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NURS FPX 6610 Assessment 2 Patient Care Plan

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    NURS FPX 6610 Assessment 2 Patient Care Plan

    Student Name

    Capella University

    NURS-FPX 6610 Introduction to Care Coordination

    Prof. Name

    Date

    Patient ID: 6700891

    Patient Medical Diagnosis: Poorly controlled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia.

    Nursing Diagnosis, Assessment Data, Goals and Outcome, Nursing Interventions, Rationale, Outcome Evaluation, and Re-planning

    Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis. Write two goal statements for each nursing diagnosis. Goals must be patient- and family-focused, measurable, attainable, reasonable, and time-specific. List at least three nursing or collaborative interventions; provide the rationale for each goal and outcome. Explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention. Were the goals met? How would you revise the plan of care according to the patient’s response to the current plan of care? Support your conclusions with outcome measures and professional standards.

    Nursing Diagnosis

    First Diagnosis: Improper healthcare management and the least education about the risk of diabetes can lead to serious consequences.

    Risk of improper healthcare management Subjective: Mrs. Snyder, married, mother of two, 56 years old, is under treatment for hyperglycemia and uncontrolled diabetes.

    Risk of a consistent rise in diabetes. Objective: Admitted with sugar levels of 230-389, dyspnea on exertion, low abdominal discomfort, malaise, urination problems, and HTN.

    Second Diagnosis: Higher domestic burden and difficulty making meals for family members who are allergic to some food and lactose intolerant. Mrs. Snyder neglects her health due to validation and compliments from her husband.

    First Goal: Ensure Mrs. Snyder’s blood pressure and diabetes level are under control. Diabetes management is crucial due to cancer-related hormonal changes.

    NURS FPX 6610 Assessment 2 Patient Care Plan

    Patient will report improvement in her eating habits and personal health. 

    First Intervention: Raise awareness about self-care management. Educate on lifestyle modifications, such as a healthy diet, physical activity, good sleep patterns, mindfulness, and practice. Reduce weight in three months. Control snacking habit in one month.

    Second Intervention: Encourage diabetes self-monitoring at home. Educate on insulin administration. Teach the patient to make an insulin syringe.

    First Goal Rationale: Thorough blood sugar level record is essential for diabetes control. Dietary modifications, adherence to insulin doses, and physical activity are crucial for health improvement.

    Outcomes: Assess efficacy of diet, exercise, and insulin dosing through glucose logs. Adjust diabetes medication dosages as needed.

    Subjective: Constant anxiety due to situational crisis leading to feeling overwhelmed, depressed, anxious, and weak. Managing households, husband not very helpful, son issues.

    Second Goal: Improved mental health and emotional well-being. Controlled blood pressure and normal cardiac pulse rate within one month under treatment.

    Second Intervention: Prescribe tolerable anxiolytics. Weekly counseling sessions (CBT) for anxiety control. Connect with social groups for mindfulness and spiritual healing.

    Second Goal Rationale: Combination of pharmacology and psychotherapy for anxiety control. Reduction in anxiety level to lower blood pressure and tachycardia.

    Outcomes: Ongoing assessment to revise the healthcare plan based on patient’s needs.

    Third Diagnosis: Patient diagnosed with Ovarian Cancer.

    Third Goal: Multiple options for better care of her mother through facility placement. Relief for Mrs. Snyder to focus on chemotherapy.

    Third Intervention: Refer Mrs. Snyder to a counselor for caregiver role. Find a social worker for a good placement facility. Pain assessment thrice a day. Patient education on nonpharmacological methods for pain relief.

    Third Goal Rationale: Elderly patient healthcare placement for caregiver relief. Nonpharmacological interventions effective for cancer patients in pain relief.

    Outcomes: Ongoing assessment; focus on care plan after finding healthcare facility for Mrs. Snyder’s mother.

    SMART Goals

    1. Control Mrs. Snyder’s diabetes within one week.
    2. Improve physical health and reduce malaise within a month.
    3. Reduce Mrs. Snyder’s anxiety level by 70% on discharge day.
    4. Find a good care facility placement for her mother within 15 days.
    5. Mrs. Snyder able to tolerate exertion within three months.
    6. Increase oxygenation by discharge date and achieve pain relief within one hour of treatment.

    Psycho-sociocultural aspects of care: 

    Mrs. Snyder’s status as a mother of five and a Jewish community member requires consideration of kosher food consumption.

    Outcomes: Goals not yet met. Continuous monitoring of patient’s pain during chemotherapy for necessary adjustments to care plan and pharmacological interventions.

    References

    Cancer.net. (2021, October 6). Managing diabetes when you have cancer. https://www.cancer.net/navigating-cancer-care/when-cancer-not-your-only-health-concern/managing-diabetes-when-you-have-cancer

    Carolina, C. M. (2019, October 16). Unlocking the full potential of self-monitoring of blood glucose. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose

    Goodtherapy.org. (2019, September 23). Therapy for self-love, therapist for self-love issues. https://www.goodtherapy.org/learn-about-therapy/issues/self-love

    Heart.org. (2021, May 6). Living healthy with diabetes. https://www.heart.org/en/health-topics/diabetes/prevention–treatment-of-diabetes/living-healthy-with-diabetes

    SeniolLiving.org. (2022, May 26). Ass

    isted living & senior placement agencies. https://www.seniorliving.org/placement-agencies/

    Pegg, S., Hill, K., Argiros, A., Olatunji, B. O., & Kujawa, A. (2022). Cognitive behavioral therapy for anxiety disorders in youth: Efficacy, moderators, and new advances in predicting outcomes. Current Psychiatry Reports, 24(12). https://doi.org/10.1007/s11920-022-01384-7

    NURS FPX 6610 Assessment 2 Patient Care Plan

    Ramzan, B., Harun, S. N., Butt, F. Z., Butt, R. Z., Hashmi, F., Gardezi, S., Hussain, I., & Rasool, M. F. (2022). Impact of diabetes educator on diabetes management: Findings from diabetes educator assisted management study of Diabetes. Archives of Pharmacy Practice, 13(2), 43–50. https://doi.org/10.51847/2njmwzsnld

    Sheikhalipour, Z., Ghahramanian, A., Fateh, A., Ghiahi, R., & Onyeka, T. C. (2019). Quality of life in women with cancer and its influencing factors. Journal of Caring Sciences, 8(1), 9–15. https://doi.org/10.15171/jcs.2019.002

    Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Aerzteblatt Online, 115(37). https://doi.org/10.3238/arztebl.2018.0611

    Nursing.usc.edu. (2018, January 9). What does self-care mean for diabetic patients? https://nursing.usc.edu/blog/self-care-with-diabetes/