NURS FPX 6610 Assessment 2 Patient Medical Diagnosis

Stage IV ovarian cancer, DM, HTN, hypercholesterolemia, anxiety, and obesity

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.	NURS FPX 6610 Assessment 2 Patient Care Plan explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention.	Were the goals met? How would you revise the care plan according to the patient’s response to the current care plan? Support your conclusions with outcome measures and professional standards.
Nursing Diagnosis One: Muscular weakness and weariness, which increases the risk of falls as demonstrated by: Objective data: The patient says that he or she has to take frequent rests due to feeling tired and gets breathless even while walking. Empirical evidence: The level of oxygen saturation was 91% during walking and got up to 92% when the person was seated.	Objective 1: The patient will be gradually improving their ability to walk during the following week as evidenced by the frequency of the breaks and pulse oximetry readings of 95% and above during the walks. Objective 2: Within the next month, the patient will improve their physical endurance to a level that will allow them to complete 10 minutes of walking without significant fatigue or shortness of breath, and the patient’s pulse oximetry level will be 95% or above during this activity.	Intervention 1: Develop an exercise regime for the patient which is structured and would meet their requirements and abilities. Strength training exercises and endurance training exercises should be incorporated in this plan. It has been discovered that with the practice of exercise on a consistent basis the muscles are strengthened and they are able to endure for longer periods of time. This makes people less likely to fall because they are able to balance or even perform some acrobatics. It is also an effective way to increase the health of your heart and lungs, and this will enhance the circulation of blood in the body and reduce exhaustion during walking. Second, consult with physical therapy to identify and address any issues related to balance or gait by employing specific treatment approaches and mobility aids, where necessary. According to Rieger et al. (2020), physical treatment is helpful in increasing chances of balance and movement, which in turn reduces the number of falls. It is crucial for the patient’s joint issues to be managed and for them to be provided with the appropriate walker or cane to reduce their chances of getting hurt while walking. Intervention Three: Explain to the patient and their relatives how to prevent falls, which include how to walk safely, the shoes to put on, and how to modify the environment in order to reduce the risk of falling (Montero-Odasso et al. , 2021). According to Briewell (2020), educating the patient and his/her caretakers on how to prevent falls can go a long way in reducing the frequency of falls in the home setting that occurs. They can get rid of all the trash, put bars to grab on to, and make other such changes to ensure that they are safe in their living area and they do not fall easily.	Every action is required and useful because it addresses factors that increase the risk of the patient falling. The exercise regimen organized helps in building strength and endurance that is a crucial factor when it comes to balancing and stability during ambulation hence reducing the chances of falls (Adams et al. , 2023). Cooperation with a physical therapist allows specific actions to be made to enhance the patient’s balance and walking, or simply make it even safer for him or her to navigate around. Another advantage of educating the patient and their family on how to prevent falling is that it empowers the patient to control their environment and to make appropriate choices on issues to do with walking and other similar activities (Bridewell, 2020). In combination, these treatments present a holistic approach to reducing the risk of falls and enhancing the overall well-being and well-being of the patient.	When the care plan for managing poorly with the new cancer diagnosis of Rebecca Snyder has been implemented, it is necessary to assess the effectiveness of the treatments and whether the goals were achieved. As the result of the looking back, it seems that Rebecca has some improvement in her performance, but she has not achieved the goals she set within the time limits. There is still room for improvement in her way of handling these issues, although she has discussed her worry and grief because of side effects of treatment, and how to cope with pain.   If the care plan has to be altered based on what Rebecca said, it is necessary to consider how she deals with stress and pain at the moment. This can be done by engaging her in a daily or weekly conversation about her experiences, fears, or any issues she may be having in the process of implementing the recommendations made. It is also important to incorporate cognitive-behavioral therapy techniques, breathing exercises and modify her pain medicine schedules according to the reaction that she displays (Reddy et al. , 2020).   In order to compare the results and monitor the changes in the child’s development over time, the outcome measures such as self-report of worry, discomfort, pain on VAS, and the child’s functional state can be used. The guidelines indicate that the care plan should be developed in a manner that would allow for constant changes due to the patient’s dynamic needs and responses to interventions. Therefore, any alterations in the plan should be done involving Rebecca, with reference to her care plan, preferences, and values. This is because by monitoring how Rebecca reacts to the interventions made then adjusting them, then her general health and well-being as she undergoes cancer treatment will be enhanced.
