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Patient Care Plan
Mrs. Snyder, our patient, depicts a sad scenario, which encompasses not only healthcare challenges but also opportunities. To achieve our task, which is to develop the patient care plan for her, it is not enough to pay attention only to her immediate medical needs but also to negotiate the additional difficulties related to care coordination in dealing with her chronic conditions and other things. Correspondingly with the National Strategy for Quality Improvement in Health Care (Agency for Healthcare Research and Quality [AHRQ], our program aims to enhance Mrs Snyder’s quality of life, eliminate ill-usage of healthcare resources, and decrease preventable inpatient healthcare readmissions through a patient-centred, proactive approach. NURS FPX 6610 Assessment 2: Literature Search: The care plan is more than a mere document. It is a detailed systemic model that ensures that the patient respects and application of her preferences, values and dignity. Through the process of amalgamation of information acquired from fictitious interviews with relatives of Mrs Snyder, family members, and experienced healthcare workers, we formulate a comprehensive plan that not only takes care of her acute medical needs now but also paves the way towards securing health in the long term.
Patient’s Condition from a Coordinated Care Perspective
The patient’s condition will be assessed from a holistic care perspective, which involves an integrated evaluation of various aspects of her health. This comprehensive approach is possible through collaboration with Mrs Snyder, her family, and healthcare workers. Their input provides a deeper understanding of her condition, which is crucial for making an effective nursing diagnosis.
Medical History and Current Health Status: Mrs. Snyder is a seventy-two-year-old female who recently underwent a hip replacement operation for osteoarthritis. The surgery was quite a success; she has been battling with issues like mobility and pain management. The doctor has mentioned that Mrs. Snyder’s family is notoriously known to have a history of diabetes and hypertension, which requires persistent control. NURS FPX 6610 Assessment 2: Literature Search: She is experiencing loneliness and isolation since she remained the only person in the house following the death of her husband two years ago.
Functional Assessment: Mrs. Snyder’s movement is significantly reduced due to complications following hip replacement surgery. She needs help with the basics of life, like showering, dressing up, and preparing meals. Her weakened mobility now puts her at greater risk of falling, leading to reduced independence. Besides, she has a problem with hip pain, and she wants to be able to participate in physical activities.
Psychosocial Assessment: Another critical challenge we must address is Mrs. Snyder’s emotional health. She tells (or says) about being depressed and lonely since the death of her husband. She is in a poor environment, with weak support, and is lonely from her friends and the community. For Martha, the lack of independence coupled with her mobility issues makes her not only sad but resentful.
NURS FPX 6610 Assessment 2: Nursing Diagnoses
Mr Snyder’s hip replacement surgery tore down new barriers to his mobility and revealed that he has a critical nursing diagnosis named mobility impairment (American Nurses Association [ANA], 2019). Through the SMART goals which concentrate on reestablishing our patient’s independence and capability, progressively regaining her mobility is the focus in the recovery phase after the operation. We will have our target for Mrs. Snyder to do this by herself and only support her at the very moment one week from the day of the surgery. NURS FPX 6610 Assessment 2: Literature Search: At the end of two weeks, she shall ambulate with a lap for a distance of 10 feet without any hand aid. Hence, we intend to implement a comprehensive mobility program encompassing a range of motion exercises, gait training, and cross-functional teamwork with rehab to achieve these results (Hodges et al., 2020). The therapy will not only be an instrument for her speedy recovery but also will augment circulation, foreclose chances of deep vein thrombosis, build muscle strength, and enhance the flexibility of the joints, agreeing with Mrs Sone’s holistic well-being.
As well as being a stumbling block because of the physical constraints and the grief over her lost husband, Mrs Snyder is also in danger of losing her social life and getting left all alone. The social-psychological part of care delivery is also the focus of our SMART goals, designed to achieve social connections and patient engagement. After one month, Mrs. Winter could be persuaded to pick any activities that would make her more social and participate in one of those two per week. Throughout the next three months, she should set up regular conversation sessions with at least one person from a friend or a family circle who may become her supporter.
Appropriate Nursing or Collaborative Interventions
For the nursing assessment of impaired mobility, the interventions should involve supporting Mrs. Snyder to regain good physical function by addressing the problems arising from the hip replacement surgery. Results indicate that selections for early mobilisation and rehabilitation may lead to better-functioning outcomes post-surgery and reduce pain (Hodges et al., 2020). In this case, adopting a progress mobility plan such as move-limit activity and walk training is vital. Furthermore, teaching people about correct body mechanics and the selection of assist devices is important to ensure secure movement and avoid falls, among the most frequent complication cases with people following hip surgery. NURS FPX 6610 Assessment 2: Literature Search: Cooperation with physical therapy care only reinforces that rather than being based on some common scheme, the rehabilitation should be an individualised plan crafted for Mrs. Snyder in particular.
