A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta
A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.
He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?” he asks. “The doctor already knows the sugars are high.”
A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.
During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).
His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health.
A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.
Physical Exam
A physical examination reveals the following:
- Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m2
- Fasting capillary glucose: 166 mg/dl
- Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg
- Pulse: 88 bpm; respirations 20 per minute
- Eyes: corrective lenses, pupils equal and reactive to light and accommodation, no retinopathy
- Lungs: clear to auscultation
- Heart: Rate and rhythm regular, no murmurs or gallops
- Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally
- Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes
Lab Results
Results of laboratory tests (drawn 5 days before the office visit) are as follows:
- Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
- Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
- Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
- Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
- Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
- Lipid panel
• Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
• HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)
• LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)
• Triglycerides: 177 mg/dl (normal: <150 mg/dl)
• Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)
- A1C: 8.1% (normal: 4–6%)
- Urine microalbumin: 45 mg (normal: <30 mg)
Assessment
Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:
- Uncontrolled type 2 diabetes (A1C >7%)
- Obesity (BMI 32.4 kg/m2)
- Hyperlipidemia (controlled with atorvastatin)
- Peripheral neuropathy (distal and symmetrical by exam)
- Hypertension (by previous chart data and exam)
- Elevated urine microalbumin level
- Self-care management/lifestyle deficits
• Limited exercise
• High carbohydrate intake
• No SMBG program
- Poor understanding of diabetes
Question 1
Is teaching a priority of care for Mr. B at this time? Why or why not?
Question 2
What actions should the nurse take at this time?
Question 3
Can learning take place? Why or why not? Discuss factors that affect or inhibit learning.
Question 4
Discuss strategies that the nurse could use to enhance Mr. B’s readiness to learn.
Question 5
Which learning theory would be best used for teaching Mr. B and why?
Question 6
Discuss which priority topics need to be discussed and how the nurse could teach Mr. B using strategies that would enhance learning.
Question 7
List a priority NANDA for Mr. B and a measurable goal based on desired learning outcomes.
Question 8
Describe how to implement and evaluate Mr. B’s teaching plan.
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