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Diagnosis in Nursing Two Ineffective ways of dealing with a new cancer diagnosis, as highlighted by Subjective information: Here is an example of how a patient might respond to the question: “I don’t want to be in pain. ” “I don’t want to feel sick at all!” and being able to cry during the discussion of the side effects of chemotherapy. Facts and figures: The patient self-terminated from the anxiousness medication because of the effects.	Goal 1: In one week, patient will demonstrate ways of handling worry and sadness resulting from cancer diagnosis and effects of treatment. Goal 2: In two weeks time, the patient will be able to verbalize on how to manage the pain and that the pain is at a bearable level as to engage in daily activities.	Nursing Intervention 1: Therapeutic Communication: Show concern and respect for a patient by speaking to them in a compassionate manner that recognizes their pain. This strategy helps in establishing rapport with the patient and helps the patient to express him or herself on the things that are troubling him or her hence helping in processing the feelings (Singh & Dey, 2020). Intervention 2 by the nurse: teaching people how to cope with stress: Educate the concerned patient about different forms of mindfulness, relaxation techniques, and guided imagery to manage worry and concern (Parizad et al. , 2021). These techniques can help the patient regain some measure of control over their mental health, which in turn will help them address things. Consult with a psychologist or therapist to assess and address the worry issues of the patient as part of the third interprofessional teamwork intervention. Consultation with mental health professionals ensures comprehensive care that addresses both the physical and the psychological aspects of the patient. This enables them to manage the conditions and reduces the chances of worsening their mental health issues (NURS FPX 6610 Assessment 2 Patient Care Plan).	Effective communication also helps the patient to open up and feel comfortable with the healthcare providers, thus developing trust in the healthcare workers (Singh & Dey, 2020). It is also important to listen to the patient actively and respond with empathy to support the patient’s feelings, which reduces feelings of loneliness or anxiety (Babaii et al. , 2021). Therapeutic conversation enables the patient to manage his/her emotions and adapt to the given cancer news by acknowledging his/her concerns. This enhances their overall well being and resilience.   Enabling the patient information means that the patient is able to manage their worry and anxiety about their condition; this increases the patient’s participation in his/her care (Rashid et al. , 202 ). In this way, through awareness and relaxation the patient is taught to regulate his/her emotions and reduce stress. According to Ragkåsa et al. (2020), education makes people feel powerful and effective to meet their own psychological needs and to address the issues of having cancer and being treated.   3. Talking to a mental health professional: Engaging mental health professionals ensures that the patient’s mental health is assessed and that appropriate treatment modalities are applied. It is important to note that professionals who work in the field of mental health understand how to manage anxiety and mood issues and can assist with things such as CBT or when it is necessary to manage medicines (González-Robles et al. , 2022). Speaking to these specialists during the initial stages helps in identifying and addressing mental health issues that the patient may be experiencing, thus enhancing the patient’s management and care across the cancer journey.	When the care plan for managing poorly with the new cancer diagnosis of Rebecca Snyder has been implemented, it is necessary to assess the effectiveness of the treatments and whether the goals were achieved. As the result of the looking back, it seems that Rebecca has some improvement in her performance, but she has not achieved the goals she set within the time limits. There is still room for improvement in her way of handling these issues, although she has discussed her worry and grief because of side effects of treatment, and how to cope with pain.   If the care plan has to be altered based on what Rebecca said, it is necessary to consider how she deals with stress and pain at the moment. This can be done by engaging her in a daily or weekly conversation about her experiences, fears, or any issues she may be having in the process of implementing the recommendations made. It is also important to incorporate the cognitive-behavioral therapy techniques, breathing exercises and modify her pain medicine schedules according to the reaction that she displays (Reddy et al. , 2020).   In order to compare the results and monitor the changes in the child’s development over time, the outcome measures such as self-report of worry, discomfort, pain on VAS, and the child’s functional state can be used. The guidelines indicate that the care plan should be developed in a manner that would allow for constant changes due to the patient’s dynamic needs and responses to interventions. Therefore, any alterations in the plan should be done involving Rebecca, with reference to her care plan, preferences, and values. This is because by monitoring how Rebecca reacts to the interventions made then adjusting them, then her general health and well-being as she undergoes cancer treatment will be enhanced.
