NURS FPX 6610 Assessment 2 Patient Care Plan

NURS FPX 6610 Assessment 2 Patient Care Plan

Patient Care Plan NURS FPX 6610 Assessment 2


Capella University

NURS-FPX6610: Introduction to Care Coordination

Instructor’s Name

Date: 26/02.2024 

Patient Identifier: SNY-2024-0023 Patient Medical Diagnosis: Ovarian cancer, uncontrolled diabetes and hyperglycemia

Nursing Diagnosis
Assessment Data

Goals and Outcome

Nursing Interventions


Outcome Evaluation
and Re-planning

First Diagnosis: 

Risk for Impaired Glycemic Control

Assessment Data: 

Mrs. Snyder’s recent admission to St. Anthony Medical Center was primarily due to uncontrolled diabetes and hyperglycemia.

Mrs. Snyder reports difficulty managing her diabetes regimen amidst the stress of her ovarian cancer diagnosis and treatment.

She expresses concern about the impact of her diabetes on her overall health and ability to undergo cancer treatment effectively.

SMART Goals: 

Specific: Mrs. Snyder will achieve blood glucose levels within the target range. 

Measurable: Blood glucose levels will be monitored using a glucometer, with readings recorded in the medical chart at least four times daily.

Achievable: Achieving and maintaining target blood glucose levels is feasible through insulin therapy, dietary modifications, and regular monitoring.

Relevant: Tight glycemic control reduces the risk of diabetes-related complications and promotes overall well-being during cancer treatment.

Time-bound: Target will be achieved within one week of hospitalization.

  • Mrs. Snyder will show that she can independently check her blood glucose levels and report readings that fall within the desired range in a week
  • By the end of hospitalization, Mrs. Snyder will collaborate with the diabetes educator to develop a personalized diabetes management plan tailored to her lifestyle and treatment needs.
  • Educate Mrs. Snyder about the importance of regular blood glucose monitoring and provide instruction on how to use a glucometer.
  • Collaborate with the diabetes educator to assess current diabetes regimen and adjust medications or insulin dosages as necessary (Oba et al., 2020).
  • Offer emotional support and encouragement to Mrs. Snyder to alleviate stress and facilitate adherence to her diabetes management plan.
Empowering Mrs. Snyder to monitor her blood glucose levels independently promotes self-management and enhances glycemic control.

Collaborating with the diabetes educator ensures that Mrs. Snyder receives personalized guidance and support in managing her diabetes effectively.

Providing emotional support helps reduce stress levels, which can contribute to improved glycemic control (Sia et al., 2021).

Evaluation: Mrs. Snyder demonstrates improved understanding of diabetes management techniques and reports more stable blood glucose levels.

Re-planning: If targets are not reached, review Mrs. Snyder’s diabetes treatment plan and look into other resources, such support groups for people with diabetes, to improve adherence. 

Second diagnosis: 

Risk for Imbalanced Nutrition

Assessment Data: 

Mrs. Snyder’s recent diagnosis of advanced ovarian cancer and impending chemotherapy/radiation treatment raise concerns about potential appetite changes and nutritional deficits.

She expresses apprehension about undergoing treatment and worries about experiencing nausea, vomiting, and changes in taste perception, which may affect her dietary intake.

Mrs. Snyder reports following a kosher diet due to her Orthodox Jewish faith, which may pose challenges in meeting nutritional needs during treatment.

SMART Goals: 

Specific: Mrs. Snyder will maintain adequate oral intake and demonstrate tolerance of prescribed dietary modifications.

Measurable: Mrs. Snyder’s weight will remain stable. 

Achievable: Customized dietary modifications and supportive interventions can mitigate treatment-related side effects and ensure adequate nutrition intake.

Relevant: Proper nutrition supports Mrs. Snyder’s overall health and enhances her ability to tolerate cancer treatment and recover effectively.

Time-bound: Mrs. Snyder will achieve stable oral intake and tolerance of dietary modifications within one week of hospitalization.

  • Within one week, Mrs. Snyder will maintain adequate oral intake and demonstrate tolerance of prescribed dietary modifications, as evidenced by stable weight and absence of dehydration.
  • By the end of hospitalization, Mrs. Snyder will consult with a registered dietitian to develop a culturally sensitive and nutritionally balanced meal plan that aligns with her kosher dietary restrictions.
  • Assess Mrs. Snyder’s dietary preferences, cultural dietary restrictions, and any anticipated treatment-related side effects affecting nutrition (Bhargavan et al., 2023).
  • Collaborate with the healthcare team to develop a customized dietary plan that accommodates Mrs. Snyder’s kosher dietary requirements and addresses potential treatment-related side effects (Hamaker et al., 2020).
  • Provide education to Mrs. Snyder and her family about strategies to manage common chemotherapy/radiation therapy side effects, such as nausea, vomiting, and taste changes, to promote optimal nutrition intake.
Assessing Mrs. Snyder’s dietary preferences and cultural considerations ensures the development of a tailored nutrition plan that respects her cultural and religious beliefs.

Collaborating with a registered dietitian helps optimize Mrs. Snyder’s nutritional intake and addresses any dietary challenges arising from her cancer treatment.

Providing education empowers patient and her family to proactively manage treatment-related side effects, promoting adherence to the prescribed dietary plan and overall nutritional well-being (Reber et al., 2021).

Evaluation: Mrs. Snyder demonstrates adherence to the prescribed dietary modifications and reports minimal treatment-related side effects impacting nutrition intake.

