NURS FPX 6610 Assessment 2 Patient Care Plan CS

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 plan of care? Support your conclusions with outcome measures and professional standards.

Nursing Diagnosis 

First Diagnosis:

Improper healthcare management and the least education about the risk of diabetes can lead to serious consequences. 

• Risk of improper healthcare management
  • Subjective: The subjective data is that the patient’s name is Mrs. Snyder, married, mother of two, 56 years old. She is under treatment for hyperglycemia and uncontrolled diabetes.
• Risk of a consistent rise in diabetes. 

• Objective: She was admitted to a hospital’s emergency department (ED) with a consistent rise in sugar levels. The sugar level was 230-389, and they had dyspnea on exertion, low abdominal discomfort, malaise, and urination problems. She also had HTN while got admission to ED. She also consumed too many cookies and snacks. 

Second Diagnosis:

Higher domestic burden and difficulty making meals for family members who are allergic to some food and lactose intolerant. She gets validation and compliments from her husband, that’s why she neglects her health. 

First Goal:

• The first goal is to ensure that Mrs. Snyder’s blood pressure and diabetes level are under control. She is a cancer patient which means her diabetes can increase due to cancer. Cancer can trigger different hormones in the body that is responsible to enhance sugar level in the body (Cancer, 2021). Mrs. Snyder can face a weak immune system due to consistent diabetes and cancer (Cancer, 2021). So, diabetes management is the major goal. 

• Patient will report improvement in her eating habits and personal health. (Ramzan et al., 2022). 

First Intervention:

Health care professional should raise awareness about self-care management (USC, 2018). Self-care management will help patient with lifestyle modifications such as a healthy diet, physical activity, good sleep patterns, mindfulness, and practice. Patient will reduce her weight in three months. Patient will control snacking habit in one month. 

The second intervention is to encourage diabetes self-monitoring at home through daily eye, blood sugar, and food exam (Carolina, 2019). The patient will learn the right technique to -administer insulin on time. The nurse will educate the patient on how to make an insulin syringe. 

First Goal Rationale:

The rationale behind the proposed intervention is that the patient’s primary responsibility in controlling her diabetes is keeping a thorough record of her blood sugar level. She can struggle to manage her condition without any assistance and education. Change in her health condition depends on her dietary modifications, strict adherence to daily insulin doses, and a specific amount of physical activity (Heart, 2021). The interventions will help her in enhancing collaboration between the patient, care provider nurse, nutritionist, and diabetes educator to achieve good health by examining the daily patient data.

Outcomes:

Mrs. Snyder’s care team will be better able to assess the efficacy of her diet, exercise routine, and insulin dosing with the help of the glucose logs she keeps regularly. As her lifestyle evolves during her disease management, her doctor will likely need to adjust the dosages of her diabetes medications.

• Subjective: The subjective data is that the patient suffered from constant anxiety due to situational crisis, and this made her overwhelmed, depressed, anxious, and weak. This is the reason behind high blood pressure and tachycardia. She developed the pressure of managing households because her husband is available but not very helpful, and her son has some issues with her. 
• She reported irregular intake of anxiolytics. Mrs. Snyder is the primary care provider for her sick mother. She manages everything from house chores to business and finances. Get free NURS FPX 6610 Assessment 2 Patient Care Plan CS

Second Goal:

The outcome of the goal will be her improved mental health and emotional well-being. She will be able to improve her health condition by focusing on medicine and cognitive behavioral therapy (CBT) (Pegg et al., 2022). She will have controlled blood pressure of not more than 130/90mmHg and a normal cardiac pulse rate between 60-100Bpm within one month under treatment. 

Second Intervention:

To treat anxiety, tolerable anxiolytics will be prescribed by the primary care provider. The patient will take weekly counseling sessions (CBT) to learn different methods of controlling anxiety in non-pharmacological ways (Pegg et al., 2022). Contact the social groups relevant to a Jewish community that offers mindfulness and spiritual healing therapies.

