Client Name
Capella University
NURS-FPX6610: Introduction to Care Coordination
Instructor’s Name
August 2024
Name: Rebecca Snyder Date: 29/08/24
Patient Identifier: 6700891 Patient Medical Diagnosis: Stage 4 ovarian cancer, type 2 diabetes, obesity, hypertension.
| 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 plan of care? Support your conclusions with outcome measures and professional standards. |
| First Diagnosis: Pain Related to Chronic Disease and its TreatmentMrs. Snyder is feeling pain due to advanced stage 4 level ovarian cancer. This pain can also be the result of chemotherapy (Wu et al., 2023). The continuous pain impacts the daily routine of Mrs. Snyder and creates stress from the inability to perform different activities. | SMART Goal 1: Pain ManagementMrs. Snyder is concerned about the pain and she wants to reduce it through proper, timely medication and getting information about other methods of pain relief (Kerns et al., 2022). Educating herself on new ways of pain reduction motivates her to be consistent in her efforts regarding acquiring information on managing pain efficiently. | Assessment of PainRegularly assess the pain of Mrs.Snyder to understand the rate of relief in pain and the requirements and changes that need to be done in the management plan regarding pain (Fenske et al., 2021). | Assessment of PainIt will help in identifying the areas of concern regarding change and improvement (Fenske et al., 2021). Collaborative and Supportive CareThese strategies will help in improving the condition of Mrs.Snyder other than the medications (Kim & Yoo, 2023). | Outcome EvaluationEvaluating the pain felt by Mrs.Snyder during her chemotherapy treatment for ovarian cancer. The outcome of pain management will depend on assessing the pain levels observed by Mrs.Snyder during chemotherapy. To assess the levels of pain Numeric Rating Scale (NRS) can be used in which ratings from 0 to 10 are provided and Mrs.Snyder needs to mark one number according to the level of pain she felt. |
| Nursing Diagnosis Assessment Data | Goals and Outcome | Nursing Interventions | Rationale | Outcome Evaluation and Re-planning |
|---|---|---|---|---|
| Subjective:Mrs. Snyder feels intense pain and shows fear in expressing her pain to the healthcare providers.Objective:Analysis of medical reports shows that Mrs. Snyder is feeling pain while doing physical movements. Severe disturbing pain. | Short-Term Goal: By carefully applying the pain-managing techniques Mrs. Snyder will be able to observe a decrease in pain at the end of the week. The decrease will reduce to 2/5 from the severe pain of 4/5 by week 4.Long-Term Goal:In 6-7 weeks Mrs. Snyder will be able to reduce pain through other physical activities instead of medicines.Mrs. Snyder will educate herself about other pain management techniques. | Collaborative and Supportive CareTherapies and care improvement strategies need to be part of Mrs. Snyder (Kim & Yoo, 2023). Pain Management PlanA Proper pain management plan needs to be implemented to identify the impacts of pain on a patient’s condition (Fenske et al., 2021). | Pain Management PlanThis plan guides in applying changes to the patient’s conditions according to the changing health needs of the patients (Fenske et al., 2021). | On the NRS zero means no mean while 10 represents severe pain. Re-PlanningIf the outcomes evaluation is not successful then the changes regarding the medications and pain relief strategies need to be implemented in the pain management plan. The plan then needs to be evaluated every week to understand the condition of Mrs.Snyder in dealing with pain. |
| Second Diagnosis: Inadequate Health Maintenance BehaviorMrs. Snyder’s diabetes control management is poor which is due to the gaps in taking medicines or inappropriate adjustment of dosage concerning the change in the situation of health. Ineffective habits of diet also escalate diabetes which shows Mrs.Snyder is ignorant of her diabetic diet (Hussain et al., 2023). Irregular assessment of the blood glucose level leads to adverse diabetic conditions. | SMART Goal 2: Blood Glucose Level ManagementTo maintain her health efficiently Mrs. Snyder aims to take a proper diet that will have a positive impact on diabetes. The normal glucose level is between 80-130 mg/dL but in the case of Mrs. Snyder, it remains at a high level of 190 mg/dL after taking the meal and 150 mg/dL before taking the meal. Moreover, she decided to keep effectively monitoring her insulin level and develop habits that are useful to manage her diet and insulin level efficiently (Gray & Threlkeld, 2024). She will try to implement careful measures to control her glycemic level. | Diabetes EducationEducation regarding diabetes and the impact of diet on the escalating condition of diabetes should be provided to Mrs.Snyder (Kim & Hur, 2021). Training and