Assessment 2: Patient Care Plan
Name
Capella University
Introduction to Care Coordination
Prof. Name
June 25, 2024
Name: Rebecca Synder Date: 25/04/2024
Patient Identifier:6700891 Patient Medical Diagnosis: Stage 4 ovarian cancer, type 2 diabetes, obesity, hypertension, 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 care plan? Support your conclusions with outcome measures and professional standards. |
| First Diagnosis:1. Complex Chronic Disease ManagementMrs. Snyder has multiple chronic conditions: advanced ovarian cancer, type 2 diabetes, obesity, hypertension, and high cholesterol. These conditions complicate treatment and self-care, increasing risks like cardiovascular events and poor glucose control. Managing her health requires a coordinated, multidisciplinary approach.Subjective:Experiences constant fatigue and difficulty managing daily activities due to multiple chronic conditions.Feels overwhelmed and anxious about complex medication regimens and frequent medical appointments.Objective:Medical records: Increased blood sugar, unmanaged high blood pressure despite medication.Physical assessment: BMI 32 (obesity), high cholesterol in recent labs (Colvin et al., 2023). | SMART Goal 1: Management of Blood Glucose: Short-Term Goal:S: Mrs. Snyder will achieve better control of her blood glucose levels.M: Lower fasting glucose levels to between 80 and 130 mg/dL.A: With the help of a diabetes educator and a personalized meal plan.R: Improved glucose control will help manage diabetes-related symptoms.T: Within the next four weeks.Long-Term Goal:S: Mrs. Snyder will improve her overall health status by managing her chronic conditions more effectively.M: Maintain blood pressure below 130/80 mmHg, lose 5% of her body weight, and reduce LDL cholesterol to below 100 mg/dL (Chen et al., 2023).A: Through regular follow-ups with her healthcare team, adherence to prescribed medication, and lifestyle changes, including diet and exercise.R: Effective managing her chronic conditions will enhance her quality of life and reduce the risk of complications.T: Within the next six months | 1. Nutritional Counseling:Regular sessions with a registered dietitian.Develop a personalized meal plan (Alghnam et al., 2021).Rationale: Manage blood glucose, reduce BP, promote weight loss, and lower cholesterol (Angelousi et al., 2023).2. Medication Management:Implement a medication schedule and adherence education (Al-Jawaldeh & Abbass, 2022).Rationale: Control of blood glucose, BP, and cholesterol is crucial for achieving health goals.3. Physical Activity Plan:Create a safe, individualized exercise program with a physical therapist (Chen et al., 2023).Rationale: Improve insulin sensitivity, aid weight loss, reduce BP, and enhance cardiovascular health (Garg et al., 2022). | 1. Nutritional Counseling:Stabilizes blood sugar, lowers BP and cholesterol, and promotes weight loss (Wilson, 2021).2. Medication Management:Controls blood glucose, manages BP and cholesterol, and improves health outcomes (Jawaldeh & Abbass, 2022).3. Physical Activity Plan:Enhances insulin sensitivity, aids weight loss, and strengthens cardiovascular health (Almalki et al., 2021). | Outcome Evaluation:Nutritional Counseling: Monitor blood glucose, BP, cholesterol levels, and weight to assess effectiveness (Alrobaiq et al., 2023).Medication Management: Track medication adherence and its impact on blood glucose, BP, and cholesterol (Angelousi et al., 2023).Physical Activity Plan: Evaluate improvements in insulin sensitivity, weight loss, and cardiovascular health (Almalki et al., 2021).Re-planning:Nutritional Counseling: Adjust the meal plan based on evaluation results to better meet health goals (Alrobaiq et al., 2023).Medication Management: Modify the medication regimen and adherence strategies if targets are unmet.Physical Activity Plan: Update the exercise program to address any physical limitations or lack of progress (Angelousi et al., 2023). |
2. Chronic Pain and Stress Due to Multiple Health ConditionsThis diagnosis addresses the persistent pain and stress Mrs Snyder experiences from her health issues and their impact on her daily life. She may suffer from discomfort, limited mobility, and high-stress levels, affecting her overall well-being. Subjective: Persistent discomfort from Mrs. Snyder’s ovarian cancer and arthritis.Affects her capacity to complete daily activities.She feels burdened by her medical condition.Objective: Observations of grimacing, limited range of motion, frequent use of pain medication, and signs of stress such as restlessness and irritability (Tomkins et al., 2022). | SMART Goal 2: Short-Term Goals:Identify and communicate specific pain and