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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.

Subject Name: Health Care

Level: Undergraduate

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