Assessment and Care Plan for Mr John


The present essay will discuss about a selected case study of Mr John which is a pseudonym assigned as per the General Data Protection Regulation (GDPR, 2018). The patient was manifesting the signs and indications of Type 2 Diabetes (T2D) along with Diabetic Ketoacidosis (DKA). The study will detail about the systematic approach of evaluation of the critical condition of the patient with regard to the process of decision making throughout the assessment phase of the patient by the healthcare practitioner. The assignment will look at the Biopsychosocial model of care and it will then describe the care plan for Mr John using the above mentioned model. It will then give recommendations for changes to the care plan supported by scientific evidences.


Clinical History (Biological factor):

The patient, Mr. John is 57 years old reached the acute care hospital with the following symptomatic manifestations of pain in the abdomen, tachycardia and queasiness along with signs of dehydration. The previous medical history of the patient reported that he had been suffering from T2D from the last ten years. The weight of the patient was 63 Kg. He had managed his condition of T2D with the aid of anti diabetic medication metformin hydrochloride twice daily.

Psychological Factor:

The mental state of the patient was found to be slightly altered and he was diagnosed with the ailment Diabetic Ketoacidosis. The patient had suffered from a traumatic experience of the death of his wife in a car accident and thereafter he got so much reliant on the habits of addiction to overcome his phases of depression. He also stated that he was not taking his medication properly on a daily basis because of his altered mental condition.

Social or Background History:

When the details of the social life of the patient were taken into consideration, he revealed that he leads a lonely life and also had a propensity for smoking and drinking. He was a chronic smoker with one bundle of cigarettes every day and consumed around four pints of alcohol every week. The condition of diabetes and his altered mental state has totally devastated his social life and therefore hardly had any contacts with his relatives who could have taken proper care of him.

The laboratory findings of the blood examination report of John confirmed that he was suffering from the moderate level problem of diabetic ketoacidosis as the glucose level of blood plasma is higher than >250 mg/dl, the concentration of bicarbonate is in lower than 15 mEq/l, pH range was within 7.0-7.24 (Wolfsdorf, et al., 2009).

The NEWS 2 chart was used to evaluate the signs and indications of the patient as it can warn the practitioners about the probable worsening condition of the patient. The guidelines highlights that a overall score of 5 or above acts as “trigger score” and demonstrate immediate clinical attention by the ward physicians. John had scored an aggregate score of 7 which highlighted about the critical condition of the patient. Moreover, he obtained red score for the vital sign of oxygen saturation which necessitates urgent clinical consideration by the physician as the situation indicates abnormality in health condition which can turn fatal within a short period (RCP, 2017).

Biopsychosocial model

This particular model was first hypothesized by George Engel in the year, 1977. The model highlights that to comprehend the medical condition of a patient, the healthcare professionals should not only consider the biological parameters but also the psychological and the social parameters (Adler, 2009).


The Look Listen and Feel (LLF) approach was used to the presence of any blockage within the respiratory pathway as the RR demonstrated NEWS score 2 (Resuscitation board, 2011). Then the physical evaluation approach was taken into consideration and therefore the head of the patient was tilted to comprehend any hindrance in the passage. A deep sound was heard due to which a suction pump was used to pull out the foreign substance. This care approach helped to remove the blockage and in turn prevent any further infection (Bush, 2015). This was the reason behind the feeling of queasiness and therefore the airway assessment was a necessity.


The LLF approach was used to assess John who was showing signs of tachycardia and Kussmaul breath (Hilliard, et al, 2016). This condition was attributed to the accumulation of carbonic acid due to gas carbon dioxide. The saturation level of oxygen was found to be below 96% therefore supplemental oxygen was administered to accomplish the suggested target oxygen level of 88 -92% having the SpO2 scale 2 as reference as per the guidelines of NEWS chart 2 (RCP, 2017).


The pulse of the patient was measured by hand and the patient had scored NEWS score 2. It was recommended to monitor the patient at regular intervals of half an hour. The capillary refill time (CRT) of the patient was found to be 6 seconds and it highlighted about the dehydrating condition of John (Shimizu, et al., 2012). Therefore, the clinical state of the patient was reported to senior staff to call the physician for recommendations. When the physician arrived the charge of the patient was handed over via the Situation, Background, Assessment, Recommendation (SBAR) approach and I also informed about the recent investigation such as blood reports and clinical and background history of the patient (Adrogué, et al., 2010; Lower, et al, 2010). Twelve lead ECG was recommended for further evaluation which demonstrated the condition of sinus tachycardia and blood test was suggested by the physician. The patient was advised with administration of fluid and therefore he was cannulised. The ECG test affirmed the accurate management of the patient (NICE, 2016).