stress triggers to your healthcare provider, and engage in daily relaxation techniques for at least 10 minutes per day for the next two weeks.S: Identify triggers and daily relaxation techniquesM: Communicate to provider; 10 minutes per dayA: Within two weeksR: Improve understanding of pain and stress, reduce pain and stressT: Two weeksLong-Term Goals:Reduce pain and stress levels by 30% over three months, assessed using the Numeric Pain Rating Scale and individual perception Stress Scale, through regular participation in stress management activities and support group sessions.S: Reduce pain and stressM: 30% reductionA: Within three monthsR: Improve quality of life and emotional well-beingT: Three months | Second Intervention:1. Pain and Stress Management Consultation: Refer Mrs. Snyder to a pain and stress specialist for comprehensive management strategies (Garg et al., 2022).2. Physical Therapy: Create a personalized exercise regimen with a physical therapist to enhance mobility, diminish pain, and relieve stress (Dragomanovich & Shubrook, 2021).3. Alternative Pain and Stress Relief: Introduce non-pharmacological pain and stress relief methods such as acupuncture, massage therapy, or mindfulness meditation (Dragomanovich & Shubrook, 2021). | Second Goal Rationale:1. Pain and Stress Management Consultation: Professional guidance helps formulate effective pain and stress management plans (Dragomanovich & Shubrook, 2021).2. Physical Therapy: Tailored exercises can alleviate pain, enhance mobility, and reduce stress (Ernawati et al., 2021).3. Alternative Pain and Stress Relief: Techniques like acupuncture, massage, or mindfulness can provide significant pain and stress relief (Dragomanovich & Shubrook, 2021). | Outcome Evaluation:Assess pain and stress levels through regular consultations with the pain and stress specialist, physical therapy sessions, and alternative relief methods. Outcomes will be evaluated based on a 30% reduction in pain and stress levels. Effective outcomes will reflect Mrs. Snyder’s improved ability to perform daily activities with reduced pain and stress (Liu et al., 2023). Re-planning:If goals are unmet, consider adjusting the management plan, increasing physical therapy sessions, or exploring additional alternative pain and stress relief approaches |
| Third Diagnosis:3. Limited understanding of managing multiple chronic conditionsThis evaluation highlights Mrs. Snyder’s limited understanding of managing her type 2 diabetes, hypertension, and obesity during treatment for stage 4 ovarian cancer. Her lack of awareness may result in adverse health consequences and heightened stress, requiring thorough education and assistance.Subjective: Mrs. Snyder expresses confusion about managing her diabetes and hypertension, struggles with medication schedules, and is unsure about dietary adjustments while receiving cancer treatment.Objective: Unstable blood sugar levels, incorrect usage of blood pressure medications, and failure to follow dietary guidelines, exacerbated by cancer treatment side effects (Pettersson et al., 2022). | SMART Goal 3: Comprehensive Chronic Disease Management Short-Term Goal:Mrs. Snyder will understand her medication regimens, the importance of monitoring blood glucose and blood pressure, and use a daily monitoring device.S: Understand medication regimens and monitoring; daily use of monitoring devices.M: Comprehension assessed by a healthcare provider; daily use recorded in a log.A: Achieved through education sessions and provided devices with instructions.R: Improve self-management adherence and ensure proper disease management.T: Understanding within one week; daily monitoring within the next two weeks.Long-Term Goal:Mrs. Snyder will consistently monitor and follow her chronic disease management plan, including a diet and exercise regimen, to improve her health metrics.S: Consistent monitoring, adherence, and following dietary and exercise plans.M: Regular logs, check-ups, and health metrics (BMI, blood pressure, glucose levels).A: With regular follow-ups, personalized plans, and support.R: Long-term health improvement and accommodation cancer treatment.T: Over three months. | Third Intervention:Instruction and Guidance: Offer individualized instruction on managing diabetes, hypertension, and obesity, addressing the challenges brought on by cancer treatment (Huang et al., 2024).Team-Based Support: A diabetes specialist, dietitian, and oncology nurse should provide thorough and customized guidance (Kumar et al., 2022).Ongoing Evaluation: Conduct weekly assessments to review Mrs. Snyder’s understanding and dedication to the plan, considering the changing demands of cancer treatment. | Third