Running Head: INDIVIDUALIZED CARE PLAN: MRS.

YOUNG

Individualized Care Plan: Mrs. Young

Delaware Community College

NUR 320 Health Assessment

Kei-Sha Dollard
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Individualized Care Plan: Mrs. Young

Mrs. Young is 35-year-old African American female with a medical history of type 2

Diabetes (DM2), hypertension (HTN), and obesity and former tobacco user. Family history of

cardiovascular disease, stroke, obesity, and DM2. Mrs. Young states that she has not been seen

by a primary care provider in over 2 years. She has complaints of frequent yeast infections,

blurry vision, frequent urination, and increased thirst. Laboratory test show her HbA1C was 8.

Physical exam revealed hot, dry skin, dry mucus membranes, feet were swollen, red and scaly.

Blood pressure was 162/96, height 5’4”, weight 175 pounds, and BMI of 30. Mrs. Young stated

that she has not been compliant with her medication regimen because she was not feeling bad.

She also stated that she was not properly educated on how to use a glucose monitor and did not

know she needed to monitor her blood sugars daily. Her medications include amlodipine,

metformin, Novolog, and Lantus. She said that she ran out of her medications over six months

ago and started noticing problems in the past 3 months. Mrs. Young said her mother told her she

need to see a doctor to get her health back on track before she ended up having a stroke or heart

attack. She is now seeking medical care to improve her over all well-being. Using the nursing

process steps assessment, diagnosis, planning, implantation, and evaluation as well as including

evidence-based interventions; a plan of care was implemented to assist Mrs. Young’s journey to

a healthier lifestyle.

Assessment

Mrs. Young presents with subjective complaints of vaginal itching, frequent urination,

increased thirst, numbness in the feet and blurry vision. Objective data revealed hypertension,

blood pressure of 162/96, temperature 37°C, heart rate 87, respiratory rate 18, and SpO2 95% on
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room air. Feet are red, swollen and scaly, skin is hot and mucous membranes are dry, and lungs

are clear on physical exam.

Diagnosis

Using the Nursing Diagnosis Handbook, three nursing diagnoses were implanted into

Mrs. Young’s plan of care. Ineffective Health Management related to insufficient knowledge of

therapeutic regimen as evidence by noncompliance with medication administration. Deficient

Knowledge related to insufficient information about DM2 and lack of knowledge of resources

available, as evidence by not knowing how to use a glucose monitor and unaware that blood

sugar (BS) should be monitored daily. Overweight related to physical inactivity and unhealthy

eating habits, as evidence by a BMI of 30.

Planning

During the planning process, Mrs. Young was asked what her goals were in improving

her health and well-being. She stated, she wanted to lose weight and get her diabetes and blood

pressure under control. Her goals are to prevent complications of diabetes by achieving the

following:

 Having a HbA1C of 7.0 or less and checked every 3 to 6 months.

 Loose 10-15 lbs.

 Be able to maintain a medication regimen as prescribed.

 Maintain a healthy blood pressure of < 140/90.

 Implement 30-60 minutes of physical activity every other day each week.

 Follow the basic principles of diabetes and cardiac carbohydrate-controlled meal

planning.
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 Keep blood sugars in a safe range: 80-130 mg/dL before meals and less than 180 mg/dL

on hour after meals.

 Monitor blood sugar regularly and keep a BS diary.

 Have good foot care.

 Have your urine tested for microalbumin each year to evaluate for kidney damage.

 Have a yearly eye exam.

 Know Sick Day management.

 Stay compliant with consultations and follow-up appointments with care team.

 Keep a diary of meals, BS and physical activity to show at your follow-up appointments.

 Learn how to prepare healthy meals for her and her family.

 Reduce alcohol intake to the recommended amount of 1 drink (5 oz of wine) per day.

Implementation

A patient-centered care model was followed while implementing interventions. A

collaborative partnership was established with the client for purposes of meeting health-related

goals. The client was assessed using subjective and objected data as mentioned above. Mrs.

Young was educated on the use of a glucose monitor and how to obtain and read her BS

readings. She received verbal education and print outs about Diabetes management and how to

take her medications, monitor her blood pressure at home, Sick Day management, Foot Care,

healthy dietary and physical activity plans as well as referrals to an Endocrinologist, Optometrist

and Dietician. She watched videos on hypoglycemia and hyperglycemia management and was

provided with information on several Diabetes Self-Management classes and additional

resources (magazine subscriptions, books, cookbooks and websites) she could access for

additional information such as the American Diabetes Association as well as a few walking parks
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in the area. She was also educated on her risk for stroke and cardiovascular disease and how to

recognize the signs and symptoms of a heart attack and stroke. According to Ackley, Ladwig &

Makic (2015) the use of various formats to provide information about the therapeutic regimen,

including group education, brochures, videotapes, written instructions, computer-based

programs, and telephone contact should be used to help with the client progress in the treatment

plan.

Evaluation

Mrs. Young was asked to teach back what she learned from the encounter before she

went home. She was able to demonstrate how to check her blood sugar and use her insulin pen,

and to teach back understanding of how to perform foot care, Sick Day management, signs and

symptoms of stroke using the FAST acronym, as well as heart attack signs and symptoms. To

evaluated Mrs. Youngs progress over the next six months, she will receive follow-up phone calls

to assess her progress every month. Referral provider notes will be reviewed, and Mrs. Young

was given a lab slip to have her lab work drawn a month before her follow up visit.

Inconclusion, Mrs. Young is expected to comply with her care plan. She will return in

six months for a follow-up visit and she will have her blood sugar, meal prep and physical

activity diaries available for review. At the visit we will once again use the nursing process to

reevaluate her care plan and implement changes as needed. Mrs. Young is to call the office with

any questions and concerns related to her care.

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Resources

American Diabetes Association (n.d.) Living with diabetes. Retrieved from:

http://www.diabetes.org

Ackley, B., Ladwig, G., Makic, M. (2015). Nursing diagnosis handbook: an evidence-based

guide to planning care 8th edition. St. Louis, MI: Elsevier

Office of Disease Prevention and Health Promotion (2015) 2015-2020 Dietary guidelines for

for Americans. Retrieved from:

https://health.gov/dietaryguidelines/2015/?_ga=2.220427672.1475423641.1556591544-

162133275.1555979677

Lenhard, M. (n.d.) Managing your diabetes guide. Christiana Care Health System