The conscious state of the patient was evaluated using the Alert, Verbal, Pain, Unresponsive (AVPU) scale. The patient showed reactions to some of the voice commands. The altered mental condition was evaluated using the Glasgow Coma Score (GCS) which was necessary for the evaluation of airway patency (Resuscitation Council, 2011). The verbal and eye response of John was found to be 4.


After the assessment of the condition based on vital signs and clinical reports of investigation conducted of John, he was referred to the intensive care unit for further monitoring. As per the instruction of physician, the JBDS, 2010 group on diabetes was corresponded urgently for John (Hilliard et al., 2016). As he was diabetic therefore, the multidisciplinary care approach should be required that involved a registered dietician, psychologist and social workers along with the physicians for the betterment of his health. The patient was also educated to inform the healthcare staffs in case of any uneasiness faced by him (McDonald, et al., 2012).

Biological interventions:

The initial evaluation of the condition DKA is thought to be essential as the condition of hypoxia and hypothermia acts as triggering cause of metabolic acidosis (Gosmanov et al., 2014). Paracetamol was administered intravenously to John to reduce his suffering from torment. After the administration of the medication the torment score reduced from 6 to 2 (Greener, 2010). The patient was also administered with immediate insulin required by the body instantly to suppress the ketone bodies produced (Savage, et al., 2011). The evaluation of torment is considered to be under one vital aspect under the holistic approach of care plan as it impacts the decision making process of the clinicians (Rose et al., 2010). The patient was administered with crystalloid fluid of 0.9% of 1lt of normal saline for one hour and 0.9% potassium chloride for two hours respectively. The amount of fluid administered was properly documented and the patient’s skin was tested for the signs of oedema. Moreover, the balance chart of fluid was kept up to date after each hour and the patient was monitored at a regular interval of 30 minutes which was later extended to 60 minutes (Coresh, et al, 2014). The patient was catheterized as the mental state was not found to be normal and he was passing urine unknowingly. The urine sample was collected for subsequent analysis for the concentration of ketones and glucose. For the proper diagnosis of John, as a diagnostic approach ultrasonography was also conducted to evaluate the reasons behind the torment in the abdominal region (Hoffmann, et al., 2012). The patient had been referred to dietician to follow a strict nourishment regime to control his blood sugar and weight. The dietician educated the patient about the importance of correct meal routine and the medication metformin which should be administered at the accurate time to prevent the recurrence of the condition (Asma, et al., 2016).

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Social interventions:

As a part of the care approach John was educated about the ailments T2D and diabetic ketoacidosis, the importance of life style modifications (such as smoking abstinence and strict avoidance to alcohol) and adherence to treatment guidelines (NMC, 2015). Before the onset of the treatment plan he was informed according to the guidelines of NMC code, 2015. The social workers have a unique role to play as an early intervention services to diminish the burden of diabetes among the patients specifically by addressing the psychosocial factors that influences the outcomes of the treatment. They expanded the vital information and the resources needed by the patient and also conducted a comprehensive assessment of the psychosocial factors because of the chronic sickness that has been incorporated into the care plan. They provided the patient with the psychological or the emotional support, educated the client about the way of life changes and most importantly assisted the patient to obtain medication and the health insurance as he survives a lonely life (Miller, et al., 2013).

Psychological interventions:

However as his mental state was altered therefore the best plan of care was advocated by the in charge healthcare professional (Towle, et al., 2010). Psychologist was also communicated with in consideration of his altered mental condition and to uplift his withdrawal mood (McDonald, et al., 2012). The healthcare staff members also showed empathetic attitude towards the patient and inquired him about any uneasiness felt by the patient which could potentially warn about any forthcoming danger. Moreover, the patient was referred to the support service, diabetes, in the UK for counselling and education (NMC, 2015).

The patient identity and personal details were anonymised throughout the assignment as per NMC code, 2015.


