key needs and requirements of the patient. They also serve as a stakeholder in the process of involvement and carrying out effective therapeutic communication between the patient as well as the inter-professional team (Alsalem 2021).

Key members of the inter-professional health care team:
Focusing on the health needs of Mrs. Jane Summers, the interdisciplinary team of care will involve professionals from diverse backgrounds with relevance to her health needs. It will initially involve vitreoretinal surgeons in order to assist her with the condition of diabetic retinopathy and risk of Vitreous hemorrhage as these health care professionals are specialized in treating the condition with vitreoretinal surgery as well as laser treatments (Khan et al. 2018). The cardiologist will be involved focusing on the issues of hypertension in Mrs. Jane Summers as she has been earlier diagnosed with hypertension. Professionals such as physicians and dietitians will be involved in order to assist her with her condition of obesity whereas psychologists and diabetes educators will help her guide regarding her condition and the measure, she needs to address in her life to overcome the condition and minimize the risk in future. Pharmacists and medicine specialists will be included focusing on the issues of medication overdose and negative outcome as Mrs. Jane Summers sustains the risk of renal failure and hypoglycemia. Also, a diabetologist should be involved in the care plan in order to help her with the issue of diabetes which is the main reason behind the development of debates retinopathy (Kumar, Agarwal and Kumar 2021). In order to make the acre plan more effective for Mrs. Jane Summers, community care providers need to be involved in order to help her with other needs that she might require while leading a life alone at her home.

A person-centered and interprofessional plan of care:
It will initially require to involve person-centered approach in the care plan where Mrs. Jane Summers will take equal participation in the care and treatment plan. She will be taken as a team member and will help the team with the aim as well as needs for her health condition (Santanaet al. 2018). The interprofessional plan of care will focus on addressing initially the issues of diabetes retinopathy and Vitreous hemorrhage by maintaining and monitoring the blood sugar level. It is so because if the condition of high sugar level as well as diabetes retinopathy remains untreated, the condition of the blood vessels of the eye will become worse and will lead to severe damage of the eyes due to Vitreous hemorrhage. The care plan will involve assessing the medication dosage in order to minimize the risk of the risk of renal failure and hypoglycemia.It will be necessary to develop a proper healthy diet as wellas physical activity routine for Mrs. Jane Summers in order to help her manage her weight as well as blood glucose and hemoglobin level which tends to remain in an abnormal range. It is necessary to manage her weight as it increases the risk of cardiovascular diseases as well as thrombosis due to diabetes and hypertension. It is also necessary to provide Mrs. Jane Summers with community cares service where she will be provided with residential care visits as well as a routine check-up for her health condition and will also be assisted with her needs and requires as she sustains major risk of health complication (Douglaset al. 2017).

The assessment provided a detailed understand related to the condition witnessed by the patient “Mrs. Jane Summers" due to diabetes and hypertension. It has been found that it is necessary to have a proper inter-professional approach within a treatment plan for a patient with multiple co-morbidities at an elderly age as the lack of any factor associated with health may develop the risk of further complications and death. The assessment helped in understanding the mode of actions of the drugs used for the condition of diabetes as well as hypertension. Detailed analysis and evaluation of the condition of diabetes retinopathy was carried out that has been identified in case of the patient due to lack of management of heathy diet and medication for the condition of diabetes and hypertension. ?

Alsalem, T.N.S., 2021. The Effect of an Interdisciplinary Team and Multiple Uses of Erigo Robotic Machine in Cervical Spinal Cord Injury Incomplete Case. J Neurol Sci Res, 2(1), pp.1-06.

Antoszyk, A.N., Glassman, A.R., Beaulieu, W.T., Jampol, L.M., Jhaveri, C.D., Punjabi, O.S., Salehi-Had, H., Wells, J.A., Maguire, M.G., Stockdale, C.R. and Martin, D.F., 2020. Effect of Intravitreous Aflibercept vs Vitrectomy With Panretinal Photocoagulation on Visual Acuity in Patients With Vitreous Hemorrhage From Proliferative Diabetic Retinopathy: A Randomized Clinical Trial. JAMA, 324(23), pp.2383-2395.

Brocker, C.N., Velenosi, T., Flaten, H.K., McWilliams, G., McDaniel, K., Shelton, S.K., Saben, J., Krausz, K.W., Gonzalez, F.J. and Monte, A.A., 2020. Metabolomic profiling of metoprolol hypertension treatment reveals altered gut microbiota-derived urinary metabolites. Human genomics, 14(1), pp.1-9.

Burgess, A., van Diggele, C., Roberts, C. and Mellis, C., 2020. Teaching clinical handover with ISBAR. BMC Medical Education, 20(2), pp.1-8.

Douglas, H.E., Georgiou, A., Tariq, A., Prgomet, M., Warland, M.A., Armour, M.P. and Westbrook, J.I., 2017. Implementing information and communication technology to support community aged care service integration: lessons from an Australian aged care provider. International journal of integrated care, 17(1).

Duh, E.J., Sun, J.K. and Stitt, A.W., 2017. Diabetic retinopathy: current understanding, mechanisms, and treatment strategies. JCI insight, 2(14). Khan, M., Srivastava, S.K., Reese, J.L., Shwani, Z. and Ehlers, J.P., 2018. Intraoperative OCT-assisted surgery for proliferative diabetic retinopathy in the DISCOVER study.
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Kumar, A., Agarwal, D. and Kumar, A., 2021. Diabetic retinopathy screening and management in India: Challenges and possible solutions. Indian Journal of Ophthalmology, 69(3), p.479.

Maraccini, A.M., Houmanfar, R.A., Kemmelmeier, M., Piasecki, M. and Slonim, A.D., 2018. An inter-professional approach to train and evaluate communication accuracy and completeness during the delivery of nurse-physician student handoffs. Journal of Interprofessional Education & Practice, 12, pp.65-72.

Rena, G., Hardie, D.G. and Pearson, E.R., 2017. The mechanisms of action of metformin. Diabetologia, 60(9), pp.1577-1585.

Salvatore, T., Pafundi, P.C., Marfella, R., Sardu, C., Rinaldi, L., Monaco, L., Ricozzi, C., Imbriani, S., Nevola, R., Adinolfi, L.E. and Sasso, F.C., 2019. Metformin lactic acidosis: Should we still be afraid?. diabetes research and clinical practice, 157, p.107879.

Santana, M.J., Manalili, K., Jolley, R.J., Zelinsky, S., Quan, H. and Lu, M., 2018. How to practice person?centred care: A conceptual framework. Health Expectations, 21(2), pp.429-440.

Wang, W. and Lo, A.C., 2018.Diabetic retinopathy: pathophysiology and treatments. International journal of molecular sciences, 19(6), p.1816.


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