A patient with diabetes has an elevated hemoglobin A1c of 8.5%, diminished sensation in her feet, and early signs of diabetic retinopathy. Her blood pressure is 150/92 mmHg despite being on antihypertensive medication. Which nursing intervention is most critical to prioritize in this patient's care?

C) Reviewing antihypertensive medication adherence and possible adjustments.

A) Discussing dietary modifications to improve blood glucose control.

B) Educating the patient on foot care to prevent complications from neuropathy.

C) Reviewing antihypertensive medication adherence and possible adjustments.

D) Referring the patient for a comprehensive ophthalmologic evaluation.

A patient with poorly controlled type 2 diabetes, hypertension, and stage 3 chronic kidney disease presents with elevated hemoglobin A1c, peripheral neuropathy, and early diabetic retinopathy. Which nursing intervention is most appropriate to address her current condition and prevent further complications?

B) Educate the patient on the importance of regular foot inspections to prevent injury

A) Encourage the patient to increase her protein intake to improve kidney function

B) Educate the patient on the importance of regular foot inspections to prevent injury

C) Recommend reducing antihypertensive medication to avoid potential side effects

D) Suggest decreasing physical activity to prevent exacerbation of neuropathic pain

A patient with type 2 diabetes, hypertension, and declining renal function has been experiencing fatigue and dizziness, especially when standing. Her serum potassium level is elevated at 5.4 mEq/L, and her eGFR is 50 mL/min/1.73m². Which nursing intervention is most appropriate to address the patient's current condition?

B) Advise the patient to rise slowly from sitting or lying positions to reduce dizziness.

A) Encourage increased intake of potassium-rich foods to combat fatigue.

B) Advise the patient to rise slowly from sitting or lying positions to reduce dizziness.

C) Suggest reducing fluid intake to decrease workload on the kidneys.

D) Recommend discontinuing all antihypertensive medications immediately.

A patient with diabetes and hypertension is experiencing fatigue and dizziness upon standing. Her recent lab results show an eGFR of 50 mL/min/1.73m² and a serum potassium level of 5.4 mEq/L. Which of the following nursing interventions should be prioritized to address her current symptoms and lab findings?

B) Review the patient's medication regimen for potential contributors to hyperkalemia and consult with the healthcare provider.

A) Encourage the patient to increase fluid intake to improve kidney function.

B) Review the patient's medication regimen for potential contributors to hyperkalemia and consult with the healthcare provider.

C) Advise the patient to consume more potassium-rich foods to manage fatigue.

D) Suggest the patient take her antihypertensive medication at bedtime to reduce dizziness.

A patient with a history of reduced renal function presents with increased fatigue, lower extremity swelling, and shortness of breath. Her blood pressure is 150/92 mmHg and she has 2+ pitting edema. The healthcare team plans to introduce a diuretic. Which nursing intervention is most important to monitor for this patient to prevent complications?

A) Monitor daily weight and report a gain of more than 2 pounds in 24 hours

B) Encourage intake of potassium-rich foods to prevent hypokalemia

C) Advise the patient to drink 2 liters of fluid daily to maintain hydration

D) Monitor blood pressure every 4 hours to assess for hypotension

A patient with a recent history of hypertension and reduced renal function presents with symptoms of fatigue, lower extremity swelling, and mild shortness of breath. Given her current presentation and the suspicion of congestive heart failure, which medication adjustment would be most appropriate to manage her condition while minimizing risks to her renal function?

C) Start a loop diuretic with close monitoring.

A) Increase the dose of her ACE inhibitor.

B) Introduce a thiazide diuretic.

C) Start a loop diuretic with close monitoring.

D) Switch to a calcium channel blocker.

A patient with a recent diagnosis of congestive heart failure presents with mild hyperkalemia and decreased renal function. Which nursing intervention is the most appropriate for managing this patient's electrolyte imbalance while considering their cardiac condition?

C) Administer a loop diuretic such as furosemide to manage fluid overload and reduce potassium levels.

A) Administer a potassium-sparing diuretic such as spironolactone to manage fluid overload.

B) Implement a diet high in potassium to counteract the effects of loop diuretics.

C) Administer a loop diuretic such as furosemide to manage fluid overload and reduce potassium levels.

D) Hold all diuretics to prevent further decline in renal function.

A patient with congestive heart failure and mild hyperkalemia is being treated with furosemide and a reduced dose of an ACE inhibitor. Which assessment finding would most likely indicate that the treatment plan requires modification?

B) The patient's serum potassium level decreases to 3.0 mEq/L.

A) The patient's blood pressure is 110/70 mmHg.

B) The patient's serum potassium level decreases to 3.0 mEq/L.

C) The patient's serum creatinine level decreases to 1.3 mg/dL.

D) The patient's B-type natriuretic peptide (BNP) level decreases to 400 pg/mL.

A patient with persistent fluid overload, despite diuretic therapy, presents with increased fatigue, occasional shortness of breath, and mild peripheral edema. Laboratory results indicate stable but elevated BNP levels and mildly decreased serum potassium. What is the most appropriate nursing action to address the patient's current symptoms while minimizing potential renal complications?

