Reverse Case Study: Holistic and Culturally Humble
Care for a Native American Patient with
Diabetic Foot Ulcer and Comorbid Depression
NUR 302 Project Two: Reverse Case Study
Institution: Southern New Hampshire University
Instructor: [Instructor Name]
Date: June 10, 2026
, NUR 302 Project Two: Reverse Case Study
Abstract
This reverse case study examines the care of Sequoia, a 54-year-old widowed Native
American female presenting with a non-healing diabetic foot ulcer, poorly controlled
type 2 diabetes mellitus (HbA1c 9.4%), hypertension, and recent-onset major depressive
disorder following the death of her spouse eight months prior. The analysis applies the
NCSBN Clinical Judgment Measurement Model (NCJMM) to work backward from the
clinical presentation to the underlying pathophysiology—chronic hyperglycemia
causing peripheral neuropathy and impaired wound healing, compounded by
grief-related depression and social isolation. Evidence-based interventions for diabetic
foot ulcer management, glycemic optimization, and depression screening are integrated
with cultural humility principles, including the respectful incorporation of traditional
healing practices and acknowledgment of historical trauma. Social Determinants of
Health—rural residence, transportation barriers, food insecurity, and social
isolation—are identified as primary drivers of the health crisis, necessitating
interprofessional collaboration with wound care specialists, social workers, dietitians,
and tribal health resources.
Keywords: reverse case study, diabetic foot ulcer, Native American health, cultural
humility, social determinants of health, clinical judgment, type 2 diabetes
1. Introduction
A reverse case study requires the clinician to begin with the patient's current presentation and
work backward through the pathophysiology, contextual factors, and systemic barriers that
produced it. This approach illuminates not only the biological mechanisms of disease but also the
social, cultural, and psychological determinants that shape patient outcomes. Sequoia, a 54-year-old
widowed Native American female, presents with a non-healing plantar foot ulcer, an HbA1c of
9.4%, blood pressure of 148/92 mmHg, and expressed hopelessness about managing her health. Her
clinical picture is inseparable from her social context: she lives alone in a rural area with limited
transportation, has lost her spouse—her primary support system—eight months ago, and reports a
sense of purposelessness that raises concerns for depression and potential suicidal ideation. This
paper applies the NCJMM to identify prioritized nursing hypotheses, outlines evidence-based
interventions, and integrates cultural humility and SDOH into a holistic, interprofessional care plan.
2. Pathophysiology and Clinical Judgment
Applying the NCJMM begins with recognizing cues: an elevated HbA1c of 9.4%, fasting blood
glucose of 185 mg/dL, a non-healing plantar ulcer, hypertension, recent widowhood, expressed
hopelessness, rural residence, and limited transportation access. Analyzing these cues reveals the
interplay of chronic hyperglycemia, psychological distress, and social deprivation. Twelve years of
poorly controlled type 2 diabetes mellitus (T2DM) has caused progressive microvascular and
macrovascular damage, resulting in peripheral neuropathy—the loss of protective sensation in the
feet—and impaired tissue perfusion that compromises wound healing [1]. The plantar surface,
bearing maximum mechanical stress during ambulation, is particularly vulnerable to ulceration in
the insensate foot.
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Care for a Native American Patient with
Diabetic Foot Ulcer and Comorbid Depression
NUR 302 Project Two: Reverse Case Study
Institution: Southern New Hampshire University
Instructor: [Instructor Name]
Date: June 10, 2026
, NUR 302 Project Two: Reverse Case Study
Abstract
This reverse case study examines the care of Sequoia, a 54-year-old widowed Native
American female presenting with a non-healing diabetic foot ulcer, poorly controlled
type 2 diabetes mellitus (HbA1c 9.4%), hypertension, and recent-onset major depressive
disorder following the death of her spouse eight months prior. The analysis applies the
NCSBN Clinical Judgment Measurement Model (NCJMM) to work backward from the
clinical presentation to the underlying pathophysiology—chronic hyperglycemia
causing peripheral neuropathy and impaired wound healing, compounded by
grief-related depression and social isolation. Evidence-based interventions for diabetic
foot ulcer management, glycemic optimization, and depression screening are integrated
with cultural humility principles, including the respectful incorporation of traditional
healing practices and acknowledgment of historical trauma. Social Determinants of
Health—rural residence, transportation barriers, food insecurity, and social
isolation—are identified as primary drivers of the health crisis, necessitating
interprofessional collaboration with wound care specialists, social workers, dietitians,
and tribal health resources.
Keywords: reverse case study, diabetic foot ulcer, Native American health, cultural
humility, social determinants of health, clinical judgment, type 2 diabetes
1. Introduction
A reverse case study requires the clinician to begin with the patient's current presentation and
work backward through the pathophysiology, contextual factors, and systemic barriers that
produced it. This approach illuminates not only the biological mechanisms of disease but also the
social, cultural, and psychological determinants that shape patient outcomes. Sequoia, a 54-year-old
widowed Native American female, presents with a non-healing plantar foot ulcer, an HbA1c of
9.4%, blood pressure of 148/92 mmHg, and expressed hopelessness about managing her health. Her
clinical picture is inseparable from her social context: she lives alone in a rural area with limited
transportation, has lost her spouse—her primary support system—eight months ago, and reports a
sense of purposelessness that raises concerns for depression and potential suicidal ideation. This
paper applies the NCJMM to identify prioritized nursing hypotheses, outlines evidence-based
interventions, and integrates cultural humility and SDOH into a holistic, interprofessional care plan.
2. Pathophysiology and Clinical Judgment
Applying the NCJMM begins with recognizing cues: an elevated HbA1c of 9.4%, fasting blood
glucose of 185 mg/dL, a non-healing plantar ulcer, hypertension, recent widowhood, expressed
hopelessness, rural residence, and limited transportation access. Analyzing these cues reveals the
interplay of chronic hyperglycemia, psychological distress, and social deprivation. Twelve years of
poorly controlled type 2 diabetes mellitus (T2DM) has caused progressive microvascular and
macrovascular damage, resulting in peripheral neuropathy—the loss of protective sensation in the
feet—and impaired tissue perfusion that compromises wound healing [1]. The plantar surface,
bearing maximum mechanical stress during ambulation, is particularly vulnerable to ulceration in
the insensate foot.
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