MSN 6610 Assessment 2 Patient Care Plan
Sample Answer for MSN 6610 Assessment 2 Patient Care Plan
Patient Medical Diagnosis:
| Nursing DiagnosisAssessment of Data | Goals and Outcome | Nursing Interventions | Rationale | Outcome Evaluation and Re-Planning |
| Include 3–5 subjective and/or objective pieces of data that lead to the nursing diagnosis. | Two statements are required for each nursing diagnosis. Must be patient- and/or family-focused, measurable, time-specific, and reasonable. | List at least three nursing or collaborative interventions with rationale for each goal and outcome. | Provide a reason why an intervention is indicated or therapeutic; provide references. | Were the goals met? How would you revise the plan of care according to the patient’s response to the current plan of care? |
| The client has uncontrolled diabetes and is also overweight and has been losing and gaining 15 pounds for years, hence unable to control her weight.The client finds it hard to eat healthily and uses food as a crutch when she gets stressed out. | The patient can control her weight within normal ranges based on her BMI (Powers et al., 2016). | With the help of a dietician, come up with a good diet plan with foods that are easy to digest and high in proteins.Enroll the patient on a controlled and monitored physical exercise daily (Powers et al., 2016). Educate the patient on the importance of eating healthy and physical exercise. | A controlled diet with easily digestible food high in protein will help the patient control her weight and give her strength to during cancer treatment (Powers et al., 2016).Monitored physical exercise will make sure that the patient is having the right amount of exercise that will help her lose some pounds.Patient education will help promote knowledge and compliance (Powers et al., 2016). | The goals have been met so far and are still ongoing. |
| The patient will closely monitor and maintain her blood sugar level within the normal range (Powers et al., 2016). | Encourage the patient to monitor her sugar level daily.Encourage the patient to strictly adhere to her diabetic meds (Powers et al., 2016).Encourage the patient to avoid food which will raise her sugar levels above normal (Powers et al., 2016). | Close monitoring will help the patient know when to seek medical attention.Adhering to the treatment regimen helps promote the outcome (Powers et al., 2016).Diabetic patients must adhere to a healthy diet which will not compromise their health (Powers et al., 2016). | ||
| The client is worried about the pain and nausea that are brought about by chemo and radiation. | The patient will verbalize understanding of other pharmacological intervention of managing nausea and pain (Cooper et al., 2016). | Educate the patient on the various pain medications available. Acknowledge the patient on the importance of chemo and radiation over pain (Cooper et al., 2016).Educate the patient on how to manage her nausea both pharmacologically and non-pharmacologically. | Helps in promoting knowledge and boosting patient’s compliance (Cooper et al., 2016).Helps in making the patient understand the importance of promoting health and wellness. Promotes patient knowledge and compliance on the treatment regimen. | Goals were met |
| The patient will be able to go through chemo and radiation therapy comfortably with the support of her family. | Involve the family member in encouraging the patient to go through chemo and radiation.Educate the family members on the importance of their full support in helping the patient manage her condition (Epstein et al., 2016).Assign each family members different days to take care of their mother by helping her take her meds, diet control, and physical exercise. | Helps in making the patient realize that she is loved and not alone, hence promoting her compliance.Promotes family support which is essential in boosting health and wellness (Epstein et al., 2016).Make the family members actively involved in the management of the patient’s condition. | ||
| Client stopped taking anti-anxiety pills claiming that they make her sleepy and tired. | The patient will appreciate the need for diet among other non-pharmacological intervention of managing her anxiety (Olding et al., 2016). | Educate the patient on the importance of maintaining her anxiety.Educate the patient on non-pharmacological measures of maintaining her anxiety (Olding et al., 2016). Advise the patient to join a support group or see a therapist to manage her anxiety. | To help the patient stay calm and choose a treatment plan to manage her anxiety. Promote patient’s knowledge of the different methods that she can use to maintain her anxiety (Olding et al., 2016). The support group will help the patient know that she is not alone, and gain support to reduce her anxious state. | Goals were properly met. |
| The patient will be able to manage her anxiety and go through chemo and radiation comfortably (Epstein et al., 2016). | Educate the patient on the importance of chemo and radiation therapy. Advise the patient to join a support group (Epstein et al., 2016).Make the patient know that you are aware of the complications of chemo and radiation and help her realize the importance of the process (Epstein et al., 2016). | Promote patient’s knowledge on the relevance of chemo and radiation therapy among cancer patients (Epstein et al., 2016).To promote patient support as she manages her cancer.To promote the patient’s knowledge of the adverse effects of chemotherapy. | ||
| The client is terrified of doctors and pain. | The patient will understand the role and importance of doctors in managing her diagnosis (Silver et al., 2015). | Acknowledge to the patient that you are aware of her fear for doctors and that you understand. Educate the patient on how to reduce her anxiety and fear when around doctors (Epstein et al., 2016).Inform the patient about the impact of the doctors’ presence in her diagnosis. | Make the patient feel that her fears are normal and there is a way that she can deal with it. Help the patient feel freer around doctors for proper diagnosis and health care plan (Epstein et al., 2016).Promote patient’s knowledge on the doctor’s role in the diagnosis and management of terminal illness. | Goals were met, while others are still underway. |
| The patient will manage her pain using pharmacological approaches. | Educate the patient on the available over the counter pain medications and their side effects.Put the patient on pain medications such as Tylenol (Silver et al., 2015).Educate the patient on the importance of adhering to the treatment regimen. | Promote patient’s knowledge on pain meds available over the counter, their benefits and side effects (Silver et al., 2015).Promote patient’s health and wellness.Adhering to the treatment regimen helps boost the outcome. |
References
Cooper, Z., Koritsanszky, L. A., Cauley, C. E., Frydman, J. L., Bernacki, R. E., Mosenthal, A. C., Gawande, A. A., … Block, S. D. (January 01, 2016). Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients with Emergency Surgical Conditions. Annals of Surgery, 263(1), 1-6.
Epstein, R. M., Duberstein, P. R., Fenton, J. J., Fiscella, K., Hoerger, M., Tancredi, D. J., Xing, G., … Kravitz, R. L. (September 09, 2016). Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial. Jama Oncology.
Olding, M., McMillan, S. E., Reeves, S., Schmitt, M. H., Puntillo, K., & Kitto, S. (December 01, 2016). Patient and family involvement in adult critical and intensive care settings: a scoping review. Health Expectations, 19(6), 1183-1202.
Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., Maryniuk, M. D., … Vivian, E. (April 01, 2016). Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Clinical Diabetes, 34(2), 70-80.
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Silver, J. K., Smith, S. R., Wisotzky, E. M., Raj, V. S., Fu, J. B., & Kirch, R. A. (December 01, 2015). Response to editorial by Richard Crevenna, MD, regarding “cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services” by Silver et al. Supportive Care in Cancer, 23(12), 3409-3410.