Assessment 1: Change Strategy and Implementation


Capella University


Professor Name

March, 2024

Part 1: Concept Map

In the Vila Health scenario, the concept map is employed as a vital tool for assessing a patient admitted with renal failure. This visual representation aids in educating the patient by correlating specific interventions and their expected results with each identified diagnosis. Concept maps are effective educational tools in healthcare settings, particularly for illustrating complex care plans. For nurses, a concept map becomes an essential part of patient care. It’s about understanding the medical condition and crafting a holistic care approach that yields optimal health outcomes. In this scenario, nurses are crucial in deciphering the patient’s health status and formulating a comprehensive strategy that addresses their unique needs (Eisenmann, 2021).

The usefulness of the concept map lies in its ability to provide a clear and organized overview of the patient’s condition. This overview is not limited to just the medical diagnosis but includes a range of pharmacological and non–pharmacological interventions. For a patient with renal failure, the concept map would outline interventions like medication management, dietary adjustments, fluid balance strategies, and lifestyle modifications, all tailored to the individual’s specific health situation. Research emphasizes the importance of integrating all aspects of patient care into the concept map (Sapra & Bhandari, 2023). This integration ensures that the proposed care plan is comprehensive and coherent, with each element of care logically connected to others. 

In Vila Health, this means creating a concept map that is not only medically accurate but also personalized to fit the unique environment and resources of the facility. A concept map is a navigational tool in patient care, guiding nurses in delivering targeted, effective, and patient-centric care. It helps break down the complexity of a medical condition like renal failure into manageable segments, making it easier for healthcare professionals and patients to understand and follow the care plan.

North American Nursing Diagnosis Association (NANDA)

In the case involving the NANDA nursing diagnosis standards, we examine the healthcare journey of Ms. Anderson, who is grappling with complications arising from Type 2 Diabetes Mellitus (T2DM), notably renal failure. Employing the Biopsychosocial model, my role as her nurse involves a thorough assessment of Ms. Anderson’s current health status, her specific diagnosis, the interventions we plan to undertake, and the expected outcomes of these interventions. Our concept map centers on Ms. Anderson, a 60-year-old lady battling T2DM. She was urgently admitted to Vila Health’s Emergency Department due to critical renal failure, exacerbated hyperglycemia, and rapid heartbeat. This concept map was formulated through direct interactions with Ms. Anderson, noting significant symptoms like elevated blood pressure, increased blood sugar levels, and a quickened heart rate (Selby & Taal, 2020). Additional concerns include skin complications caused by diabetes and issues related to her nutrition. The approach to Ms. Anderson’s care involves a combination of pharmacological treatments and lifestyle adjustments. Our investigative methodology rigorously analyzes these aspects, with a strong focus on patient safety and the efficacy of her treatment regimen. Based on the principles set forth by NANDA and the Biopsychosocial (BPS) model, several critical observations are pertinent for diabetic patient care:

  • A common issue in diabetic patients is obesity coupled with high blood sugar.
  • Regular monitoring and check-ups are vital for effective glucose level management.
  • Patients with diabetes have an increased risk of developing renal failure

These considerations are particularly relevant to Ms. Anderson’s condition, as she demonstrates typical symptoms of hyperglycemia and renal failure associated with T2DM. The concept map, therefore, acts as a tailored roadmap for her care, aligning with professional nursing standards and incorporating holistic health models (Varghese & Jialal, 2023). 

Part 2: Additional Evidence

Diabetes is a significant health concern in the U.S., affecting about 37.3 million people. Among them, a substantial portion is elderly, nearly half over 65. The concept map under discussion is noteworthy for incorporating evidence-based methods for managing a patient with Type 2 Diabetes Mellitus (T2DM) and renal failure, blending pharmacological and non-pharmacological treatments. For instance, Ms. Anderson, a patient with T2DM, also battles high blood pressure and anxiety. Her high glycemic index, recorded at 8.7, necessitates vigilant blood glucose monitoring. Elevated T2DM levels can escalate the risk of severe health complications, including mortality and paralysis (Wang et al., 2020). 

