NURS FPX 6610 Assessment 2 Patient Care Plan

NURS FPX 6610 Assessment 2 Patient Care Plan

Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Patient Identifier: 6700891

Patient Medical Diagnosis: Poorly controlled anxiety, obesity, HTN, DM, and hypercholesterolemia

Nursing Diagnosis 1: Risk of Poor Healthcare Management and Diabetes Complications

• Assessment Data

  • Subjective: The patient, Mrs. Snyder, a 56-year-old married mother of two, is receiving treatment for hyperglycemia and uncontrolled diabetes. She has a history of consuming high-sugar snacks.
  • Objective: Mrs. Snyder was admitted to the emergency department with elevated blood sugar levels (230–389), dyspnea, abdominal discomfort, and urination issues. She also presents with HTN.

• Goals and Outcome

  • Goal 1: Mrs. Snyder will maintain blood glucose levels within the range of 90–140 mg/dL over the next two months.
  • Goal 2: Mrs. Snyder will report improved dietary habits and weight reduction within three months by adhering to a low-sugar, balanced diet.

• Nursing Interventions

  1. Educate Mrs. Snyder on self-care management techniques such as dietary control and regular physical activity (USC, 2018).
  2. Teach Mrs. Snyder how to properly monitor blood sugar levels and administer insulin independently (Carolina, 2019).
  3. Collaborate with a dietitian to create a meal plan to reduce her sugar intake.

• Rationale

  • Intervention 1: Self-care education promotes patient autonomy and enhances the ability to manage diabetes effectively (USC, 2018).
  • Intervention 2: Blood glucose monitoring helps adjust insulin and dietary needs in real-time (Carolina, 2019).
  • Intervention 3: A structured diet plan is essential in controlling blood sugar and preventing diabetes-related complications (Heart, 2021).

• Outcome Evaluation and Re-planning
  Mrs. Snyder’s glucose levels will be monitored daily. If the goals are not met, the care plan will be adjusted by increasing follow-up visits or introducing alternative medication strategies.

Nursing Diagnosis 2: Anxiety Related to Caregiving and Health Issues

• Assessment Data

  • Subjective: Mrs. Snyder reports anxiety due to household responsibilities and caregiving for her elderly mother. She feels overwhelmed and suffers from high blood pressure and tachycardia.
  • Objective: Mrs. Snyder has irregular intake of anxiolytics, and her vital signs show elevated BP (145/95 mmHg) and tachycardia (105 BPM).

• Goals and Outcome

  • Goal 1: Mrs. Snyder’s anxiety levels will decrease by 50% within one month of implementing non-pharmacological interventions.
  • Goal 2: Mrs. Snyder’s blood pressure will stabilize at 130/90 mmHg, and her heart rate will normalize within one month.

• Nursing Interventions

  1. Administer prescribed anxiolytics as per the care plan to manage anxiety levels (Ströhle et al., 2018).
  2. Refer Mrs. Snyder to weekly cognitive behavioral therapy (CBT) sessions (Pegg et al., 2022).
  3. Connect Mrs. Snyder to a support group for Jewish women dealing with caregiving stress.

• Rationale

  • Intervention 1: Anxiolytics help reduce anxiety and promote mental stability (Ströhle et al., 2018).
  • Intervention 2: CBT is proven effective in treating anxiety and provides coping strategies (Pegg et al., 2022).
  • Intervention 3: Social support improves emotional well-being and helps reduce stress.

• Outcome Evaluation and Re-planning
  Mrs. Snyder’s anxiety and BP levels will be reviewed weekly. If these are not improving, the anxiolytic dose may be altered, or additional therapy sessions will be arranged.

Nursing Diagnosis 3: Caregiver Role Strain and Fear of Cancer Treatment

• Assessment Data

  • Subjective: Mrs. Snyder expresses fear about chemotherapy for her ovarian cancer and concerns about managing her mother’s care.
  • Objective: Mrs. Snyder reports shortness of breath with oxygen saturation dropping to 91% during ambulation and an inability to tolerate exertion due to her obesity.

• Goals and Outcome

  • Goal 1: Mrs. Snyder will arrange long-term care for her mother within two weeks to focus on her chemotherapy.
  • Goal 2: Mrs. Snyder’s oxygen saturation will improve to 95% with ambulation within one month of starting treatment.

• Nursing Interventions

  1. Refer Mrs. Snyder to a social worker for assistance in finding a care facility for her mother (Hoyt, 2022).
  2. Implement non-pharmacological pain management techniques, including meditation and breathing exercises (Sheikhalipour et al., 2019).
  3. Assess pain levels and oxygen saturation three times daily.

• Rationale

  • Intervention 1: Support from a social worker will ease Mrs. Snyder’s caregiving burden, allowing her to focus on her treatment (Hoyt, 2022).
  • Intervention 2: Non-pharmacological interventions reduce anxiety and pain associated with cancer treatments (Sheikhalipour et al., 2019).
  • Intervention 3: Regular assessments will ensure the early detection of complications.

• Outcome Evaluation and Re-planning
  If Mrs. Snyder’s oxygen saturation and pain management goals are not met, her care team will consider alternative treatments such as supplemental oxygen or different pain medications.

References

Cancer. (2021, October 6). Managing diabetes when you have cancer. Cancer.net. 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. Uspharmacist.com. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose

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

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

Hoyt, J. (2022, May 26). Assisted living & senior placement agencies. SeniolLiving.org. https://www.seniorliving.org/placement-agencies/

NURS FPX 6610 Assessment 2 Patient Care Plan

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

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

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