Reconstructive Surgery - Nursing Diagnoses and Goals - Liam's Case Study Nursing Assessment Answer

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Liam's Case Study Assessment Answer

TASK: Liam’s Story After suffering a knee injury at age 37, that needed reconstructive surgery and slow recovery with extensive physiotherapy, Liam was advised to give up playing rugby. Over the next 15 years, Liam’s career progressed from floor salesperson to management and his working hours and stress levels increased.  He had very little exercise and my diet wasn’t so good. He usually just grabbed food from the nearest takeaway shop. He drank a fair bit of coffee, smoked a packet of cigarettes a day and, had 6 units of alcohol most days to help him unwind. He piled on the weight and generally felt unhealthy and exhausted. Liam finally decided to visit a doctor at the medical center near his work. Several tests revealed that Liam was obese, had high blood glucose and moderately high blood pressure. The GP referred Liam for a fasting glucose tolerance test, advised him to lose weight, reduce his alcohol intake, quit smoking and return after the glucose tolerance test to discuss further actions. He was also given a referral to the medical center’s dietician for specific nutrition advice.  Liam felt overwhelmed and wasn’t really sure where to start with all the changes. Not long after this, his workload increased again and he found it difficult to manage his stress levels, lose weight, quit smoking and reduce his alcohol intake. In the end, he didn’t go for the fasting glucose tolerance test. Although he made some effort to lose weight by reducing the number of his fast food meals.  Several months later Liam was taken to hospital after he suffered severe chest pains at work. Investigations showed that his blood pressure and blood glucose levels were very high. Liam was eventually diagnosed as suffering from Type 2 Diabetes and hypertension.    During Liam’s overnight hospital stay the diabetes educator showed him how to monitor his condition and advised that diet and lifestyle changes would be essential to achieve good control of his diabetes. He was given some practical first steps to control his weight, blood pressure and blood glucose and advised to work in partnership with his GP to manage his condition over the long term.  A week later, Liam kept his appointment with the endocrinologist at the Diabetes Outpatient Clinic. The diabetes educator discussed his progress with monitoring his condition and he had a consultation with the dietitian. Liam was offered the option to attend the Diabetes Clinic on a weekly basis to learn how to manage his disease. Unfortunately, Liam’s work commitments made this very difficult. As an alternative, he was given a letter for his GP and advised to visit the GP within a week for further review. Over the next year, Liam saw his GP intermittently for review and prescriptions. As instructed, he tried to monitor his glucose levels daily, stick to a low GI diet and to walk for 20 minutes each day. He lost a small amount of weight but the charting of his glucose levels showed patchy control and still felt generally unwell.    Written Assignment: A brief introduction explaining the Patient and related Model of Care

1. You are required to develop a client-centered care plan which includes the following;  

1. Identification and discussion of the client’s needs, problems, strengths and weaknesses in the assessment.
2. Three (3) nursing diagnoses and goals
3. Clear identification of nursing interventions and rationales for these
4. A plan for referrals, including justification for each
5. A timeline for review of the client’s progress toward goals

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