Counselling of Self-ManagementCounseling and training need to be provided to Mrs. Snyder to help her understand the importance of self-management (Vainauskiene & Vaitkiene, 2021). | Diabetes EducationThe education will help Mrs.Snyder understand what to eat and what not to do to keep her level of diabetes normal (Kim & Hur, 2021). Training and Counselling of Self-ManagementCounseling will help the patient identify the factors that need to be managed and controlled for a better understanding of health management (Vainauskiene & Vaitkiene, 2021). | Outcome EvaluationEvaluating the blood glucose level management of Mrs.Snyder after a week. The outcomes should be based on the fact that Mrs.Snyder understands self-management and now she can maintain her blood glucose level and monitor her insulin levels. Fasting Blood Glucose(FBS) needs to determine the normality of glucose after 8 hours and the Diabetes Distress Scale (DDS) monitors the level of stress that can escalate the level of diabetes in the patient. Mrs. Snyder should be able to understand the different factors that can exacerbate the diabetes condition including socioeconomic factors. |
| Nursing Diagnosis Assessment Data | Goals and Outcome | Nursing Interventions | Rationale | Outcome Evaluation and Re-planning |
|---|---|---|---|---|
| Subjective:Mrs. Snyder does not have sufficient knowledge regarding her dietary food suitable for diabetes and is unable to monitor with punctuality the level of insulin.Objective:A diet based on less protein, and more carbohydrate, high glucose level between 190-150 mg/dL. HbA1c higher than 8% represents a high glycemic level. | Short-Term Goal: Mrs. Snyder will maintain her blood glucose level between the normal range of 80-130 mg/dL before meals for 4 weeks.Mrs.Snyder will implement an effective diabetes management plan at the end of 3 weeks.Long-Term Goal:Mrs.Snyder will participate in diabetes management courses.By the end of 6 months, she will be able to control and manage insulin levels. | Diabetes Management PlanA proper management plan needs to be designed and developed regarding the medical history of the patient and the impact of diabetes on health (Sugandh et al., 2023). | Diabetes Management PlanThis plan will monitor the success of the patient in controlling and effectively managing diabetes (Sugandh et al., 2023). | Re-PlanningIf outcomes are not according to expectation then adequate strategies and policies need to be implemented and introduced in the diabetes management plan to obtain better outcomes regarding the level of diabetes from Mrs.Snyder. |
| Nursing Diagnosis Assessment Data | Goals and Outcome | Nursing Interventions | Rationale | Outcome Evaluation and Re-planning |
|---|---|---|---|---|
| Third Diagnosis: Risk of Adverse Skin HealthThe increasing weight of Mrs.Snyder causes obesity which results in bad effects on skin leading to damaged skin. The overweight body is vulnerable to many health issues including damaging certain parts of the body where most of the weight pressure is applied (Jin et al., 2023). Mrs. Snyder is a cancer patient and she is under treatment. The cancer treatment hinders her physical activities and movement. The limited moment also causes the severity of obesity. Moreover, skin also got damaged during the period of cancer treatment. | SMART Goal 3: Efficient Practices for Skin CareMrs. Snyder decided to consult skin specialists to get proper skin care treatment and advice. She aims to enhance her daily skincare routine by acquiring more knowledge and education regarding skin problems and their solutions. Applying proper evidence-based practices for skin care is always beneficial as they provide the confidence of positive outcomes (Kottner et al., 2019). She will monitor and report her skin issues to her skin health practitioners for precautionary measures and instructions about further procedures and practices | Increase MobilityHelp Mrs.Snyder in developing physical practices that can help her easily move her body (Forte & Teixeira, 2023). Skin Health EducationEducation regarding the maintenance of the health of the skin using different strategies and practices should be provided to Mrs.Snyder (Raghupathi & Raghupathi, 2020). | Increase MobilityMore movement leads to less pressure on body parts thus reducing skin damage and preventing obesity from escalating (Forte & Teixeira, 2023).Skin Health EducationThis education will help her understand her skin for better application of skin health advice (Raghupathi & Raghupathi, 2020). | Outcome EvaluationEvaluating skin care practices to understand the outcome of the skin health condition of Mrs.Snyder. The expected outcome should make sure that Mrs.Snyder is now able to practice health strategies and practices that are helping her improve her skin health condition along with the proper monitoring of her obesity. |
