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Clinical Reasoning Cycle

Case Scenario

Mr. X is an 80-year-old man admitted to the hospital for uncontrolled blood sugar. He lives with his wife and is dependent on her for his daily activities. The patient has a history of type 2 diabetes, hypertension, and peripheral neuropathy. And he is taking prescribed medicines for his medical conditions which include Metformin, Pregabalin (Lyrica), Metaprolol, Novorapid (sliding scale), Clexane Vitamin D. He is also assessed for falls risk and VTE (venous thromboembolism) risk.

Pathophysiology of Diabetes

Diabetes is a chronic medical condition where concentrations of glucose, or sugar, in the bloodstream grow (Zaccardi et al., 2016). The insulin hormone helps transfer the glucose from the blood to the cell, which can be used for energy. The cells in the body are not responsive to insulin in type 2 diabetes. At the advanced stages of the disease, the body is not able to produce the insulin hormone. Unmonitored type 2 diabetes can correspond to incredibly high blood sugar levels causing multiple complications, and ultimately results in severe conditions (Zaccardi et al., 2016).

The main pathophysiological conditions of type 2 diabetes are, compromised secretion of insulin and increased resistance by insulin, which comprises a large percentage of patients with diabetes. Abnormality of the function of pancreatic β - cells are showing particular progress over time. Impaired secretion of insulin is a lowering of glucose tolerance that is observed before the onset of diabetes. More precisely, reductions in glucose-responsive early-phase insulin production are caused by impaired glucose tolerance (IGT), and reductions in subsequent insulin production after foods cause post-prandial hyperglycemia (Rehman & Akash, 2017). In IGT cases, a test for oral glucose tolerance (OGTT) typically suggests an over-response in individuals with substantially high resistance to insulin. Impaired insulin production is typically gradual, and its development requires lipo-toxicity and glucose toxicity (Rehman & Akash, 2017). Developing impaired pancreatic cell function greatly affects the management of blood glucose in the long term. Sometimes patients in initial stages after the onset of symptoms encounter a rise in postprandial blood glucose mainly as a result of resistance of insulin and decreased early-phase release. The deterioration of the function of the pancreatic cell can subsequently induce a permanent rise in the blood glucose levels. Insulin resistance is a disorder in which the insulin may not show appropriate action compared to the concentration present in the body (Kautzky-Willer et al., 2016). The loss of insulin production in main targeted organs such as muscles and liver is a general pathophysiologic symptom of diabetes.

Levitt-Jones Clinical Reasoning for Nursing Priorities

The Levitt-Jones clinical reasoning cycle plays a critical role in analysis method to evaluate the case study for Mr. X's diagnosis. This form of thinking assists in adapting to his health problem in the hospital setting during his hospitalization and in ensuring that he, as a client, receives the best possible successful outcomes with less period. Identifying the problems from the patient conditions and using the cues in establishing clinical knowledge, goals and critical thinking in nurses aims to facilitate open-minded safety of patients and person-centered care which is the positive outcome of this role (Labrague et al., 2019). The process of contemplation in the acute hospital environments assists in managerial skills and focuses on improving care. The two nursing care priorities selected are the management of the risk of falls and hypertension conditions.

Hypertension Management

Hypertension is a blood pressure that regularly reaches more than 140 mm Hg (Volpe et al., 2019). The goals of nursing care include preserving and improving patients' cardiovascular functioning. Another concern that includes nurses for a patient with hypertension is to avoid complications. Patients must be presented with information on the process/prognosis of disease and treatment plan. Even the patient needs the support and treatment to properly manage the disease (Benetos et al., 2019). Evaluate the individual's reaction to the exercise, considering pulse rates more than 20 beats per min faster than rest levels; pronounced rise in BP after and during activity (diastolic pressure rise of 20 mm Hg or systolic pressure increase of 40 mm Hg ). The chest pain, extreme fatigue, diaphoresis, blurred vision, or health conditions are monitored. The parameters mentioned are useful for assessing physiological reactions to stress from exercise and are indicators of over-exertion where they are present (Kitt et al., 2019). Assess patient symptoms, resistance to exercise, signs of acute exhaustion, swelling of the extremities, gradual weight gain, and persistent breathlessness.

