Patient Care Plan for Mrs. Snyder

NURS-FPX 6620 Assessment 2 Patient Care Plan for Mrs. Snyder

Introduction

Advanced nursing practice necessitates proficiency in managing intricate clinical situations with both technical expertise and ethical discernment. Mrs. Snyder is an older patient with many health problems and changing social needs. She is a perfect example of how important care coordination is. This paper presents a detailed patient care plan for Mrs. Snyder, emphasizing clinical stabilization, medication reconciliation, and a secure transition to the community. The following plan makes sure that Mrs. Snyder receives care that is not only based on evidence but also based on respect for her rights and dignity.

Clinical Analysis and Care Gaps

Mrs. Snyder has a history of congestive heart failure (CHF), type 2 diabetes, and early-stage cognitive decline. The main problem with her primary care is that her specialists and her primary care provider don’t work together very well, leading to miscommunication about her treatment plans and medication management. Because of this fragmentation, she is now taking a lot of different medications, which puts her at a high risk for bad drug reactions and falls.

For Mrs. Snyder to receive the best care, the first step is to do a full medication reconciliation. The American Nurses Association (2015) says that the nurse’s main duty is to the patient. Thus closing these gaps in communication is an ethical duty to keep patients safe.

The following section discusses the application of ethical principles to the care plan.

In the case of Mrs. Snyder, ethical dilemmas often arise between her safety and her autonomy, particularly when her desire for independence may conflict with the need for interventions that ensure her well-being.

Autonomy and Beneficence

When you use ethical principles about autonomy, you include Mrs. Snyder in every step of the care planning process. Even with her cognitive problems, she should still be able to say what she wants in terms of where she lives and her treatment goals. At the same time, the principle of beneficence (acting in the patient’s best interest) means that the nurse must push for changes to the home and provide assistive devices to keep the patient safe.

Justice in Resource Allocation

Justice requires that Mrs. Snyder have equitable access to community resources. The care coordinator must evaluate her social determinants of health (SDOH), such as her ability to afford medications or transport to appointments. Applying ethical principles of justice ensures that the care plan is realistic and sustainable for her specific socioeconomic context.

Interprofessional Coordination Strategies

Mrs. Snyder’s care cannot be managed by a single provider. An interprofessional team—consisting of a nurse coordinator, a pharmacist, a physical therapist, and a social worker—will be utilized.

The Role of the Transitional Care Model (TCM)

The Transitional Care Model (TCM) will guide her discharge. This evidence-based model focuses on high-risk older adults and emphasizes the use of a “transitional care nurse” who follows the patient from the hospital to the home. By applying ethical principles of fidelity, the nurse coordinator remains faithful to the patient’s long-term health goals, ensuring that no information is lost during the hand-off from the acute care setting to the home environment.

SMART Goals for Mrs. Snyder

1. Medication Safety: Mrs. Snyder will demonstrate the correct use of a pill organizer and verbalize the purpose of her top three medications with 100% accuracy within 48 hours of discharge.
2. Clinical Stability: Mrs. Snyder will maintain a stable weight (within 2 lbs of baseline) and exhibit no peripheral edema over the next 30 days.
3. Safety: Mrs. Snyder will remain free from falls during the 30-day post-discharge period through the implementation of a home safety plan.

The Role of Health Informatics

Technology is a very important part of using ethical principles in Mrs. Snyder’s care. The interprofessional team can share real-time updates by using an integrated electronic health record (EHR). This openness supports the idea of veracity by making sure that all providers are using the same “source of truth” about her health and medication list.

Conclusion

The care plan for Mrs. Snyder is a guide for nurses to follow that is both ethical and complete. The care plan recognizes that being a good doctor and serving as a moral advocate are interconnected. The interprofessional team can provide Mrs. Snyder a safe, coordinated, and respectful care experience by following the ethical principles of autonomy, beneficence, and justice. As nurse leaders, the best way to show that we care about the nursing profession and the patients we serve is to be able to coordinate care for patients like Mrs. Snyder.