| Nursing Diagnosis Assessment Data | Goals and Outcome | Nursing Interventions | Rationale | Outcome Evaluation and Re-planning |
|---|---|---|---|---|
| Subjective:Mrs. Snyder has movement issues in our house along with the tension of skin damage. She has a history of irritation in the body parts having more weight.Objective:High skin damaging risk due to 35 body mass index. Less movement and pain during physical movement. | Short-Term Goal: Mrs.Snyder will implement the practice of skin checkups.She will consult with skin health practitioners every week.Long-Term Goal:Her skin damage will stop at the end of 3 months.She will take proper education on skin health practices. | Skin Care ConsultationConsultation regarding skin care must be provided by a skin professional for better outcomes (Lee et al., 2020). | Skin Care ConsultationThe consultation will help Mrs.Snyder develop habits that are best suitable for her skin along with the diet that can help her in improving her skin health (Lee et al., 2020). | Re-PlanningIf the outcomes are not according to expectations then consultation with the healthcare professional should be done on a new schedule with insight into the present skin condition. |
NURS FPX 6610 Assessment 2 References
Fenske, J. N., Berland, D. W., Chandran, S., Harrison, R., Schneiderhan, J., Hilliard, P. E., Bialik, K. C., Clauw, D. J., Lowe, D. A., Mehari, K. S., Smith, M. A., Urba, S. G., Harrison, R., Proudlock, A. L., & Rew, K. T. (2021). Pain management. PubMed. https://www.ncbi.nlm.nih.gov/books/NBK572296/
Forte, P., & Teixeira, J. E. (2023). Exercise biomechanics for health: Evaluating lifelong activities for well-being. Healthcare, 11(6), 900. https://doi.org/10.3390/healthcare11060900
Gray, A., & Threlkeld, R. J. (2024). Nutritional recommendations for individuals with diabetes. Nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK279012/
Hussain, M. I., Naveed, F., Sheikh, M., Arif, M., Maqsood, S., Areeba, Y. & Khalid, H. (2023). Investigation of dietary habits and lifestyle in relation to diabetes mellitus type ii among private-sector employees of lahore: A cross-sectional study. Pakistan Journal of Medical & Health Science, 17(7), 2–5. https://doi.org/10.53350/pjmhs20231772
Jin, X., Qiu, T., Li, L., Yu, R., Chen, X., Li, C., Proud, C. G., & Jiang, T. (2023). Pathophysiology of obesity and its associated diseases. Acta Pharmaceutica Sinica B, 13(6). https://doi.org/10.1016/j.apsb.2023.01.012
Kerns, R. D., Burgess, D. J., Coleman, B. C., Cook, C. E., Farrokhi, S., Fritz, J. M., Goertz, C., Heapy, A., Lisi, A. J., Rhon, D. I., & Vining, R. (2022). Self-management of chronic pain: Psychologically guided core competencies for providers. Pain Medicine. https://doi.org/10.1093/pm/pnac083
Kim, S. E., & Yoo, B. (2023). Treatment strategies of improving quality of care in patients with heart failure. Korean Circulation Journal. 53. https://doi.org/10.4070/kcj.2023.0024
Kottner, J., Hahnel, E., Genedy, M., Neumann, K., & Balzer, K. (2019). Enhancing skin health and safety in aged care: A study protocol for an exploratory cluster-randomized pragmatic trial. Trials, 20(1). https://doi.org/10.1186/s13063-019-3375-7
Kim, J., & Hur, M. H. (2021). The effects of dietary education interventions on individuals with type 2 diabetes: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 18(16), 8439. https://doi.org/10.3390/ijerph18168439
Lee, Y. B., Shin, M. K., Kim, J. S., Park, Y. L., Oh, S. H., Kim, D. H., Ahn, J. Y., Lee, S. J., Kim, H. O., Kim, S. S., Lee, H. J., Lee, M. W., Lee, Y. W., & Park, M. Y. (2020). Perceptions and behavior regarding skin health and skin care products: Analysis of the questionnaires for the visitors of skin health expo 2018. Annals of Dermatology, 32(5), 375. https://doi.org/10.5021/ad.2020.32.5.375
Raghupathi, V., & Raghupathi, W. (2020). The influence of education on health: An empirical assessment of oecd countries for the period 1995–2015. Archives of Public Health, 78(1), 1–18. https://doi.org/10.1186/s13690-020-00402-5
Sugandh, F. N., Chandio, M., Raveena, F. N., Kumar, L., Karishma, F. N., Khuwaja, S., Memon, U. A., Bai, K., Kashif, M., Varrassi, G., Khatri, M., Kumar, S., Sugandh, F., Chandio, M., Raveena, F. N., Kumar, L., Karishma, F. N., Khuwaja, S., Memon, U. A., & Bai, K. (2023). Advances in the management of diabetes mellitus: A focus on personalized medicine. Cureus, 15(8), 1–13. https://doi.org/10.7759/cureus.43697
Vainauskiene, V., & Vaitkiene, R. (2021). Enablers of patient knowledge empowerment for self-management of chronic disease: An integrative review. International Journal of Environmental Research and Public Health, 18(5), 2247. https://doi.org/10.3390/ijerph18052247
Wu, W., He, X., Li, S., Jin, M., & Ni, Y. (2023). Pain nursing for gynecologic cancer patients. Frontiers in Oncology, 13. https://doi.org/10.3389/fonc.2023.1205553