Fall Prevention Management

In older people, falls are a significant cause of morbidity and disability. Over one-third of people, 65 years of age or older fall every year, and the collapses are frequent in half of those case scenarios. The probability of falling rises concerning the extent of chronic musculoskeletal pain, the numbers of joints groups affected as well as the form of physical activity intervention. Falls are triggered by many reasons and it's crucial to have a comprehensive approach to the person and environment. If a person is deemed to be at high risk for falling during the evaluation, a health care professional may perform a falls risk assessment to provide a more comprehensive description of the risk of falling for the patient (van Rhyn & Barwick, 2019). Risk evaluation for falls includes using an established approach that professionals have proven to be effective in determining the causes of falls of a person. Re-evaluation is needed when health and circumstances change for an individual. Focus on providing indications or a brace label to warn health care professionals to develop fall precautionary practices for falls-threatening patients. Keeping the beds down to the ground decreases the risk of falling and serious injury. In certain health-care settings, placing the mattress on the floor significantly reduces the possibility of falling (Tucker et al., 2019).

Health Education Based on Diabetes

Highly dependent on patient education is the order to ensure strategic decision making. Given that patients are much more informed with their condition and possible care options, they tend to be more likely to determine whether or not to get their medication. The planning of health education involves educating patients about basic information about diabetes and its management. The patient is made to understand about using devices for diabetes such as insulin pumps, blood glucose meters, insulin pens, and blood sugar monitoring (Vandenbosch et al., 2018). Patients are encouraged to develop healthier eating habits from nutrition education, involving meal preparation, weight-loss approaches as well as other nutritional therapy related to the disease. Even the learning of problem-solving strategies and strategies to self-manage diabetes is told to diabetic patients. The self-management of the diseases will make them independent. A diabetic patient should also know to Monitor blood glucose and interpretation of the readings and appropriately respond to the results. The patient can also be educated about their medication’s mechanism of action, side effects, efficacy, toxicity, prescribed dosage, and more. A diabetic patient can also be made to develop skills for handling stressful situations (Zhang & Chu, 2018).

Pharmacokinetics of The Drugs


Metformin lowers blood sugar levels by reducing hepatic glucose production (gluconeogenesis), reducing glucose uptake in the intestines, and increase insulin sensitivity by raising peripheral glucose uptake and use. Excretion of metformin is about 3.5 times greater than those of creatinine removal, suggesting that renal tubular clearance is the principal route of metformin elimination (Liang & Giacomini, 2017). After oral administration, the kidneys remove about 90 percent of the absorbed metformin within the first 24 hours after the drug is taken. The removal half-life in the plasma and the blood is around 17.6 hours, indicating that the erythrocyte mass could be affected by it. The kidney is responsible for the clearance of the metformin drug and in the kidney the main route for the removal is the tubular secretion. In the case of oral administration of metformin, within the first 24 hours, about 90% of the absorbed drug is removed through the renal excretion (Markowicz-Piasecka, et al., 2017).


Metoprolol is a cardiac-specific inhibitor of beta-1 adrenergic receptors with a marginal effect on beta-2 receptors. This interference reduces cardiac production by generating chronotropic and inotropic harmful impacts without action against membrane stabilization or inherent sympathomimetics. Metoprolol is consumed pretty much completely in the gastrointestinal tract when taken orally. The average plasma concentrations are reached 20 min after IV infusion, and 1-2 hours after orally administered (Dransfield et al., 2019). Bioavailability of metoprolol, when injected through IV, is 100 percent but when given orally it poses up to 50 percent for the tartrate derivatives and 40 percent for the succinate derivatives. Metoprolol passes under significant first-pass hepatic metabolism comprising approximately 50 percent of the dosage. Metoprolol processing is mainly regulated by the action of CYP2D6, and to a smaller extent by the action of CYP3A4. Metoprolol is predominantly excreted by the kidneys. Less than 5 percent of the dose taken is retrieved intact (García-Prieto et al., 2017). The immediately published metoprolol formulations give a half-life of roughly 3-7 hours. The estimated clearance rate in individuals with normal renal function is 0.8 L / min (Ryu et al., 2016).

