NURS FPX 6610 Assessment 2 Patient Care Plan
Student Name
Capella University
NURS-FPX 6610 Introduction to Care Coordination
Prof. Name
Date
Patient Care Plan for Mrs. Snyder
Patient Information
Patient Identifier: 6700891
Medical Diagnosis: Poorly controlled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia
Nursing Diagnosis 1: Risk of Poor Healthcare Management and Diabetes Complications
Assessment Data
Mrs. Snyder is a 56-year-old married woman with two children who presents with a history of poorly controlled diabetes. She frequently consumes high-sugar foods and has been admitted to the emergency department with hyperglycemia, with blood glucose levels ranging from 230 to 389 mg/dL. She reports dyspnea, abdominal discomfort, and frequent urination and also has a diagnosis of hypertension, which further complicates her overall health.
Goals and Outcomes
- Maintain fasting and postprandial blood glucose levels between 90–140 mg/dL within two months.
- Demonstrate improved dietary habits and achieve measurable weight reduction within three months by following a structured, low-sugar, balanced diet.
Nursing Interventions and Rationale
- Patient Education on Self-Care Management: Teach Mrs. Snyder strategies for blood sugar control, including dietary modifications, physical activity, and adherence to prescribed medication. Educating patients fosters independence and enhances long-term diabetes management (USC, 2018).
- Blood Glucose Monitoring and Insulin Administration Training: Provide hands-on instruction to ensure proper self-monitoring and insulin usage. This reduces risks of hypo- or hyperglycemia (Carolina, 2019).
- Collaboration with a Dietitian: Develop a personalized meal plan that reduces sugar and unhealthy fats while ensuring balanced nutrition. Structured dietary planning improves glycemic control and prevents complications associated with diabetes (Heart, 2021).
Outcome Evaluation and Re-planning
Daily monitoring of glucose levels will be documented. If blood glucose goals are not achieved, interventions such as additional follow-up appointments, intensified dietary counseling, or adjustment of pharmacologic therapy will be implemented.
Nursing Diagnosis 2: Anxiety Related to Caregiving and Health Issues
Assessment Data
Mrs. Snyder reports significant anxiety due to her caregiving responsibilities for her elderly mother, which contributes to feelings of being overwhelmed. She inconsistently takes her prescribed anxiolytic medications. Objectively, her vital signs show elevated blood pressure (145/95 mmHg) and tachycardia (105 BPM), indicative of heightened stress and anxiety.
Goals and Outcomes
- Reduce anxiety levels by 50% within one month using non-pharmacological interventions alongside medication.
- Stabilize blood pressure at 130/90 mmHg and normalize heart rate within one month.
Nursing Interventions and Rationale
- Administer Prescribed Anxiolytics: Medications such as benzodiazepines or SSRIs (as prescribed) help control anxiety and stabilize physiological responses (Ströhle et al., 2018).
- Referral to Cognitive Behavioral Therapy (CBT): CBT provides structured strategies for managing stress, coping with anxiety, and altering maladaptive thought patterns. Evidence supports CBT as effective for anxiety reduction (Pegg et al., 2022).
- Social Support Connection: Facilitate involvement in support groups for Jewish women dealing with caregiver stress. Emotional and social support can significantly reduce perceived stress and improve psychological well-being.
Outcome Evaluation and Re-planning
Weekly monitoring of anxiety levels, blood pressure, and heart rate will guide care. Should progress remain inadequate, adjustments to medication dosage or frequency of therapy sessions will be considered.
Nursing Diagnosis 3: Caregiver Role Strain and Fear of Cancer Treatment
Assessment Data
Mrs. Snyder expresses fear regarding upcoming chemotherapy for ovarian cancer while managing her mother’s care. She experiences shortness of breath, with objective data indicating oxygen saturation dropping to 91% during ambulation, likely related to obesity and compromised physical conditioning.
Goals and Outcomes
- Arrange long-term care support for her mother within two weeks to reduce caregiver strain.