A key strategy in the concept map is reducing HbA1c levels below 7%, aligning with studies that mark this level as crucial for minimizing diabetes risks in older adults. Regular monitoring of HbA1c is essential for preventing severe retinopathy, as highlighted in the literature. Ms. Anderson’s sugar levels, which average 230 before meals and spike to over 350 afterward, underscore the danger of hypoglycemia, potentially leading to irreversible organ and tissue damage (Samsu, 2021). 

Ms. Anderson’s symptoms, including swollen legs, are indicative of potential diabetic renal failure, a condition often characterized by impaired blood circulation. Her fatigue and concentration issues could be linked to diabetic retinopathy, a prevalent condition affecting a significant portion of diabetic patients. The National Eye Institute’s recommendations on diabetes and blood pressure control through diet and medication are crucial in early-stage retinopathy prevention. 

The concept map relies on evidence from trusted sources, including peer-reviewed publications on diabetes. Current hyperglycemia treatment guidelines suggest oral glucose or insulin therapy, which is notably effective for managing HbA1c levels in Type II diabetes patients (Sagoo & Gnudi, 2020). The emphasis on patient self-care is fundamental, as ongoing self-management is vital for avoiding complications. For chronic renal failure, the suggested treatments include dietary modifications, tailored use of diuretics, and dialysis if necessary. Moreover, addressing psychological aspects such as anxiety through cognitive-behavioral therapy (CBT) is essential for holistic care (Sandra et al., 2023). 

Interprofessional Strategies Applied to Concept Map 

In an interprofessional healthcare framework, specialists collaborate to provide comprehensive patient care, including the primary care doctor, kidney specialist, nurses, and therapists. This approach is particularly effective in cases of renal failure, where integrated care significantly improves patient outcomes. An interprofessional team ensures comprehensive treatment, with each specialist contributing uniquely:

  • Physicians manage medication.
  • Therapists address mental health aspects like anxiety.
  • Nephrologists handle specific kidney-related issues.
  • Dietitians focus on nutrition and weight management.
  • This collective effort improves decision-making and healthcare quality (O’Flynn, 2022).

Particularly in managing Type 2 Diabetes Mellitus (T2DM), this strategy is beneficial as it encompasses the expertise of physicians, nurses, pharmacists, and therapists. Patient-centered care, another aspect of this approach, places the patient at the forefront of the healthcare team’s attention. For a patient like Ms. Anderson, who has renal failure compounded by hyperglycemia and hypertension, this means that her care plan is collaboratively developed and managed by the entire team. Each professional interacts with the patient and works in unison to meet her healthcare needs, allowing for adjustments in treatment, be it pharmacological or non-pharmacological (Spracklen et al., 2020). 

The ideal outcome of such a comprehensive care plan for Ms. Anderson would include controlled diabetes and blood sugar levels, early retinopathy detection and treatment, effective renal health management, weight reduction, high self-care capability, and reduced anxiety. Integrated, patient-centered care eliminates the need for multiple, separate treatments across different healthcare units. Additionally, medication management by the interprofessional team plays a crucial role in enhancing the quality of care through appropriate pharmacological interventions. This approach streamlines patient care and ensures a more holistic treatment plan that addresses all aspects of a patient’s health condition, leading to better overall health outcomes (Sapra & Bhandari, 2023).

Potential Challenges to Implement Interprofessional Strategies 

When implementing interprofessional healthcare strategies, various challenges may be encountered, such as:

  • Team Collaboration Difficulties: Struggles in establishing effective teamwork among diverse healthcare professionals.
  • Cultural and Linguistic Barriers: Challenges arising from differences in language and cultural backgrounds of team members.
  • Communication Gaps: The need for better-structured communication channels within the team.
  • Hierarchical Issues: Problems related to power dynamics and hierarchy within the healthcare team.
  • Educational Shortcomings: Insufficiencies in educational background that can affect the team’s collaborative efficiency (Schot et al., 2020). 