The care approach of a critically sick patient was demonstrated throughout the essay along with the necessary interventions and the treatment plan adopted. The biological, psychological and the social interventions adopted for the patient are discussed to offer the best of care services and depending on evidence based practice.


Adrogué, H.J. and Madias, N.E., 2010. Secondary responses to altered acid-base status: the rules of engagement. Journal of the American Society of Nephrology, 21(6), pp.920-923.

Asma, D., Salima, A., Hana, Y., Layla, A., Shaker, S. and Mary, T., 2016. Improving glycemic control in children with diabetes through implementation of multidisciplinary team approach. J Endocrinol Diab, 3(1), pp.1-4.

Bush, S. and Ray, D., 2015. Basic airway management. Emergency Airway Management, p.20.

Clinical Biochemistry Reference Ranges Handbook Eastbourne District General Hospital Reviewed on 2019.

Coresh, J., Turin, T.C., Matsushita, K., Sang, Y., Ballew, S.H., Appel, L.J., Arima, H., Chadban, S.J., Cirillo, M., Djurdjev, O. and Green, J.A., 2014. Decline in estimated glomerular filtration rate and subsequent risk of end-stage renal disease and mortality. Jama, 311(24), pp.2518-2531.

Gosmanov, A.R., Gosmanova, E.O. and Dillard-Cannon, E., 2014. Management of adult diabetic ketoacidosis. Diabetes, metabolic syndrome and obesity: targets and therapy, 7, p.255.

Hilliard, M.E., Joyce, P., Hessler, D., Butler, A.M., Anderson, B.J. and Jaser, S., 2016. Stress and A1c among people with diabetes across the lifespan. Current diabetes reports, 16(8), p.67.

Nursing and Midwifery Council (Great Britain), 2015. The Code: Professional standards of practice and behaviour for nurses and midwives. NMC.

Resuscitation Council UK, 2011. Advanced Life Support, 6e. Resuscitation Council UK, London.

Rose, L. and Clarke, S.P., 2010. Vital signs. AJN The American Journal of Nursing, 110(5), p.11.

Shimizu, M., Kinoshita, K., Hattori, K., Ota, Y., Kanai, T., Kobayashi, H. and Tokuda, Y., 2012. Physical signs of dehydration in the elderly. Internal medicine, 51(10), pp.1207-1210.

Wolfsdorf, J., Craig, M.E., Daneman, D., Dunger, D., Edge, J., Lee, W., Rosenbloom, A., Sperling, M. and Hanas, R., 2009. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatric diabetes, 10, pp.118-133.

Adler, R.H., 2009. Engel's biopsychosocial model is still relevant today. Journal of psychosomatic research, 67(6), pp.607-611.

McDonald, J., Jayasuriya, R. and Harris, M.F., 2012. The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus. BMC Health Services Research, 12(1), pp.1-10.

Greener, M., 2010. Co-codamol: safely using an effective analgesic. Nurse Prescribing, 8(8), pp.369-374.

Savage, M.W., Dhatariya, K.K., Kilvert, A., Rayman, G., Rees, J.A., Courtney, C.H., Hilton, L., Dyer, P.H., Hamersley, M.S. and Joint, B.D.S., 2011. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic medicine: a journal of the British Diabetic Association, 28(5), p.508.

Hoffmann, B., Nürnberg, D. and Westergaard, M.C., 2012. Focus on abnormal air: diagnostic ultrasonography for the acute abdomen. European Journal of Emergency Medicine, 19(5), pp.284-291.

Miller, T.A. and DiMatteo, M.R., 2013. Importance of family/social support and impact on adherence to diabetic therapy. Diabetes, metabolic syndrome and obesity: targets and therapy, 6, p.421.

Towle, A., Bainbridge, L., Godolphin, W., Katz, A., Kline, C., Lown, B., Madularu, I., Solomon, P. and Thistlethwaite, J., 2010. Active patient involvement in the education of health professionals. Medical education, 44(1), pp.64-74.

Medical History of the patient:

The vital signs of the patient had been assessed as it was essential to comprehend the condition of Mr. John

Respiratory Rate: 22 bpm (NEWS 2; Normal range as per NEWS 2 chart: 12-20).

Heart beat: 123 bpm (NEWS 2; Normal range as per NEWS 2 chart: 51 – 90 every minute).

Blood Pressure: 143/89 (NEWS 0; Normal range of SBP as per NEWS 2 chart: 111-219).

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