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NRSG265 Principles of Nursing: Medical

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Case Study Information

Mr Vinh Nguyen is a 48-year-old male, who emigrated from Vietnam over 30 years ago. He currently lives with his mother-in-law and son (age 21) in the Inner West City of Sydney. Mr Nguyen presented to his GP clinic following a fall in his kitchen this morning, after becoming “lightheaded and dizzy while making breakfast”.  

Following the review of his laboratory tests and assessment results, Mr Nguyen has been diagnosed with Type 2 diabetes mellitus. 

He has since been referred to you, the practice nurse, for a care plan to manage his condition and improve his overall health. 

Based on the information provided in this case study, you are required to present your oral assessment using the instructions below.

Please ensure you go to the next section for more information about Mr Nguyen.

Instructions

The key components of Assessment are:

  • Step 1 and 2: Consider the patient situation and identify the key elements of assessment by:

    • developing and presenting a concept map of Mr Nguyen and his situation;
    • discussing in detail, the pathophysiology of the disease and how Mr Nguyen’s signs and symptoms reflect the underlying pathophysiology;
    • identifying the key elements including new and current information;
    • Including evidence to support the content of your concept map.

  • Step 3 and 4: Process patient information, identifies relevant activities of living impacted, and identifies nursing issues for the patient:

    • Interpret and analyse the information you have been given about his condition;
    • Identify and prioritise 3 nursing issues you must address for Mr Nguyen, and justify why they are priorities and support your discussion with evidence;
    • discuss the potential impact of the disease on Mr Nguyen’s 3 most important activities of living. Link your discussion to the Roper-Logan and Tierney model. 

  • Steps 5 and 6: Establish goals and take action:

    • Identify 3 SMART goals with comprehensive discussion of the desired outcome, within a suitable time frame;
    • Identify interventions to achieve the above goals. The interventions should:
      • be both nursing and patient based;
      • consider both pharmacological and non-pharmacological management;
      • recognise strategies to empower and education Mr Nguyen to take initiative to alter his lifestyle factors

    • Steps 7 and 8 - Evaluation and Reflection:

      • Consider what strategies/aspects would determine that the patient and nurse interventions have been successful or effective for Mr Nguyen?
      • Include your conclusion here, and part of that should include an overall statement of what have you learned from doing this case study (what has been learnt, what went well, and what could have been improved)

 Case Study - Mr Vinh Nguyen

You have been provided with the following case study about Mr Vinh Nguyen, who presented to his GP clinic following a fall in his kitchen this morning, after becoming “lightheaded and dizzy while making breakfast”.  

Mr Vinh Nguyen is a 48-year-old male, who emigrated from Vietnam over 30 years ago. He currently lives with his mother-in-law and son (age 21) in the Inner West City of Sydney. His wife passed away 6 years ago due to complications from lung cancer.

Mr Nguyen works full time as a civil construction labourer and is currently working overtime most weekends, averaging 50 hours/week. He states that he “needs the extra income to support his son, who lost his job due to COVID-19”. He has been feeling dizzy and lightheaded now for a few days, but this morning was the first time he had fallen over. He had been feeling more fatigued over the past few weeks, but attributed this to his long working hours, as well as “being up all hours during the night to urinate”, which was impacting on his sleep.

He smokes 3 packs of cigarettes per week, and drinks 2 beers every evening with his dinner as this is the “only way he can relax”. Recently, he has taken to drinking more beer in the evenings as he “was always feeling so thirsty, and only beer could quench this thirst”. Due to his long working hours, and as his mother-in-law and son cannot cook, the family eat takeaway 6 times/week and then go to his sister’s house for dinner every Sunday.

He has a past medical history of gout, asthma, and hypothyroidism, for which he is on daily thyroxine hormone replacement. He is currently awaiting a sleep study for possible Obstructive Sleep Apnoea (OSA).

Following the review of his laboratory tests and assessment results, Mr Nguyen has been diagnosed with Type 2 diabetes mellitus. He has been prescribed metformin 500mg BD, with a review of dosage scheduled for 4 weeks’ time.

He has since been referred to you, the practice nurse, for a care plan to manage his condition and improve his overall health. 

Family history:

  • Father passed away in 2015 due to an AMI.
  • Mother had lung cancer in 2017 and is in remission currently. She resides in Vietnam.

 Medications:

  • Thyroxine 100mcg daily
  • Salbutamol 2 puffs PRN
  • Budesonide 500mcg daily
  • Allopurinol 500mg daily 
  • Ibuprofen 400mg PRN for gout attacks

Current vital observations:

  • BP 102/65 mmHg
  • HR 106 bpm
  • RR 20 bpm
  • SpO2 98% on RA
  • T 36.7C

Health assessment findings:

  • Height 1.6m, Weight 90kg, excess abdominal fat evident. Waist circumference 105cm
  • Total cholesterol level - 9.2mmol/L
  • Current BGL – 23.5 mmol/L (last meal 6 hours ago). No blood ketones present
  • Urine dipstick showed glucose, no ketones
  • Alert and orientated to time, place, and person. GCS 14
  • Cool, dry hands and feet. Dry mucous membranes
  • CRT 3 seconds

NRSG265 Principles of Nursing: Medical

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