Diagnosis in Nursing Three: This is due to the fact that they have various caring jobs to attend to, and therefore, they are unable to engage in self-care. Subjective information: It was funny when the patient told me, “I are in charge of everything. ” And by everything, I think she means everything about taking care of the family. Facts and figures: According to the respondents, the patient is responsible for all the chores as well as caretaking even if she or he is unwell. Added up data: Diabetes is not well-managed in this patient, indicating that the patient is not very conscientious about his or her health condition.	Goal 1: Rebecca will demonstrate proper diabetes care by monitoring her blood glucose levels and adhering to the recommended dietary and pharmacological regimens prescribed by her doctor. Her records will reveal that in the following three weeks her HbA1c has reduced by at least 1% from her baseline. Goal 2: In two weeks, the nurse will identify the patient and ensure that he or she assigns at least one home job on a daily basis to a family member or use community resources to seek assistance on how to care for the patient.	Nursing Intervention 1: Explain to Rebecca all that she requires to know about the management of her diabetes including how to monitor her blood glucose levels effectively, how to administer insulin, and dietary restrictions (Yasmin et al. , 2020). This is especially true for diabetics because they have to know how to manage their condition and adhere to the prescribed course of action. If she increases her knowledge about diabetes and strengthens her ability to deal with it, it will be easier for Rebecca to manage her health. Reduced HbA1c can be achieved through improved glycemic control by informing people on how vital it is to monitor blood sugar levels and adhere to the prescribed medications and diet restrictions (Kumar et al. , 2022). Second Nursing Intervention: Support the conversation of how Rebecca and her family can explain how her health state influences her to perform household tasks and care for other people. Have pamphlets containing information such as home care services and support groups for caregivers made available to people in the neighborhood. A major area of concern that Rebecca should have knowledge of and address is self-neglect that results from being a helper to many. Assigning family members or community tools housework jobs can assist in reducing some of the burden from her a bit, in order to have ample time to take good care of herself and manage her diabetes (Woodard et al. , 2022). Nursing Intervention 3: For the purpose of motivating the patient, one should work with Rebecca to establish achievable goals regarding her diabetes and assisting her with house chores. It is recommended to schedule follow-up sessions on a monthly basis to see how the children are progressing, address any issues that may have arisen concerning the treatments, and provide encouragement and positive reinforcement (Howell et al. , 2020). Engaging Rebecca in establishing goals helps her to feel more included in the care plan and drives her to achieve better results. This way, you get to monitor her progress and check whether she encountered any difficulties or challenges (Smith et al. , 2022). Ensure that both parties are communicating and provide support during the periods of intervention. It will also increase the chances of her attaining her goals and maintaining her self-care and overall health.	NURS FPX 6610 Assessment 2 Patient Care Plan actions taken are deemed relevant and beneficial based on the principles of evidence-based nursing practice. Diabetes education remains crucial since it empowers people with knowledge to manage their health on their own, ensuring improved compliance and outcomes as pointed out by Kumar et al. in 2022. The ADA has documented that patient self-management education significantly reduces HbA1c levels and the risk of complications to a great extent (Katsaridis et al. , 2020). Rebecca’s self-neglect is resolved by caregivers’ availability and resource provision, in which she is provided for mentally and physically, enhancing her overall health. According to the recent studies, the interventions that assist the caregivers enhance the care givers’ working conditions and the health of the patients (Schulman-Green et al. , 2020). Engaging people in the process and establishing goals alongside following up on them are efficient strategies for patient-centered care since they make people more responsible and active (Howell et al. , 2020). Self-organization of diabetes and glucose regulation improves when people act cooperatively in terms of goal setting (Woodard et al. , 2022). These actions are in compliance with evidence-based practice, therefore, Rebecca will receive full care that meets her individual requirements.	With the information that has been presented about Rebecca Snyder’s care, it is evident that the goals that were set have not been achieved. Perhaps there was some work, but to achieve the outcome that was desired within the amount of time that was designated, does not appear sufficient. Goal 1 of addressing the issue of controlling Rebecca’s diabetes has not been achieved as envisaged; her HbA1c figures have not reduced by at least 1% as required. Likewise, there are no indications that Rebecca has begun delegating tasks around the house or seeking assistance with the childcare responsibilities, which is in conflict with Goal 2. Therefore, to alter the care plan depending on the answer given by Rebecca, it is necessary to focus on her requirements and abilities once more. According to professional standards, solutions should be prepared and adjusted according to the requirement and preference of each patient. NURS FPX 6610 Assessment 2 Patient Care Plan accurate assessment of the success the outcome indicators such as HbA1c, blood glucose diary and documentation, and documentation of home chores done and/or help sought from the community should be employed. As per the Rodriguez et al. , 2024, modifications in the plan could be the improvement of the knowledge regarding how to manage the diabetes, the identification of the factors that prevent people from delegating tasks, and the identification of the right community resources that will assist Rebecca to overcome her self-care problems in the right manner.

References

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