Re-planning: If goals are not met, reassess Mrs. Snyder’s dietary needs and explore alternative dietary strategies or supportive interventions to address nutritional deficits effectively.

Third Diagnosis: 

Risk for Ineffective Coping due to stress.

Assessment Data: 

Mrs. Snyder’s recent diagnosis of advanced ovarian cancer, coupled with uncontrolled diabetes, poses significant challenges that may impact her ability to cope effectively.

She expresses feelings of fear, anxiety, and uncertainty about her prognosis, treatment outcomes, and ability to fulfill her familial obligations.

Mrs. Snyder reports assuming the role of primary caregiver for her husband, children, and elderly mother, adding to her stress and emotional burden.

Cultural and religious expectations within Mrs. Snyder’s Orthodox Jewish community may influence her coping mechanisms and support-seeking behaviors.

SMART Goals: 

Specific: Mrs. Snyder will verbalize adaptive coping strategies and anxiety associated with her cancer. 

Measurable: Mrs. Snyder will identify and discuss at least two coping strategies during therapeutic sessions with the healthcare team.

Achievable: Therapeutic interventions and supportive counseling can help Mrs. Snyder develop and implement effective coping mechanisms.

Relevant: Improved coping skills reduce psychological distress and enhance Mrs. Snyder’s ability to navigate the challenges of her diagnosis and treatment.

Time-bound: Mrs. Snyder will verbalize adaptive coping strategies within one week of initiating therapeutic interventions.

  • Mrs. Snyder will explain adaptive coping mechanisms to control her stress and worry related to her cancer diagnosis and treatment plan in a week
  • By the end of hospitalization, Mrs. Snyder will engage in supportive therapy sessions with a mental health professional to address emotional distress and enhance coping skills.
  • Assess Mrs. Snyder’s current coping mechanisms, sources of support, and cultural/religious beliefs regarding illness and healing.
  • To assist Mrs. Snyder in managing her anxiety and fostering emotional well-being, teach her stress-reduction methods such guided imagery, mindfulness meditation, and deep breathing exercises (Wang & Feng, 2022).
  • Collaborate with the healthcare team to arrange supportive therapy sessions with a mental health professional experienced in providing culturally sensitive care to Orthodox Jewish individuals (Karbowa, 2023).
Assessing Mrs. Snyder’s coping resources and cultural beliefs facilitates the development of tailored interventions that align with her individual needs and preferences.

Teaching stress management techniques empowers Mrs. Snyder to actively participate in her emotional well-being and cultivate adaptive coping skills to navigate the challenges of her diagnosis and treatment (Antoni et al., 2022).

Collaborating with a mental health professional ensures access to specialized support services that address Mrs. Snyder’s emotional distress in a culturally sensitive manner, promoting holistic care and psychosocial well-being (Antoni et al., 2022).

Evaluation: Mrs. Snyder demonstrates improved coping skills and reports a reduction in anxiety levels.

Re-planning: If goals are not met, reassess Mrs. Snyder’s coping strategies and explore additional psychosocial support services, such as support groups or religious/spiritual counseling, to address ongoing emotional needs effectively.



Antoni, M. H., Moreno, P. I., & Penedo, F. J. (2022). Stress management interventions to facilitate psychological and physiological adaptation and optimal health outcomes in cancer patients and survivors. Annual Review of Psychology, 74(1). https://doi.org/10.1146/annurev-psych-030122-124119 

Bhargavan, R., Philip, F., Krishna, J., Augustine, P., & Thomas, S. (2023). Comparison of preoperative risk assessment tools in cancer patients undergoing oncosurgery-A prospective study. European Journal of Surgical Oncology, 49(2), e202–e202. https://doi.org/10.1016/j.ejso.2022.11.555 

Hamaker, M. E., Oosterlaan, F., Huis, L. H., Thielen, N., & Vondeling, A. (2020). Nutritional status and interventions for patients with cancer – A systematic review. Journal of Geriatric Oncology. https://doi.org/10.1016/j.jgo.2020.06.020 

Karbowa, M. (2023). Attachment styles, coping with stress, and social support among cancer patients. Contemporary Oncology (Poznan, Poland), 27(2), 95–100. https://doi.org/10.5114/wo.2023.130015 

Oba, N., Barry, C. D., & Gordon, S. C. (2020). Development of a nurse-led multidisciplinary based program to improve glycemic control for people with uncontrolled diabetes mellitus in a community hospital, Thailand. Pacific Rim International Journal of Nursing Research, 24(3), 349–362. https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/206447 

Reber, E., Schönenberger, K. A., Vasiloglou, M. F., & Stanga, Z. (2021). Nutritional risk screening in cancer patients: the first step toward better clinical outcome. Frontiers in Nutrition, 8. https://doi.org/10.3389/fnut.2021.603936 

Sia, H.-K., Kor, C.-T., Tu, S.-T., Liao, P.-Y., & Wang, J.-Y. (2021). Self-monitoring of blood glucose in association with glycemic control in newly diagnosed non-insulin-treated diabetes patients: a retrospective cohort study. Scientific Reports, 11(1), 1176. https://doi.org/10.1038/s41598-021-81024-x 

Wang, Y., & Feng, W. (2022). Cancer-related psychosocial challenges. General Psychiatry, 35(5), e100871. https://doi.org/10.1136/gpsych-2022-100871


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