- Improve oxygen saturation to 95% during ambulation within one month of initiating appropriate interventions.
Nursing Interventions and Rationale
- Referral to Social Worker: Facilitate access to long-term care resources for her mother, which allows Mrs. Snyder to focus on her cancer treatment. Reducing caregiver burden improves treatment adherence and overall well-being (Hoyt, 2022).
- Non-Pharmacological Pain and Anxiety Management: Introduce meditation, deep-breathing exercises, and guided relaxation techniques. These interventions help mitigate treatment-related anxiety and reduce perceived pain (Sheikhalipour et al., 2019).
- Monitoring Pain and Oxygen Saturation: Conduct assessments three times daily to detect early complications and ensure patient safety.
Outcome Evaluation and Re-planning
If oxygen saturation and pain management goals are not met, alternative interventions will be considered, such as supplemental oxygen or adjustment of pain medications. Care plans will be updated in collaboration with the healthcare team.
NURS FPX 6610 Assessment 2 Patient Care Plan
Patient Care Plan Summary Table
| Nursing Diagnosis | Assessment Data | Goals and Outcomes | Nursing Interventions and Rationale | Outcome Evaluation and Re-planning |
|---|---|---|---|---|
| Risk of Poor Healthcare Management and Diabetes Complications | Subjective: High-sugar snack consumption. Objective: Blood glucose 230–389 mg/dL, dyspnea, abdominal discomfort, HTN | 1. Maintain blood glucose 90–140 mg/dL in two months. 2. Improve dietary habits and reduce weight in three months. | 1. Educate on self-care management (USC, 2018). 2. Teach blood glucose monitoring & insulin administration (Carolina, 2019). 3. Collaborate with dietitian for meal planning (Heart, 2021). | Monitor daily glucose. Adjust medications or follow-up as needed. |
| Anxiety Related to Caregiving and Health Issues | Subjective: Anxiety due to caregiving. Objective: BP 145/95 mmHg, HR 105 BPM, irregular anxiolytic use | 1. Reduce anxiety by 50% in one month. 2. Stabilize BP at 130/90 mmHg and normalize HR. | 1. Administer anxiolytics (Ströhle et al., 2018). 2. Refer to CBT (Pegg et al., 2022). 3. Connect to support group. | Weekly monitoring of anxiety and BP. Adjust therapy or medications as necessary. |
| Caregiver Role Strain and Fear of Cancer Treatment | Subjective: Fears chemotherapy; struggles with caregiving. Objective: O2 saturation 91% during ambulation | 1. Arrange long-term care for mother in two weeks. 2. Improve O2 saturation to 95% in one month. | 1. Refer to social worker for caregiving support (Hoyt, 2022). 2. Implement meditation and breathing exercises (Sheikhalipour et al., 2019). 3. Assess O2 saturation and pain thrice daily. | If goals unmet, consider supplemental oxygen or alternative pain management strategies. |
References
Carolina, C. M. (2019). Unlocking the full potential of self-monitoring of blood glucose. U.S. Pharmacist. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose
Heart, J. (2021). Nutritional interventions for diabetes management. Journal of Clinical Nutrition, 15(2), 34–42.
Hoyt, J. (2022). Assisted living & senior placement agencies. SeniorLiving.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. Current Psychiatry Reports, 24(12). https://doi.org/10.1007/s11920-022-01384-7
NURS FPX 6610 Assessment 2 Patient Care Plan
Sheikhalipour, Z., Ghahramanian, A., Fateh, A., Ghiahi, R., & Onyeka, T. C. (2019). Quality of life in women with cancer. Journal of Caring Sciences, 8(1), 9–15. https://doi.org/10.15171/jcs.2019.002
Ströhle, A., et al. (2018). Pharmacological interventions for anxiety management. Journal of Anxiety Disorders, 53, 1–10.
USC. (2018). What does self-care mean for diabetic patients? Nursing.usc.edu. https://nursing.usc.edu/blog/self-care-with-diabetes/