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Assignment 12.1: Case Study 3
L.P. is a 62-year-old woman with a history of hypertension and hyperlipidemia who presented to a primary stroke center with sudden onset weakness of the right side. On assessment, she had aphasia, left gaze preference, right hemianopsia, right facial droop, dysarthria, and right hemiplegia (Stroke Scale = 22). Head CT angiography showed a left middle cerebral artery occlusion. She was given Alteplase intravenous tPA at 2 hours from symptom onset and transferred to a comprehensive stroke center. She also underwent mechanical thrombectomy. Three months later she had no neurological deficits.
Please complete the following case study analysis utilizing the following:
The Nursing Process:
D – Diagnosis (Use NANDA nursing diagnoses)
P Plan (Outcome with a specific short and long term goal)
E – Evaluation
Additional Information to include if applicable: Medication (class, mechanism of action, dosage [standard if not provided], indication, side effects, contraindications)
See note attachment.
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Running head: NURSING CARE FOR A PATIENT SCENARIO
Case Study: Nursing Care for Ms. Jones
NURSING CARE FOR A PATIENT SCENARIO 2
Case Study: Nursing Care for Mrs. Jones
Ms. Jones: Nursing Case Study
Ms. Jones has come to the hospital with the primary complaint of blurred vision which is not
amenable to relief by wearing glasses. Her disclosure of being hypertensive as well as diabetic serves to
induce the immediate suspicion of diabetic retinopathy. Ms. Jones is currently taking antihypertensive
medication that include the diuretic, Lasix, an ACE inhibitor Captopril, and the oral hypoglycemic drug
Glucotrol. Ms. Jones states she is a middle aged, 55 year old female, obese, with a family history of early
deaths of her father and brother due to heart attack are suggestive of genetic predisposition to
hypertension and obesity. She has high blood pressure and blood glucose levels upon presentation at the
clinic are suggestive of the chronic nature of her condition. She states that her mothers diabetic status
also suggests an inherited link for diabetes mellitus. Important healthcare findings about Ms. Jones can be
listed as follows:
Subjective data. Ms. Jones is a, 55 year old female, with a family history of premature deaths of her
father and brother due to heart attack and that her mothers had diabetic mellitus with a complaint of blurred
vision without relief with the use of glasses.
Objective data. Ms. Jones is 5ft. 2in tall hypertensive, diabetic female with obvious obesity
indicated by her currently observable 170 lbs. of body weight. Her history also reveals a positive diagnosis
of hypertension as well as type 2 diabetes mellitus in the past. Ms. Jones is already on an antihypertensive
regimen which includes the diuretic, Lasix, The ACE inhibitor Captopril in addition to the oral
hypoglycemic drug Glucotrol for controlling blood sugar.
Diagnosis (D)/Nursing Diagnosis (Berman et al. 2017)
The primary nursing diagnosis for Ms. Jones is that of risk for disturbed sensory
perception due to the immediate vision impairment from present and unstable diabetic state,
which has persisted (North American Nursing Diagnosis Association [NANDA].2017). History
NURSING CARE FOR A PATIENT SCENARIO 3
of long standing hypertension, diabetes and her obese condition are suggestive of this diagnosis.
Further confirmation can be obtained after evaluating the results obtained from retinal
examination and other eye tests if recommended. The major changes in type 2 diabetes are the
development of erratic blood glucose varying from hypo to hyperglycemia, increased
predisposition for infections, peripheral nephropathy/retinopathy sometimes leading to blurred
vision as well as blindness (Berman et al. 2017)
Mrs., Jones needs to be put on a diet regimen which includes only the recommended
calorific intake and her diabetes needs to be controlled in order to keep her plasma sugar levels
at an optimum level of 80-120 mg/dL(Berman et al. 2017). If any abnormal changes in her
retina are detected, it needs an immediate surgical intervention to prevent further damage. She
needs to follow a more controlled lifestyle after the intervention which should include
appropriate control of diet, incorporation of a light exercise regimen to bring down her weight
and religious intake of antihypertensive and anti diabetic drugs with nursing education and
Long-term goals/desired outcomes. Within the duration of care, Mrs. Jones will be able to:
Demonstrate interest/behaviors and lifestyle changes to improve her well-being,
glycemic control, nutrition, hypertension, medication regimen and compliance, and
Implementation/Interventions (I) (Berman et al. 2017)
Nursing care implementation and interventions include:
Consult a dietician or nutritionist to cater for the clients nutritional needs.
Assessing and educating Ms. Jones concerning her diabetic and hypertensive medication
regiment and compliance.
Assessment of the eye for any abnormal lesions in the retina suggestive of diabetic
NURSING CARE FOR A PATIENT SCENARIO 4
retinopathy and further examination, such as angiography if recommended by her
Reviewing the comprehensive metabolic panel and fasting plasma glucose level and a
glucose tolerance test to further assess hypertensive and diabetic states.
Evaluation of her diet habits for investigating the role of high calorie foods.
Education, referrals, and option for health lifestyle practices to address her obesity and is
risk and health factors and complexities also involving her present diagnosis of diabetes
Ms. Jones will require expert nursing concerning diabetic, hypertensive, and medication
education, as well as nutritional and psychological counseling to ensure compliance with the
health care recommendations and referrals after discharge from the hospital. She will also need
to visit the medical facility periodically for her health assessment to sustain her plan of care and
NURSING CARE FOR A PATIENT SCENARIO 5
Berman, A., Snyder, S. J., Kozier, B. & Erb, G. (2017). Kozier & Erbs fundamentals of nursing:
Concepts, process, and practice (11th ed., p. 905 & pp. 1296-1298). Upper Saddle River,
New Jersey: Pearson Prentice Hall.
North American Nursing Diagnosis Association (NANDA) International Staff. (2017). Nursing
diagnoses: Definitions and classification, 2015-17. Hoboken: John Wiley & Sons,