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 Information

Patient Identifier: 6700891
Medical Diagnosis: Poorly controlled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia

Assessment Data

Mrs. Snyder, a 56-year-old married mother of two, is currently undergoing treatment for hyperglycemia and uncontrolled diabetes. She was admitted to the emergency department with blood sugar levels ranging between 230-389 mg/dL, experiencing symptoms such as dyspnea, lower abdominal discomfort, malaise, and frequent urination. Additionally, she has hypertension and follows an unhealthy dietary pattern, frequently consuming cookies and snacks.

Goals and Outcomes

Goal 1: Within one month, Mrs. Snyder’s blood sugar and blood pressure levels will stabilize.
Goal 2: Over three months, Mrs. Snyder will report improvements in her eating habits and overall health (Ramzan et al., 2022).

Nursing Interventions

Education on Self-Care Management: Provide guidance on lifestyle modifications, including dietary adjustments, physical activity, and healthy sleep patterns (USC, 2018).
Encouragement of Diabetes Self-Monitoring: Teach Mrs. Snyder how to check her blood glucose daily and track her food intake to enhance diabetes management (Carolina, 2019).
Insulin Administration Education: Ensure Mrs. Snyder understands the proper techniques for insulin administration to maintain optimal blood glucose control.

Rationale

Self-care education equips patients with the knowledge necessary to manage diabetes effectively, promoting adherence to medication and lifestyle changes. Improved self-management leads to better collaboration between the patient and the healthcare team (Heart, 2021).

Outcome Evaluation and Re-planning

Mrs. Snyder’s care team will routinely review her glucose logs to assess the effectiveness of her treatment plan. Based on her progress, adjustments may be made to her dietary plan and insulin use to achieve better glycemic control.

Second Nursing Diagnosis: Anxiety Exacerbated by Domestic and Caregiving Responsibilities

Assessment Data

Mrs. Snyder reports feeling overwhelmed and anxious due to the stress of managing household responsibilities, caring for her ill mother, and conflicts with her son. She has a history of irregular anxiolytic use and presents with high blood pressure and tachycardia. Additionally, she is responsible for handling all financial and family matters, further contributing to her stress and anxiety.

Goals and Outcomes

Goal 1: Within one month, Mrs. Snyder’s blood pressure will stabilize at 130/90 mmHg, and her heart rate will return to the normal range of 60-100 bpm.
Goal 2: Mrs. Snyder’s anxiety will improve through counseling and consistent medication adherence (Pegg et al., 2022).

Nursing Interventions

Pharmacological Management: Administer anxiolytics as prescribed to alleviate anxiety symptoms.
Cognitive Behavioral Therapy (CBT): Arrange weekly counseling sessions to help Mrs. Snyder develop coping mechanisms (Pegg et al., 2022).
Support Group Referral: Connect Mrs. Snyder with a support group within her Jewish community to explore mindfulness and spiritual healing therapies.

Rationale

A combination of pharmacological treatment and non-pharmacological therapies, such as CBT, has been proven effective in reducing anxiety. This holistic approach also helps regulate blood pressure and heart rate, improving overall well-being (Ströhle et al., 2018).

Outcome Evaluation and Re-planning

Mrs. Snyder’s response to therapy and medication will be monitored weekly. Adjustments to her care plan may be made based on her progress and continued needs for stress management and emotional support.

Assessment Data

Mrs. Snyder expresses fear of undergoing chemotherapy and concerns about her ability to care for her elderly mother. She experiences abdominal pain, shortness of breath, and reduced oxygen saturation levels upon exertion.

Goals and Outcomes

Goal 1: Within 15 days, Mrs. Snyder will secure a care facility for her mother, allowing her to prioritize her own health.
Goal 2: Over three months, her physical stamina and oxygen levels will improve.

Nursing Interventions

Social Work Referral: Assist Mrs. Snyder in finding an appropriate care placement for her mother to alleviate her caregiving burden.
Routine Pain Assessment: Conduct pain assessments three times daily to monitor treatment effectiveness.
Non-Pharmacological Pain Management: Educate Mrs. Snyder on alternative pain relief strategies such as meditation and yoga (Sheikhalipour et al., 2019).

Rationale

Providing appropriate care solutions for Mrs. Snyder’s mother will reduce her stress and enable her to focus on her own health. Additionally, non-pharmacological interventions have been shown to effectively manage cancer-related pain, promoting both physical and emotional well-being (Hoyt, 2022).

Outcome Evaluation and Re-planning

Mrs. Snyder’s pain levels will be closely monitored, and her care plan will be adjusted as needed. Once her mother is placed in a care facility, she will be able to shift her focus toward her cancer treatment and overall well-being.

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, poor diet, hypertension	High anxiety due to caregiving and financial burdens, irregular anxiolytic use, tachycardia	Fear of chemotherapy, stress from caregiving, physical symptoms (abdominal pain, shortness of breath)
Goals and Outcomes	Stabilize blood sugar and BP within one month, improve dietary habits in three months	Stabilize BP and heart rate within one month, reduce anxiety with therapy and medication	Secure a care facility for mother in 15 days, improve stamina and oxygen levels in three months
Nursing Interventions	Self-care education, encourage glucose monitoring, insulin administration training	Anxiolytic administration, CBT, support group referral	Social work referral, routine pain assessment, education on non-pharmacological pain management
Rationale	Education promotes better diabetes management and adherence to treatment	Combining pharmacological and therapy-based interventions is effective in anxiety reduction	Addressing caregiving burden allows focus on self-care, non-drug pain management aids in coping
Outcome Evaluation	Regular review of glucose logs, dietary adjustments as needed	Weekly therapy assessment, care plan adjustments based on anxiety response	Monitoring pain levels, re-planning based on progress in mother’s care and personal treatment

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