C) Educate the patient on a low-sodium diet to help reduce fluid retention.

A) Increase the dose of loop diuretic and monitor renal function closely.

B) Recommend the introduction of a beta-blocker to improve cardiac output.

C) Educate the patient on a low-sodium diet to help reduce fluid retention.

D) Suggest withholding diuretic therapy to allow renal function recovery.

A patient with heart failure is experiencing increased fatigue, shortness of breath, and weight gain despite diuretic therapy. Vital signs show elevated blood pressure and heart rate, and laboratory results indicate elevated serum creatinine and BNP levels. Which of the following actions should the nurse prioritize when considering adjustments to the patient's treatment plan?

C) Monitor the patient closely for signs of renal impairment before making changes.

A) Increase the dose of the loop diuretic to manage fluid overload.

C) Monitor the patient closely for signs of renal impairment before making changes.

D) Encourage the patient to increase fluid intake to prevent dehydration.

diabetes type 2 for geriatric patient - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin resistance occurs when cells in muscles, fat, and liver do not respond well to insulin, making it difficult for glucose to enter cells, leading to increased blood sugar levels. This is often exacerbated by age-related changes in metabolism and body composition.

• Secondary mechanism: Impaired insulin secretion from pancreatic beta cells due to chronic high blood sugar and increased demand on the pancreas. Over time, the beta cells become dysfunctional and fail to produce adequate insulin.

• Key complication: Chronic hyperglycemia can lead to vascular damage, increasing the risk of cardiovascular diseases, neuropathy, and nephropathy, which are particularly concerning in geriatric patients due to their already increased vulnerability to these conditions.

Patient Profile

Demographics:

72-year-old female, retired school teacher

History:

• Key past medical history: Diagnosed with type 2 diabetes 10 years ago, hypertension, hyperlipidemia

• Current medications: Metformin, lisinopril, atorvastatin, aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and occasional blurred vision

• Key symptoms: Polyuria, polydipsia, numbness in feet, intermittent headaches

• Vital signs: Blood pressure 150/90 mmHg, heart rate 88 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, blood glucose level 220 mg/dL

Section 1

The patient's initial assessment findings reveal a concerning development: her hemoglobin A1c level is elevated at 8.5%, indicating poor long-term blood glucose control. Further examination highlights diminished sensation in her feet, consistent with peripheral neuropathy, a common complication of poorly managed diabetes. The patient's weight has increased slightly, and her body mass index (BMI) is now 29, placing her in the overweight category, which may exacerbate insulin resistance. Her blood pressure remains elevated at 150/92 mmHg, despite being on antihypertensive medication, suggesting suboptimal management of her hypertension. Additionally, retinal examination reveals early signs of diabetic retinopathy, correlating with her complaint of blurred vision.

The patient's renal function tests are also noteworthy, with a serum creatinine level of 1.3 mg/dL and an estimated glomerular filtration rate (eGFR) of 55 mL/min/1.73m², indicating stage 3 chronic kidney disease. This finding suggests the onset of diabetic nephropathy, a potentially serious complication that requires careful monitoring and management to prevent further decline. The combination of her current symptoms and lab results indicates that her diabetes management plan needs reassessment and adjustment to address these complications effectively.

These assessment findings prompt the healthcare team to consider modifications to her treatment regimen, including possible intensification of her diabetes management plan, reevaluation of her antihypertensive therapy, and the introduction of lifestyle interventions such as dietary modifications and increased physical activity. The interdisciplinary team will need to prioritize these changes to prevent further complications and improve the patient's overall health and quality of life. The next steps in her care will focus on optimizing blood glucose and blood pressure control, slowing the progression of nephropathy, and addressing neuropathic symptoms.

Section 2

Following adjustments to her diabetes management plan, including changes to her medication regimen and the introduction of structured dietary and physical activity interventions, the patient returns for a follow-up appointment four weeks later. Her blood pressure has improved slightly to 145/88 mmHg, suggesting a partial response to the revised antihypertensive therapy. However, the patient reports persistent fatigue and occasional dizziness, especially when standing up too quickly. These symptoms prompt further investigation into her cardiovascular status, as well as a review of her medication doses and potential side effects.

New diagnostic results reveal a slight improvement in her glycemic control, with her hemoglobin A1c reduced to 8.2%, indicating some positive response to the intensified diabetes management. However, the eGFR has decreased further to 50 mL/min/1.73m², raising concerns about the progression of her kidney disease. Additionally, her serum potassium level is elevated at 5.4 mEq/L, suggesting possible hyperkalemia, which may be linked to her antihypertensive regimen, particularly if it includes ACE inhibitors or ARBs. This finding necessitates an immediate review of her medications to prevent potential complications such as cardiac arrhythmias.