References for Hypertension Management in Older and Frail Older Patients

Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research124(7), 1045-1060.

Dransfield, M., Voelker, H., Bhatt, S., Brenner, K., Casaburi, R., Come, C., & Hatipo?lu, U. (2019). Metoprolol for the prevention of acute exacerbations of COPD. New England Journal of Medicine381(24), 2304-2314.

García-Prieto, J., Villena-Gutiérrez, R., Gómez, M., Bernardo, E., Pun-García, A., García-Lunar, I. & García-Ruiz, J. (2017). Neutrophil stunning by metoprolol reduces infarct size. Nature Communications8(1), 1-15.

Kautzky-Willer, A., Harreiter, J., & Pacini, G. (2016). Sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus. Endocrine Reviews37(3), 278-316.

Kitt, J., Fox, R., Tucker, K., & McManus, R. (2019). New approaches in hypertension management: A review of current and developing technologies and their potential impact on hypertension care. Current Hypertension Reports2 (6), 44.

Labrague, L., McEnroe?Petitte, D., & Tsaras, K. (2019). Predictors and outcomes of nurse professional autonomy: A cross?sectional study. International Journal of Nursing Practice25(1), e12711.

Liang, X., & Giacomini, K. (2017). Transporters involved in metformin pharmacokinetics and treatment response. Journal of Pharmaceutical Sciences106(9), 2245-2250.

Markowicz-Piasecka, M., M Huttunen, K., Mateusiak, L., Mikiciuk-Olasik, E., & Sikora, J. (2017). Is metformin a perfect drug? Updates in pharmacokinetics and pharmacodynamics. Current Pharmaceutical Design23(17), 2532-2550.

Rehman, K., & Akash, M.(2017). Mechanism of generation of oxidative stress and pathophysiology of type 2 diabetes mellitus: How are they interlinked? Journal of Cellular Biochemistry118(11), 3577-3585.

Ryu, R. J., Eyal, S., Easterling, T. R., Caritis, S. N., Venkataraman, R., Hankins, G. & Phillips, B. (2016). Pharmacokinetics of metoprolol during pregnancy and lactation. The Journal of Clinical Pharmacology56(5), 581-589.

Tucker, S., Sheikholeslami, D., Farrington, M., Picone, D., Johnson, J., Matthews, G. & Petrulevich, K. (2019). Patient, nurse, and organizational factors that influence evidence?based fall prevention for hospitalized oncology patients: An exploratory study. Worldviews on Evidence?Based Nursing16(2), 111-120.

van Rhyn, B., & Barwick, A. (2019). Health practitioners’ perceptions of falls and fall prevention in older people: A metasynthesis. Qualitative Health Research29(1), 69-79.

Vandenbosch, J., Van den Broucke, S., Schinckus, L., Schwarz, P., Doyle, G., Pelikan, J. & Terkildsen-Maindal, H. (2018). The impact of health literacy on diabetes self-management education. Health Education Journal77(3), 349-362.

Volpe, M., Battistoni, A., Rubattu, S., & Tocci, G. (2019). Hypertension in the elderly: Which are the blood pressure threshold values?. European Heart Journal Supplements: Journal of the European Society of Cardiology21(Suppl B), B105.

Zaccardi, F., Webb, D., Yates, T., & Davies, M. (2016). Pathophysiology of type 1 and type 2 diabetes mellitus: A 90-year perspective. Postgraduate Medical Journal92(1084), 63-69.

Zhang, Y., & Chu, L. (2018). Effectiveness of systematic health education model for type 2 diabetes patients. International Journal of Endocrinology2018.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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