Primary Care of the Maturing and Aged Family Case Study Chamberlain College of Nursing
NR 601
The purpose of this paper is to analyze a case study prov
... [Show More] ided with patient information, lab work, subjective, and objective data. Diagnosis will be developed from reviewing the given information, as well as a management plan will be implemented. Demonstrating skills, such as writing a SOAP note, will be mastered, and this paper will help the FNP prepare for upcoming patients and case studies in the future, by mastering this assignment.
Assessment Primary Diagnosis: Type 2 diabetes mellitus (E11)
Pathophysiology: Type 2 diabetes mellitus is a metabolic disorder, which occurs when the body does not utilize insulin properly (ADA, 2019). The pancreas will try to overcompensate by making more insulin in efforts to get glucose into cells, but over time the pancreas can not keep up, leading to an excess amount of sugar in the blood (ADA, 2019). Classic signs and symptoms include the following: polydipsia, polyuria, and polyphagia (ADA, 2019).
Pertinent positive findings: Type 2 diabetes mellitus was chosen because of many subjective and objective findings. The patient has risk factors such as his race (African American), age of 57 years, and weight of 210 pounds (ADA, 2019). According to the American Diabetes Association, people are at a higher risk of developing type 2 diabetes, who are overweight, are of Hispanic or African American decent, and live a sedentary lifestyle.
Pertinent negative findings: This patient does not live a sedentary lifestyle, as he has mentioned working out at least 3-4 days a week, and walking for 30 minutes on the
treadmill. Despite his efforts of living a more active lifestyle, he is still overweight, with a BMI of 31 (obese), which puts him at risk for T2DM (ADA, 2019).
Rationale for the diagnosis: Lab values contributing to this diagnosis are the following: glucose of 136, hemoglobin A1C 6.8%, and small amount of glucose (+1) found in urine. According to the American Diabetes Association guidelines, patients with an A1C greater than 6.5% puts you at the diabetes mark, along with a glucose over 126 mg/dl (2019). [Show Less]