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NURS FPX 6610 Assessment 2 Patient Care Plan

NURS FPX 6610 Assessment 2 Patient Care Plan

Student Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name


Patient Identifier: #6700891

Patient Medical Diagnosis: Anxiety Issues, Ovarian Cancer, uncontrolled diabetes, obesity and hyperglycemia

Nursing Diagnosis
Assessment Data
Goals and OutcomesNursing InterventionsRationaleOutcome 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 and provide the rationale for each goal and outcome.Explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention.Were the goals met? How would you revise the plan of care according to the patient’s response to the current plan of care? Support your conclusions with outcome measures and professional standards.
Nursing diagnosis First Diagnosis: Anxiety Issues
Lack of Rest due to excessive household duties, from meal prep, to cleaning to looking out for her mother. Regardless of her health, she often takes on duties that are bigger than her physical health limits because she feels that her husband is happy with her (attention seeking behavior). The majority of the verbatim of Mrs. Snyder, and his family was associated with her being the sole caretaker of many people around her, which reflected a lot of duties for her and made her feel fatigued and tired most of the time. constant anxiety of not fulfilling the homemaker role perfectly and constant in stress of taking care of another dependent person excessive use of medication due to stress factors 
First goal: The underlying issue is that Mrs. Snyder is facing a problem related to her mental health, especially in the lines of compassion fatigue since she herself is taking care of her mother, who has dementia, and over top of that, she is managing her house with her health complications. . The first goal is to introduce counseling and anxiety management through CBT and behavioral activation. Outcome: The outcome is to help Rebacca manage her expressed emotions while helping her to control her anxiety. The goal will help in managing the anxiety as well as to help her regulate her emotions and be able to accept the change of roles in the family such as giving away some of their responsibilities. she will have better mood, while being able to move through the transitional phase smoothly First intervention 
Refer the patient to the psychologist for psychological intervention and family therapy to help the patient adjust to her new role where she prioritizes her health and family therapy to help the family understand her needs and ways to support her. providing a regulated amount of anxiolytics to ensure the client does not overdose on the medication. 
The rationale for referring her to the psychologist is that the majority of the stress factors for Mrs. Snyder are associated with her overcompensating behavior and taking care of her mother and her family. Somehow, it can be associated with the fact that providing care is the only way she receives attention and validation; thus, not being able to fulfill her role is making her anxious. This suggests that Mrs Synder is currently facing issues in adjusting to the new reality of life and is unable to transition into the new life situations. Therefore, it is important to offer psychological intervention and to involve family to reduce the psychological stress and help the family to provide support in the way that is needed by her. Similarly, studies have highlighted that psychological interventions play a significant role in providing results and reducing anxieties without major harm (Colizzi et al., 2020).These goals and treatment options are proposed, but none of them are being implemented currently. Thus, to provide a better picture of outcomes and to plan how to move forward, it is important to address the weekly assessments. 
Second Diagnosis: Ovarian Cancer
The patient has been recently diagnosed with ovarian cancer and has undergone radiation and chemotherapy.She misses her chemotherapy appointments as she often feels nauseous afterwards and often reports that her mother requires her help; therefore, she misses her appointments.She expressed her dislike for the post therapy symptoms and how difficult it is to work after it. 
Second Goal:
The goal is to help her become regular to chemotherapy and medication adherence, as with her condition, it is inevitable to miss appointments. Suggesting other care facilities for her mother to help her focus on her health 
The aim is to bring acceptance, help her understand the importance of chemotherapy, and motivate her to be better. thus, gaol will help her to accept and become punctual to the therapy session 
Second Intervention suggesting strategies to keep track of the appointments and reminders. involving other family members to come to therapy to support herconstant the oncologist to help her manage her post-chemotherapy session symptoms and to help her feel better The rationale here is to help the patient accept her condition while contacting social support services to help her find better caring alternatives for her mother. Studies have highlighted that chemotherapy holds a significant place in cancer management, and with the progressive stage, chemo can help increase life expectancy (Amjad, & Kasi, 2020). The aim is to help the patient become regular and to provide as much palliative care as possible. as with progressive stages, the palliative care provides a cushion that helps reduce cancer related pain and help the patient live better life (‌World Health Organization, 2020) These goals and treatment options are proposed, but none of them are being implemented currently. Thus, to provide a better picture of outcomes and to plan how to move forward, it is important to address the weekly assessments. 
Third Diagnosis: Uncontrolled Diabetes 
Lack of awareness for the disease management excessive house stress and lack of regulation of diet and medication adherence irregular blood sugar levels that may seem dangerous, as she might be facing more health complications. obesity due to excessive stress eating and other associated health factors. 
Third Goal: Being a cancer patient, it is imperative to manage the patient’s blood sugar levels, as both of these conditions in combination can become hazardous for the patient. 
Outcome the patient will report medication adherence and improved clean diet 
Third Intervention: Refer to a nutritionist to help the patient know her diet and what she can eat, and how much she should eat. With her complications, only pace walk is suggested, as she constantly feels fatigued. medication adherence and education on regulated diet to help the client adopt a healthy lifestyle. selfcare management and diet regulation strategies to help the client be more engaged in managing her health issues. Lack of medication adherence, information on how to self care and irregular diet can have many major complications that can become dangerous for the patient (Afaya et al., 2020). Thus, the rationale of these is to help the client follow a healthy lifestyle and educate her on her condition, and provide as much support as she requires. First evaluate the suggested changes and then work further on different aspects. 
These goals and treatment options are proposed, but none of them are being implemented currently. Thus, to provide a better picture of outcomes and to plan how to move further it is important to address the weekly assessments. 
Priority SMART Goals
 To manage the diabetes with medication and Ivs To have a nutritionist awareness session and to follow a diet chart to regulate her diet to contact Social services to help her manage her household responsibilities such as her mother with dementia On discharge day, she would have her diet chart, stress management strategies To reduce anxiety upto 60% within 4 weeks of the therapy. To refer the oncologist to manage the post-chemotherapy symptoms and issues to provide awareness and education on self care and disease management. to increase the pain relief and manage the oxygenation issues. 


Afaya, R. A., Bam, V., Azongo, T. B., Afaya, A., Kusi-Amponsah, A., Ajusiyine, J. M., & Abdul Hamid, T. (2020). Medication adherence and self-care behaviours among patients with type 2 diabetes mellitus in Ghana. PloS one, 15(8), e0237710.

Amjad, M. T., & Kasi, A. (2020). Cancer Chemotherapy. PubMed; StatPearls Publishing.

NURS FPX 6610 Assessment 2 Patient Care Plan

Colizzi, M., Lasalvia, A., & Ruggeri, M. (2020). Prevention and early intervention in youth mental health: Is it time for a multidisciplinary and trans-diagnostic model for care? International Journal of Mental Health Systems, 14(1), 1–14.

‌World Health Organization. (2020, August 5). Palliative care. World Health Organization; World Health Organization.