Patience Williams: Clinical Case Study and Nursing Management

Assignment Brief

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Patience Williams

Patience is a 58-year-old woman who has lived in the UK since coming with her parents from Jamaica in the late 1960s. Patience trained as a nurse in the 1980s but gave up after marrying her late husband, Lionel. After marriage, Patience lost contact with her parents and two brothers as they disapproved of her marriage to a white man. Patience has four grown-up children, her eldest daughter Amber lives nearby with her wife Susan, but Patience refuses to maintain contact because she disapproves of her same-sex relationship.  Patience’s second daughter Rebecca and eldest son Aaron both now live in Australia and her youngest son Rodell has just started university in Liverpool. Lionel died in a road accident sixteen years ago when Rodell was under two. After this Patience began to struggle with depressionand started to gain weight. Patience is visited daily by her friend Cantrice from the local Kingdom Hall of Jehovah’s Witnesses that Patience used to attend, she shops and cleans for Patience and provides her with cooked meals five days a week.

Patience now has a BMI of 37 and struggles with mobility; she lives in a third-floor council flat. She was diagnosed with Type-2 diabetes 10 years ago and this is poorly controlled.

Patience is visited at home by the community nurse who is anxious that her condition is deteriorating and feels she needs reviewing by the diabetic consultant clinic. Patience is not keen on attending the hospital.  

Following review by the diabetic consultant Patience’s diabetic control improves. On her latest visit, her blood sugar was 12.5mmol/l and her HbA1c has improved from 13.8 to 10.9. However, Patience is still gaining weight and has become even more depressed and immobile.

OBSERVATIONS TAKEN BY COMMUNITY NURSE AT TIME INITIAL OF HOME VISIT

Airway: Able to talk in full sentences when at rest.

Breathing: RR 25 at rest, feels breathless with deep gasping breaths.

Circulation: HR 114, BP 205/110,

Disability: AVPU: Patience is alert and orientated.

Exposure:  Temperature 36.4C, Blood sugar ‘HI’ on BM test.

Problem 1:

Using the A-E approach, what are the nursing priorities for Patience’s care?

Problem 2:

Provide a rationale for the care you have suggested in Problem 1. Remember to use relevant pathophysiology, pharmacology and appropriate care guidelines to support your argument.

Developing Scenario:

Two years later Patience is much better. Following counselling and successful help with dieting, her BMI is now 28 and she has regained considerable mobility and is again attending the Kingdom Hall. Patience’s type-2 diabetes is now much better controlled. Microvascular complications from Patience’s diabetes persist however.

Problem 3:

How might Patience’s rehabilitation in terms of regaining movement and returning to previous life activities have been managed in the community taking into account the multi-disciplinary team and the likely availability of services to help Patience to rehabilitate.

Sample Answer

Patience Williams: Clinical Case Study and Nursing Management

Introduction

Long-term conditions such as Type 2 Diabetes Mellitus (T2DM) are among the leading causes of morbidity in the United Kingdom, significantly affecting physical, psychological, and social wellbeing. Effective nursing care for individuals with chronic diseases requires not only clinical competence but also an understanding of the biopsychosocial factors influencing the patient’s health. This essay analyses the case of Patience Williams, a 58-year-old woman with poorly controlled T2DM and obesity, using the A–E approach to identify nursing priorities, provide evidence-based rationales, and discuss her long-term rehabilitation and recovery in the community setting.

Problem 1: Nursing Priorities for Patience’s Care (A–E Approach)

The A–E approach (Airway, Breathing, Circulation, Disability, Exposure) provides a systematic and structured assessment framework for identifying and managing patient deterioration (Resuscitation Council UK, 2021).

Airway

Patience is able to talk in full sentences, indicating that her airway is patent. However, continuous assessment is necessary because diabetic ketoacidosis (DKA) or severe hyperglycaemia can cause dehydration, leading to reduced consciousness and airway compromise.

Priority: Maintain airway patency through regular monitoring, ensuring readiness to escalate if consciousness deteriorates.

Breathing

Patience’s respiratory rate is 25 breaths per minute with deep, gasping respirations, which are consistent with Kussmaul breathing, a compensatory mechanism for metabolic acidosis due to hyperglycaemia (McCance & Huether, 2019). This indicates that her body is attempting to reduce CO₂ to buffer blood pH.

Priority: Monitor respiratory rate, oxygen saturation, and effort. Administer oxygen if SpO₂ falls below 94% (NICE, 2023). Immediate blood gas analysis should be undertaken to confirm acidosis. Encourage upright positioning to ease breathing and prepare for urgent medical review if deterioration occurs.

Circulation

Patience’s heart rate is 114 bpm (tachycardic) and blood pressure is 205/110 mmHg, which suggests hypertension and possible cardiovascular strain. Hyperglycaemia contributes to endothelial dysfunction and increased vascular resistance, exacerbating hypertension (Association of British Clinical Diabetologists, 2022). Her circulation is therefore a critical concern.

Priority: Record pulse, BP, and capillary refill time regularly. Administer antihypertensive therapy as prescribed (e.g., ACE inhibitors or calcium channel blockers). Monitor for signs of dehydration, as hyperglycaemia leads to osmotic diuresis and volume loss. Initiate fluid balance monitoring and document urine output.

Disability

Patience is alert and oriented, which is reassuring, but her blood glucose reading is ‘HI’ on bedside monitoring, indicating dangerously high levels (likely >33 mmol/L). This could lead to hyperosmolar hyperglycaemic state (HHS), a potentially fatal condition characterised by altered consciousness, dehydration, and electrolyte imbalance (Joint British Diabetes Societies, 2020).

Priority: Conduct neurological observations regularly. Assess for confusion, slurred speech, or weakness, which could suggest evolving HHS or stroke secondary to hypertension.

Continued...