Goal Rationale:Instruction and Guidance: Customized instruction corrects knowledge gaps and enhances adherence to the chronic disease management plan, particularly with the complexities of cancer treatment (Garg et al., 2022).Team-Based Support: Working with specialists provides expert guidance and culturally appropriate advice for managing multiple chronic illnesses and cancer (Hyun et al., 2023).Ongoing Evaluation: Regular check-ins guarantee continual advancement and empower adjustments to the plan to manage the impacts of cancer treatment (Lee et al., 2022). | Outcome Evaluation: Regular weekly assessments monitor Mrs. Snyder’s grasp and compliance with her chronic disease management regimen, factoring in the effects of cancer treatment. Evaluate her ability to adhere to the plan, monitor glucose and blood pressure, use prescribed medications, and uphold diet and exercise routines. Stage 4 ovarian cancer complicates adherence,Regular follow-up appointments are crucial for monitoring advancements and addressing any knowledge gaps.Re-planning:If objectives are not achieved, modify educational sessions, enhance the frequency of follow-ups, or work with additional specialists to tackle specific issues related to stage 4 ovarian cancer (Mazhari et al., 2022). |
NURS FPX 6610 Assessment 2 Patient Care Plan References
Alghnam, S., Alessy, S. A., Bosaad, M., Alzahrani, S., Al Alwan, I. I., Alqarni, A., Alshammari, R., Dubayee, M., & Alfadhel, M. (2021). The association between obesity and chronic conditions: Results from a large electronic health records system in Saudi Arabia. International Journal of Environmental Research and Public Health, 18(23), 12361. https://doi.org/10.3390/ijerph182312361
Jawaldeh, A., & Abbass, S. (2022). Unhealthy dietary habits and obesity: The major risk factors beyond non-communicable diseases in the Eastern Mediterranean Region. Frontiers in Nutrition, p. 9, 817808. https://doi.org/10.3389/fnut.2022.817808
Almalki, H., Ahmad, M., Brema, I., Almehthel, M., AlDahmani, M., Mahzari, M., & Beshyah, A. (2021). Management of diabetes insipidus following surgery for pituitary and suprasellar tumours. Sultan Qaboos University Medical Journal, 21(3), 354–364. https://doi.org/10.18295/squmj.4.2021.010
Alrobaiq, B. M., Alharbi, R. S., Alhoshan, F. S., Alnasyan, M. A., Alahideb, A., & Omair, A. (2023). Hypertension and ovarian cancer: A case-control study in Saudi Arabia. Cureus, 15(2), e35294. https://doi.org/10.7759/cureus.35294
Angelousi, A., Alexandraki, K. I., Mytareli, C., Grossman, A. B., & Kaltsas, G. (2023). New developments and concepts in the diagnosis and management of diabetes insipidus (AVP-deficiency and resistance). Journal of Neuroendocrinology, 35(1), e13233. https://doi.org/10.1111/jne.13233
Chen, Z., Liu, Z., Yang, H., Liu, C., & Kong, F. (2023). Metabolic syndrome and risk of ovarian cancer: A systematic review and meta-analysis. Frontiers in Endocrinology, 14, 1219827. https://doi.org/10.3389/fendo.2023.1219827
Colvin, C. L., Akinyelure, O. P., Rajan, M., Safford, M. M., Carson, A. P., Muntner, P., Colantonio, L. D., & Kern, L. M. (2023). Diabetes, gaps in care coordination, and preventable adverse events. The American Journal of Managed Care, 29(6), e162–e168. https://doi.org/10.37765/ajmc.2023.89374
Dragomanovich, H. M., & Shubrook, J. H. (2021). Improving cultural humility and competency in diabetes care for primary care providers. Clinical Diabetes: A Publication of the American Diabetes Association, 39(2), 220–224. https://doi.org/10.2337/cd20-0063
Ernawati, U., Wihastuti, T. A., & Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus (T2DM) patients: Systematic literature review. Journal of Public Health Research, 10(2), 2240. https://doi.org/10.4081/jphr.2021.2240
Garg, V., Rastogi, S., Kalra, K., Bhoriwal, S., Barwad, A., Dhamija, E., Upadhyay, A., & Gamangatti, S. (2022). Health-related quality of life (HRQoL), anxiety, and depression in patients with desmoid type fibromatosis. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 30(12), 10089–10098. https://doi.org/10.1007/s00520-022-07445-0
Huang, J., Huang, Z. T., Sun, X. C., Chen, T. T., & Wu, X. T. (2024). Mental health status and related factors influencing healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. PLOS ONE, 19(1), e0289454. https://doi.org/10.1371/journal.pone.0289454
Hyun, M. K., Lee, J. W., & Ko, S. H. (2023). Chronic disease management program applied to type 2 diabetes patients and prevention of diabetic complications: A retrospective cohort study using nationwide data. BMC Public Health, 23, 928. https://doi.org/10.1186/s12889-023-15763-z
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