NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Nursing Diagnosis and Care Plan for Mrs. Snyder

Patient Identifier: 6700891

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

First Nursing Diagnosis:

Improper healthcare management and poor education about diabetes risks

Assessment Data:

• Subjective: Mrs. Snyder, a 56-year-old married mother of two, is undergoing treatment for hyperglycemia and uncontrolled diabetes.
• Objective: Admitted to the emergency department with blood sugar levels between 230-389 mg/dL, presenting with dyspnea, low abdominal discomfort, malaise, and frequent urination. She also has hypertension and a poor dietary habit involving excessive consumption of cookies and snacks.

Goals and Outcome:

• Goal 1: Mrs. Snyder’s blood sugar and blood pressure levels will be stabilized within one month.
• Goal 2: Mrs. Snyder will report improvement in eating habits and better personal health in three months (Ramzan et al., 2022).

Nursing Interventions:

• Intervention 1: Provide education on self-care management, focusing on lifestyle modifications such as a healthy diet, physical activity, and sleep patterns (USC, 2018).
• Intervention 2: Encourage diabetes self-monitoring through daily blood glucose checks and food intake tracking (Carolina, 2019).
• Intervention 3: Educate the patient on proper insulin administration techniques.

Rationale:

• Self-care education empowers patients to manage their diabetes through lifestyle changes and adherence to insulin therapy. These practices will improve collaboration between the patient and healthcare team (Heart, 2021).

Outcome Evaluation and Re-planning:

Mrs. Snyder’s care team will regularly assess her glucose logs to evaluate the effectiveness of her treatment regimen and make necessary adjustments. Based on her progress, the care plan may be revised to better address her dietary habits and insulin use.

Second Nursing Diagnosis:

Anxiety exacerbated by domestic and caregiving responsibilities

Assessment Data:

• Subjective: Mrs. Snyder reports feeling overwhelmed and anxious due to household responsibilities, caregiving for her sick mother, and conflicts with her son. She has irregularly taken anxiolytics and reports high blood pressure and tachycardia.
• Objective: Mrs. Snyder is responsible for managing all family and financial matters, contributing to her anxiety.

Goals and Outcome:

• Goal 1: Mrs. Snyder’s blood pressure will be stabilized at 130/90 mmHg, and her heart rate will normalize to 60-100 bpm within one month.
• Goal 2: Her anxiety levels will improve with counseling and medication adherence (Pegg et al., 2022).

Nursing Interventions:

• Intervention 1: Prescribe anxiolytics to manage her anxiety.
• Intervention 2: Provide cognitive behavioral therapy (CBT) through weekly counseling sessions (Pegg et al., 2022).
• Intervention 3: Refer her to a support group within her Jewish community to explore mindfulness and spiritual healing therapies.

Rationale:

• Combining pharmacological and non-pharmacological treatments like CBT is effective in reducing anxiety (Ströhle et al., 2018). This holistic approach will also reduce her blood pressure and heart rate.

Outcome Evaluation and Re-planning:

Weekly assessments will monitor the impact of therapy on Mrs. Snyder’s anxiety and cardiac health. The care plan will be revised as necessary, depending on her response to counseling and medication.

Third Nursing Diagnosis:

Psychosocial concerns related to ovarian cancer and caregiving role

Assessment Data:

• Subjective: Mrs. Snyder is fearful of chemotherapy and expresses concerns about her ability to care for her elderly mother.
• Objective: She reports abdominal pain, shortness of breath, and reduced oxygen saturation levels during exertion.

Goals and Outcome:

• Goal 1: Mrs. Snyder will secure a care facility for her mother within 15 days, allowing her to focus on her treatment.
• Goal 2: Mrs. Snyder’s physical stamina and oxygen levels will improve within three months.

Nursing Interventions:

• Intervention 1: Refer Mrs. Snyder to a social worker to find a suitable placement for her mother.
• Intervention 2: Implement a thrice-daily pain assessment to monitor her response to treatment.
• Intervention 3: Educate her on non-pharmacological pain management techniques, such as meditation and yoga (Sheikhalipour et al., 2019).

Rationale:

• Providing care options for Mrs. Snyder’s mother will alleviate her caregiver burden, allowing her to focus on her own health. Non-pharmacological interventions can effectively manage her cancer-related pain, improving her emotional and physical well-being (Hoyt, 2022).

Outcome Evaluation and Re-planning:

Pain levels will be closely monitored, and Mrs. Snyder’s care plan will be updated as her condition and pain management needs evolve. After her mother is placed in a care facility, her focus can shift entirely to her own health.

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/

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 1 Comprehensive Needs Assessment

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/