Given these developments, the healthcare team must engage in clinical reasoning to adjust her treatment plan effectively. The focus will be on balancing her blood pressure control without exacerbating her renal function decline or causing electrolyte imbalances. This may involve switching to alternative antihypertensive medications that have a renal protective effect with a lower risk of hyperkalemia. Additionally, her diabetes management plan may require further refinement, potentially incorporating newer agents with cardiovascular and renal benefits. The team will also need to reinforce lifestyle modifications, emphasizing the importance of adherence to dietary recommendations, including potassium and sodium intake adjustments, to support her overall health status.

Section 3

Change in Patient Status:

Two weeks after her follow-up appointment, the patient presents to the clinic with new concerns. She reports experiencing increased episodes of fatigue and has noticed some swelling in her lower extremities. Additionally, she describes a mild yet persistent shortness of breath, notably when climbing stairs or performing her usual daily activities. These symptoms prompt the healthcare team to conduct a thorough clinical assessment, suspecting potential fluid retention and congestive heart failure as underlying issues.

On examination, the patient's vital signs reveal a blood pressure of 150/92 mmHg, indicating a slight increase from her last visit. Her heart rate is 88 beats per minute, and her respirations are 20 breaths per minute. Auscultation of her lungs reveals mild bilateral crackles at the bases, suggesting fluid accumulation. An examination of her ankles confirms 2+ pitting edema. The team is concerned about the implications of these findings, particularly in the context of her reduced renal function and recent medication adjustments.

Given these developments, the healthcare team needs to address the potential exacerbation of heart failure. This situation requires careful modification of her antihypertensive regimen to manage blood pressure without worsening her renal impairment or causing further electrolyte disturbances. The team considers introducing a diuretic with caution, given her history of hyperkalemia, and plans to monitor her renal function and electrolytes closely. Additionally, the team revisits her dietary plan, emphasizing sodium restriction and fluid management, and reinforces the importance of weight management and regular physical activity within her tolerance level. These steps are crucial in stabilizing her condition and preventing further complications.

Section 4

New Diagnostic Results:

Following the initial assessment, the healthcare team proceeds with a series of diagnostic tests to better understand the patient's current condition and guide further management. Blood tests reveal a sodium level of 134 mEq/L, slightly below the normal range, and a potassium level of 5.5 mEq/L, indicating mild hyperkalemia. Her serum creatinine has risen to 1.6 mg/dL from a previous value of 1.4 mg/dL, suggesting a potential decline in renal function. A B-type natriuretic peptide (BNP) test shows elevated levels at 450 pg/mL, which supports the suspicion of congestive heart failure. An echocardiogram is performed, revealing a reduced ejection fraction of 45%, indicative of systolic dysfunction. These results align with the clinical picture of fluid overload and cardiac compromise.

In light of these findings, the healthcare team is tasked with refining the patient's treatment plan to address both her cardiac and renal concerns. The mild hyperkalemia requires careful consideration in selecting a diuretic, leaning towards a loop diuretic like furosemide, which is less likely to exacerbate her potassium levels compared to potassium-sparing options. The team also decides to adjust her antihypertensive regimen by reducing the dose of her ACE inhibitor to mitigate renal strain while maintaining adequate blood pressure control. The importance of close monitoring of her renal function and electrolyte balance is reinforced, with regular follow-up appointments scheduled to assess response to treatment.

These diagnostic insights provide the healthcare team with a clearer understanding of the patient's condition, allowing for targeted interventions. The plan prioritizes the stabilization of her heart failure symptoms and careful management of her renal function, aiming to improve her quality of life and prevent progression of complications. The next steps involve evaluating the patient's response to the modified treatment regimen and adjusting as necessary based on subsequent assessments and lab results.

Section 5

Following the implementation of the revised treatment plan, the healthcare team closely monitors the patient for any changes in her condition. During a follow-up visit, the patient reports experiencing increased fatigue and occasional shortness of breath, particularly during exertion. Vital signs reveal a blood pressure of 140/85 mmHg, a heart rate of 92 beats per minute, and a respiratory rate of 22 breaths per minute. Notably, her weight has increased by 2 kilograms since the last visit, suggesting ongoing fluid retention. Physical examination reveals mild peripheral edema and crackles in the lung bases, indicating persistent fluid overload despite the diuretic therapy.

Laboratory results show that her serum potassium level has decreased slightly to 5.1 mEq/L, a positive response to the loop diuretic. However, her serum creatinine remains elevated at 1.7 mg/dL, raising concerns about further renal impairment. The BNP level is unchanged, remaining elevated at 450 pg/mL. These findings suggest that while there has been some improvement in electrolyte balance, the patient's cardiac and renal functions may not be responding optimally to the current treatment regimen.

In light of this situation, the healthcare team considers further adjustments to her management plan. Increasing the dose of the loop diuretic may be necessary to more effectively address fluid overload, but this must be balanced against the risk of exacerbating renal dysfunction. Additionally, the possibility of introducing a beta-blocker to improve cardiac output and reduce heart rate is discussed, with careful titration advised to minimize adverse effects. The team emphasizes the importance of continued monitoring, with frequent assessments of vital signs, weight, and laboratory values to guide ongoing treatment decisions. These steps aim to stabilize the patient's condition and prevent further complications, paving the way for improved symptom control and quality of life.