Kyle’s Plan of Care 1

Plan of Care

Patient: Kyle H

Delaware Technical and Community College

Nur 320- Nursing Assessment

Lindsay O’Hara

April 20, 2018

Kyle’s Plan of Care 2

Patient History

My plan of care is for a 32-year-old male, Kyle, who has a height of 6’, weight of 195

lbs., with stable vitals. I took a thorough health history of the patient, and found that he was

currently experiencing allergy rhinitis, but experiencing no other medical problems. After

delving into Kyle’s family history, I found he is at risk for two major health illnesses. Kyle’s

brother is a Type I diabetic and his mother is a Type II diabetic. With two immediate family

members with Diabetes, this puts Kyle at an increased risk for developing Diabetes. In addition

to Diabetes, Kyle is at increased risk for Major Depressive Disorder and Bipolar Disorder.

Kyle’s mother has suffered from mental illness for greater than 15 years. While what causes

mental illness is still unknown, there is a genetic predisposition for developing a mental disorder

if a family member has it. After analysis of Kyle’s health history and physical examination, I

decided to use his current health problem of allergy rhinitis for my plan of care, and also include

two major risk for illnesses in Diabetes and Major Depressive Disorder.

Allergy Rhinitis

The only medical problem Kyle was currently experiencing at the time of examination

was signs and symptoms of allergy rhinitis. Kyle stated he was experiencing allergies. Since it is

spring and the trees are in bloom, he stated he had been experiencing an increase in typical

allergy symptoms. An increase in nasal drainage, throat irritation, non-productive cough, and

teary eyes. He also stated he occasionally has a headache. After examination, I suggested a

course of action that would keep the symptoms of allergy rhinitis at a tolerable level for the

patient. Implementation of the plan included over the counter antihistamine. Antihistamines are
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one the first lines of defense against allergy rhinitis. “Antihistamines are best administered

before exposure, i.e. two weeks before the start of the hay fever season. For protection to be

maintained, antihistamines should be taken every day, without breaks on days when low pollen

counts are forecast” (Ryan, 2016, p.56). In addition to antihistamines, nasal irrigation and topical

nasal steroid such as fluticasone are suggested. Nasal irrigation will flush out any allergens in the

nasal passages and the topical steroid will decrease the inflammation caused by sneezing and

blowing the nose. Another was to manage symptoms is to avoid going outdoors during high

pollen days, which may not always be possible. Wearing sunglasses and spending as little time

as possible during these days can help manage symptoms. Two weeks after implementation,

Kyle reported his symptoms are at a manageable level. Kyle started a medication regimen of

fexofenadine and fluticasone. While symptoms have not completely subsided, they have

drastically decreased. He also reports using the local weather channel to monitor the pollen

levels.

Risk for Diabetes

Kyle’s current medical problem is nothing compared to the two major diseases he is at

risk for. With two immediate family members with diabetes, Kyle is at an increased risk for

developing this life altering disease. The goal to prevent the development of diabetes includes an

evidence based practice plan of dietary education and physical fitness routine. Kyle’s individual

dietary needs include an increased intake of protein, to meet his physical fitness needs and

limiting amounts of sugar. Kyle already has a workout routine that included weight lifting three

times a week. By adding in a cardiovascular routine, Kyle can drastically reduce his risk for

developing diabetes. “Findings demonstrated the effectiveness of combined diet and physical

activity programs in reducing the risk of type 2 diabetes, increasing the likelihood of reverting to
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normoglycemia, and reducing weight among people at increased risk of type 2 diabetes. These

programs also were effective at reducing participants' blood glucose and blood pressure, and

improving their lipid levels” (Office of Disease Prevention and Health Promotion, 2015).

Referrals can be made to local diabetes educators for prevention education and to a personal

trainer that will be able to personalize a diet and work out program to meet all of his needs.

Risk for Mental Illness

The other major medical problem is at risk for is Major Depression Disorder and Bipolar

disorder. Kyle is at an increased risk because his mother suffers from both illnesses. Currently,

Kyle shows no signs or symptoms of either disorder, but it is important to educate on symptoms

and have routine screening by a primary care physician. “Primary care providers are usually

responsible for routine screening for and diagnosing of depressive disorders; initiating treatment

for depression; and referring patients to mental health specialists as needed” (Office of Disease

Prevention and Health Promotion, 2016). By using this evidence based practice, Kyle can be

routinely monitored and potentially lead to early diagnosis and treatment if need be. Stress can

be a major factor in the development of MDD. Coping techniques can help combat stress and

reduce the risk for development of the disorder. It’s important to make sure Kyle is established

with a PCP, in order to have routine screenings, and that the PCP is able to make a referral to a

mental health specialist as needed.

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Evaluation

Scheduling a follow up appointment with Kyle, including a physical examination and

routine blood work will aid in ensuring that he is following the plan of care. Keeping the routine

bi-yearly primary care appointments will help Kyle continue to monitor his risk for diabetes and

mental illness. If I were to alter this plan of care, I would suggest routine A1C bloodwork every

three months to monitor blood glucose levels.

Conclusion

All in all, Kyle is a very healthy 32-year-old male in good physical shape. His current

health status is good. If he follows the plan of care for prevention of diabetes and mental illness,

he can avoid two life altering disorders.

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References

The Community Guide [Internet]. Mental Health and Mental Illness: Collaborative Care for the

Management of Depressive Disorders. c2010– [cited 2016 Dec 30]. Available from:

https://www.thecommunityguide.org/findings/mental-health-and-mental-illness-

collaborative-care-management-depressive-disorders

The Community Guide [Internet]. Diabetes: Combined Diet and Physical Activity Promotion

Programs to Prevent Type 2 Diabetes Among People at Increased Risk. c2014– [cited

2016 May 9]. Available from: https://www.thecommunityguide.org/findings/diabetes-

combined-diet-and-physical-activity-promotion-programs-prevent-type-2-diabetes

Ryan, D. (2016). How to identify and manage seasonal allergic rhinitis. Journal Of Community

Nursing, 30(2), 54-59.