Addressing these challenges is crucial for enhancing interprofessional collaboration in healthcare settings.

Area of Uncertainty 

Understanding the impact of diabetes on renal health has been a complex issue due to various unresolved questions by healthcare providers. Challenges in diagnosing and managing the renal complications of diabetes are further compounded by factors such as the gaps in knowledge and skills of nurses and the general public’s lack of awareness about diabetes control. Additionally, the cultural diversity and language differences among interprofessional healthcare team members complicate the creation of an effective patient-focused concept map. It is very important to understand the pathophysiology and evaluation methods of chronic kidney disease in the context of diabetes, emphasizing the role of primary care physicians in mitigating the risks and complications associated with this condition (Charles & Ferris, 2020).

NURS FPX 6021 Assessment 1 Change Strategy and Implementation Conclusion :

To formulate an effective treatment plan, it is crucial to construct a comprehensive concept map that encompasses all facets of healthcare issue diagnosis. Nurses play a vital role in this process, as their competence in developing accurate concept maps is key to educating patients about their health conditions. This approach must be grounded in reliable evidence and research to ensure the efficacy of the healthcare outcomes (Cummings et al., 2021). 

NURS FPX 6021 Assessment 1 Change Strategy and Implementation References :

Charles, C., & Ferris, A. H. (2020). Chronic kidney disease. Primary Care, 47(4), 585–595. 

Cummings, G. G., Lee, S., Tate, K., Penconek, T., Micaroni, S. P. M., Paananen, T., & Chatterjee, G. E. (2021). The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership. International Journal of Nursing Studies, 115, 103842.

Eisenmann N. (2021). An innovative clinical concept map to promote clinical judgment in nursing students. The Journal of Nursing Education, 60(3), 143–149.

O’Flynn S. (2022). Nurses’ role in diabetes management and prevention in community care. British Journal of Community Nursing, 27(8), 374–376.

Sagoo, M. K., & Gnudi, L. (2020). Diabetic nephropathy: An overview. Methods in Molecular Biology, 2067, 3–7.

Samsu N. (2021). Diabetic Nephropathy: Challenges in pathogenesis, diagnosis, and treatment. BioMed Research International, 2021, 1497449.

Sandra C. Naaman, George L. (2023). Bakris; Diabetic nephropathy: Update on pillars of therapy slowing progression. Diabetes Care; 46 (9): 1574–1586.

Sapra, A., & Bhandari, P. (2023). Diabetes. In StatPearls. StatPearls Publishing.

Schot, E., Tummers, L., & Noordegraaf, M. (2020). Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. Journal of Interprofessional Care, 34(3), 332–342. 

Selby, N. M., & Taal, M. W. (2020). An updated overview of diabetic nephropathy: Diagnosis, prognosis, treatment goals and latest guidelines. Diabetes, Obesity & Metabolism, 22 Suppl 1, 3–15.

Spracklen, C. N., Horikoshi, M., Kim, Y. J., Lin, K., Bragg, F., Moon, S., Suzuki, K., Tam, C. H. T., Tabara, Y., Kwak, S. H., Takeuchi, F., Long, J., Lim, V. J. Y., Chai, J. F., Chen, C. H., Nakatochi, M., Yao, J., Choi, H. S., Iyengar, A. K., Perrin, H. J., Sim, X. (2020). Identification of type 2 diabetes loci in 433,540 East Asian individuals. Nature, 582(7811), 240–245.

Varghese, R. T., & Jialal, I. (2023). Diabetic nephropathy. In StatPearls. StatPearls Publishing.

Wang, J., Wang, Z., Yu, J., Kahkoska, A. R., Buse, J. B., & Gu, Z. (2020). Glucose-responsive insulin and delivery systems: Innovation and translation. Advanced Materials (Deerfield Beach, Fla.), 32(13), e1902004. 

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