Second Goal Rationale:

The rationale behind these interventions is to ensure that education resources will manage the defenses of Mrs. Snyder in an anxiety state. Ströhle et al. (2018) suggested that pharmacology and psychotherapy are the best combinations of healthcare interventions to control anxiety. The patient will be able to stabilize in her critical health situation, and the reduction in anxiety level will reduce her blood pressure and tachycardia. 

Outcomes:

Currently, no treatment goals are met as all are proposed as a new care plan. The constant weekly assessment of the patient’s condition will help the care coordination healthcare team to revise the healthcare plan according to her physical health needs. 

Third Diagnosis:

The patient diagnosed with Ovarian Cancer 

• Subjective: She needs chemotherapies, ultimately making her weak and less immune. She reported her fear and anxiety about chemotherapies. 
• She has a huge fear of failing as a caregiver of an elderly mother. Her mother needs ADL care and neglects chemotherapies because her elderly mother is dependent on her.
• The patient declared the fear of acute pain relevant to chemotherapy as she is already suffering from headaches, tachycardia, and mild abdominal pain. The patient is not comfortable with having surgery as the CT scan revealed liver masses and colorectal mass.
• The patient has high obesity, airway difficulty, and a low level of oxygenation on exertion that causes shortness of breath. In the ambulation, the oximetry level dropped by 91%.

SMART Goals 

• To control Mrs. Snyder’s diabetes within one week.  
• The patient will improve her physical health and reduce malaise within a month through strict adherence to medicine intake.
• On discharge day from the hospital, a patient will report a reduction in her anxiety level by 70%.
• Her mother will get a good option for care facility placement within 15 days.

• • The patient will be able to tolerate exertion within three months of treatment. 
• Increased oxygenation by the discharge date and pain relief within one hour of taking nonphonological and pharmacological treatments.

Psycho-sociocultural aspects of care

• The fact that Mrs. Snyder is a mother of five children and a Jewish community member necessitates that she consumes kosher food, which will harm her health.

Third Goal:

• Mrs. Snyder will have multiple options for better care of her mother through facility placement. It will provide relief to the patient, and she will be able to get chemotherapy on her next follow-up.

The patient will show clear acceptance of the placement option for her mother by evaluating all options. In one month, her mother will share her good experience of care in the placement facility (Goodtherapy, 2019).  

Third Intervention:

• Refer Mrs. Sunder to a counselor to deal with her caregiver role. Find a social worker to find a good placement facility for her mother.  Pain assessment thrice a day. 

Patient education to consider nonpharmacological methods of managing pain, such as exercise, meditation, yoga, breathing practices, and many more. The non-pharmacological interventions have a highly positive impact on relieving pain and improving the emotional and physical well-being of the individuals (Sheikhalipour et al., 2019).

Third Goal Rationale:

Hoyt. (2022) declared the effective role of elderly patients’ healthcare placement facilities that can assist family members in providing relief from caregiving. Dementia caregiving can be extremely rewarding, but it also increases the caregiver’s risk of developing health problems and possibly depression.

Mrs. Snyder is facing healthcare challenges and needs all of her strength and therapeutic assistance to deal with those to get rid of the caregiving patterns (Goodtherapy, 2019). 

The Sheikhalipour et al. (2019) declared that nonpharmacological interventions are highly effective for cancer patients in pain relief. The interventions can be meditations, aroma therapy, or acupuncture techniques for pain relief.  The patient will be able to manage her pain by engaging in healthy activities. She can find a sense of purpose and emotional regulation in that self-care time. She can also feel free from medicines intake or anxiety.  Furthermore, the pain assessment intervention can help care coordination healthcare providers to assess patient needs and the effectiveness of medicine on patient pain relief.

Outcomes:

Currently, no goal has been met. Mrs. Snyder will be able to focus on her care plan by assuring that her mother is receiving excellent care if she can locate a facility that will fulfill all her medical assistance needs. After finding a healthcare facility for her mother, Mrs. Snyder’s care plan will be revised so she can focus on herself.

The goals are not executed yet. In chemotherapy, the patient’s pain will be monitored. It is expected that pain levels will fluctuate throughout treatment, so there will be a necessity to make adjustments to her care plan and pharmacological interventions during treatment.