Risk of social isolation is the nursing diagnosis for Mrs. Snyder; therefore, her treatment includes interventions such as social networks. Research evidence demonstrates that social connection is directly connected to mental health improvement and promotes general health and happiness (Choi & Kim, 2021). So, the help in building up a collection of groups within the local community that offer various social-oriented activities is what Mrs Snyder needs to socialise meaningfully and be actively engaged. Promote participation in online forums or support groups as another method of mitigating the feelings of loneliness and isolation, which are more apparent in recent widowhood (Frost et al., 2020). Moreover, her emotional support and frequent communication filled her feelings of being valued and she felt connected too. As a result, she could cope with the whole situation, and thus, her emotional resilience was enhanced too.
NURS FPX 6610 Assessment 2: Each Intervention is Indicated or Therapeutic
While carrying out nursing interventions, it is important to develop rationales with them in order to practice treatments that not only satisfy but also help address Mrs. Snyder’s needs.
Progressive Mobility Program:
Rationale: It will be essential to start the mobilization process as soon as possible and rehabilitation afterwards for Mr Snyder to have a successful hip replacement surgery. It was found that late stretching mobilisation can result in muscle weakness and joint tension as well as increased complications such as deep vein thrombosis (Hodges et al., 2020; Artz et al., 2015). NURS FPX 6610 Assessment 2: Literature Search: Though the adaptation of a progressive mobility program that consists of a range of motion exercises and gait training is our main objective, with which we want to achieve an improvement in Mrs Snyder’s functional independence using joint flexibility and muscle strength, we believe that we can effectively enable her rehabilitation process.
NURS FPX 6610 Assessment 2: Facilitating Social Connections:
Rationale: Social isolation, as well as loneliness, are important factors that could lead to mental health problems and poor life satisfaction generally (Holt-Lunstad et al., 2017; Choi & Kim, 2021). Numerous studies point out that social interactions contribute significantly to lowering the risk of depression and social isolation (Choi & Kim, 2021). We endeavour to establish community links with local community organisations and online support groups, helping Mrs Snyder to socialise, talk to someone, and feel part of something more; in short, we aim to reduce social isolation and promote overall positive mental health.
Care Coordination Outcomes
Evaluating the care coordination outcomes encompasses examining whether the care plan’s agreed goals were fully, partially, or not achieved at all (Gill et al., 2020). This involves the assessment of the results of care integration and identifying the zones where approved levels need to be added. By reviewing all objectives in the treatment plan and physical indicators as clinical labeling and progress notes, providers can understand the degree to which patient’s needs are addressed.
Upon the assessing success of the targets that were set, it is prudent to figure out what influenced the failure or even mere attainment of some of the goals (Gittell et al., 2019). Consequently, special investigations might be conducted to unleash and investigate several factors participating in the outcomes such as complications or unexpected health issues, patient non-compliance, resource limitations, or communication gaps within the healthcare team. By conducting this research, you may know the aspects that cause challenges during the coordinating process between providers. To empower the evaluation procedure, evidence-based analysis would be a critical mandate. NURS FPX 6610 Assessment 2: Literature Search: Using relevant research data, clinical guidelines, as well as quality improvement is a good base on which to understand whether the stated goals are achieved or not to put up the right course of action (Hwang et al., 2021). In the face of a wide range of health conditions, basing evaluation on introduced evidence allows patient care providers to refine the managing plan of care and respond to specific areas of concern and achieve better outcomes.
NURS FPX 6610 Assessment 2: Conclusion
Evaluating the care coordination outcomes encompasses examining whether the care plan’s agreed goals were fully, partially, or not achieved at all. This involves the assessment of the results of care integration and identifying the zones where approved levels need to be added. By reviewing all objectives in the treatment plan and physical indicators as clinical labeling and progress notes, providers can understand the degree to which patient’s needs are addressed. Upon assessing the targets’ success, it is prudent to figure out what influenced the failure or even the mere attainment of some of the goals. Consequently, special investigations might be conducted to unleash and investigate several factors participating in the outcomes such as complications or unexpected health issues, patient non-compliance, resource limitations, or communication gaps within the healthcare team. NURS FPX 6610 Assessment 2: Literature Search: By conducting this research, you may know the aspects that cause challenges during the coordinating process between providers. To empower the evaluation procedure, evidence-based analysis would be a critical mandate. Using relevant research data, clinical guidelines, as well as quality improvement is a good base on which to understand whether the stated goals are achieved or not to put up the right course of action. In the face of a wide range of health conditions, basing evaluation on introduced evidence allows patient care providers to refine the managing plan of care as well as to respond to specific areas of concern and achieve better outcomes.
References
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