NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment
Student Name
Capella University
NURS-FPX 6610 Introduction to Care Coordination
Prof. Name
Date
Nursing Diagnosis and Care Plan for Mrs. Snyder
Patient Information
Patient Identifier: 6700891
Medical Diagnosis: Poorly controlled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia
First Nursing Diagnosis: Ineffective Health Management Related to Poor Diabetes Education
Assessment Data
Mrs. Snyder is a 56-year-old married mother of two, currently receiving treatment for hyperglycemia and poorly controlled diabetes. She presented to the emergency department with blood glucose readings between 230–389 mg/dL, accompanied by dyspnea, lower abdominal discomfort, malaise, and frequent urination. Her medical history includes hypertension, and she maintains an unhealthy dietary pattern, consuming cookies and snacks frequently, which may exacerbate her diabetes and cardiovascular risk.
Goals and Outcomes
- Within one month, Mrs. Snyder’s blood glucose and blood pressure will stabilize within recommended ranges.
- Within three months, she will demonstrate improvement in her dietary habits and overall health, including adherence to lifestyle modifications (Ramzan et al., 2022).
Nursing Interventions
- Education on Self-Care Management: Provide comprehensive guidance on lifestyle changes, including dietary adjustments, physical activity, and healthy sleep hygiene (USC, 2018).
- Encouragement of Diabetes Self-Monitoring: Instruct Mrs. Snyder on daily blood glucose monitoring and maintaining a detailed log of dietary intake to facilitate self-management (Carolina, 2019).
- Insulin Administration Education: Teach proper techniques for insulin administration to optimize glycemic control.
Rationale
Patient education empowers individuals with diabetes to take active roles in managing their condition. Understanding medication schedules, dietary choices, and monitoring techniques fosters better adherence, enhances patient-provider collaboration, and reduces the risk of complications (Heart, 2021).
Outcome Evaluation and Re-planning
The care team will review Mrs. Snyder’s glucose logs regularly to evaluate treatment effectiveness. Dietary plans and insulin regimens will be adjusted based on ongoing glucose readings to achieve optimal glycemic control.
Second Nursing Diagnosis: Anxiety Exacerbated by Domestic and Caregiving Responsibilities
Assessment Data
Mrs. Snyder reports feeling overwhelmed due to household responsibilities, caring for her elderly mother, and conflicts with her son. She has a history of inconsistent anxiolytic use and presents with hypertension and tachycardia. Additionally, she manages all family finances and responsibilities, further contributing to heightened stress and anxiety levels.
Goals and Outcomes
- Within one month, Mrs. Snyder’s blood pressure will stabilize at approximately 130/90 mmHg, and her heart rate will normalize (60–100 bpm).
- Anxiety levels will decrease through consistent use of prescribed medications and counseling interventions (Pegg et al., 2022).
Nursing Interventions
- Pharmacological Management: Administer prescribed anxiolytics to manage anxiety symptoms.
- Cognitive Behavioral Therapy (CBT): Schedule weekly therapy sessions to help develop effective coping strategies (Pegg et al., 2022).
- Support Group Referral: Connect Mrs. Snyder with a local support group within her community to promote mindfulness and spiritual well-being.
Rationale
An integrated approach using pharmacological therapy combined with CBT and social support has been shown to effectively reduce anxiety, regulate blood pressure, and improve overall psychological well-being (Ströhle et al., 2018).
Outcome Evaluation and Re-planning
The care team will monitor Mrs. Snyder’s response to therapy and medication weekly. Adjustments will be made as necessary based on her anxiety management progress and continued stress levels.
Third Nursing Diagnosis: Psychosocial Distress Related to Ovarian Cancer and Caregiving Burden
Assessment Data
Mrs. Snyder expresses apprehension about chemotherapy and concerns regarding her ability to care for her elderly mother. She experiences abdominal pain, dyspnea, and reduced oxygen saturation during physical exertion, which impacts her daily functioning.
NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment
Goals and Outcomes
- Within 15 days, Mrs. Snyder will secure a care facility for her mother, allowing her to focus on her own health needs.
- Over three months, improvements in physical stamina, pain management, and oxygenation levels will be observed.
Nursing Interventions
- Social Work Referral: Assist in finding an appropriate care placement for her mother to relieve caregiving responsibilities.
- Routine Pain Assessment: Conduct frequent pain evaluations (three times daily) to track treatment effectiveness.
- Non-Pharmacological Pain Management: Educate Mrs. Snyder on alternative methods such as meditation, yoga, and breathing exercises for managing pain and anxiety (Sheikhalipour et al., 2019).
Rationale
Alleviating caregiving burdens allows patients to prioritize their own health. Non-pharmacological interventions are effective in managing cancer-related pain, reducing stress, and enhancing both physical and psychological resilience (Hoyt, 2022).
Outcome Evaluation and Re-planning
Pain levels and functional capacity will be continuously monitored. Care plans will be adjusted based on progress in pain management, caregiving arrangements, and overall treatment response.
Summary Table of Nursing Diagnoses, Interventions, and Outcomes
| Category | First Nursing Diagnosis: Ineffective Health Management | Second Nursing Diagnosis: Anxiety Related to Domestic and Caregiving Stress | Third Nursing Diagnosis: Psychosocial Distress Due to Cancer and Caregiving |
|---|---|---|---|
| Assessment Data | Uncontrolled diabetes, hyperglycemia, unhealthy diet, hypertension | High anxiety from caregiving and financial pressures, irregular anxiolytic use, tachycardia | Fear of chemotherapy, stress from caregiving, physical symptoms (abdominal pain, dyspnea) |
| Goals and Outcomes | Stabilize blood glucose and BP within 1 month, improve diet within 3 months | Stabilize BP and heart rate within 1 month, reduce anxiety via therapy and medication | Secure mother’s care placement in 15 days, improve stamina and oxygen levels within 3 months |
| Nursing Interventions | Self-care education, blood glucose monitoring, insulin administration training | Anxiolytic administration, CBT sessions, support group referral | Social work referral, routine pain assessment, education on non-pharmacological pain management |
| Rationale | Education promotes effective self-management and adherence to treatment | Pharmacological and therapy-based interventions reduce anxiety and regulate vitals | Reducing caregiving burden allows self-care; non-drug interventions manage pain effectively |
| Outcome Evaluation | Regular review of glucose logs; adjust diet and insulin as needed | Weekly therapy assessment; modify care plan based on anxiety response | Monitor pain and physical status; re-plan based on mother’s care and patient progress |
References
Carolina, C. M. (2019). Unlocking the full potential of self-monitoring of blood glucose. US Pharmacist. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose
Heart. (2021). Living healthy with diabetes. American Heart Association. https://www.heart.org/en/health-topics/diabetes/prevention–treatment-of-diabetes/living-healthy-with-diabetes
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, M., et al. (2022). Lifestyle interventions for diabetes management: Evidence and outcomes. Journal of Diabetes Research, 2022(5), 1–12.
Sheikhalipour, Z., et al. (2019). Mind-body interventions in cancer care: Evidence for stress reduction and improved quality of life. Supportive Care in Cancer, 27(8), 2913–2923.
Ströhle, A., et al. (2018). Integrative approaches in anxiety management. Frontiers in Psychiatry, 9, 364. https://doi.org/10.3389/fpsyt.2018.00364
USC. (2018). What does self-care mean for diabetic patients? University of Southern California Nursing. https://nursing.usc.edu/blog/self-care-with-diabetes/
Hoyt, M. (2022). Pain management in oncology: Non-pharmacological strategies. Cancer Nursing Practice, 21(4), 22–30.