Plan of Care: Nursing Goals and the Importance of It

Introduction

A care plan is essential especially to persons with long-term ailments. Under a care plan, a healthcare professional and a client enter into an agreement for provisions of healthcare services; for instance, nursing services on the day-to-day basis. Since these services are demand-focused, the clients are highly required to talk to a nurse, a social worker, or even his or her GP on the most plausible ways in which the healthcare provider would manage the care plan better. This way, the client can contribute acutely to the care plan control and hence the likelihood of success of such a plan is magnificently high. Care plans are dependent on the unique diagnostic tests of every patient and hence organized according to the patients’ specific needs. Consequently, even though the care plans are different depending on the geographical place under consideration, such plans are commonly designed in such a way that they profile the SMART criteria. In these criteria, the diagnosis results, goals, outcomes, orders of nursing, and evaluation strategies deserve to come out precisely for realization of an effective care plan, whether in the short term or long-term contexts.

From the given information, in assignment II case scenario two, the sick person has a past record high blood pressure, obesity, high cholesterol levels among other ailments, which while related to her age (79 years), her health condition becomes even worse. In addition, the patients need to develop a positive perception of the need to visit her GP: failure of which may profoundly impair the control and evaluation of both medical and therapeutic interventions considered in the care plan. In formulations of any care plan, diagnosis is the first step. In this paper, the diagnostic results of the patient presented in the case scenario two propose an effective care plan that would work profoundly and yield results in a community based settings.

Nursing goals

In nursing care plans, goals appear in terms of the anticipated clients’ responses. More precisely, a goal entangles what the nurse expects upon implementation of the planned nursing orders. The most fundamental goal from nursing context and following case scenario two is perhaps more consistent with the Johnsons1968 theory of nursing in which he was concerned about the capacity of the patient to adapt to illness and the manner in which potential or actual stress can build up and influence the capacity to adapt (Wills & Melanie 2002, p.45). In this line of view, the most crucial goal would be to ensure reduction of stress in an effort to ensure that the patient advances steadily in the recovery process. Inception of the healing process requires a willingness of the patient to obey the care plan as spelt out by the healthcare personnel. In the case scenario, the patient not only posse’s self care deficits as evidences by her inability to bath or even fix up cloth buttons but also suffers chronic ailments which are advocated as being inappropriately controlled. The reduction of hypertension to an acceptable level, reduction of cholesterol level and even dealing with obesity would demand frequent checkups by health professionals, monitoring and evaluation of the realized results. Unfortunately, the patient does not accept to seek such attention for periods not less than six months. It, therefore, becomes a paramount goal to enhance the adaptability of the patient to illness. This way, she may learn to accept that she has a clinical condition that requires an intervention. On achieving this, one can then deploy medication and therapeutic interventions with optimal anticipations that they would work as part of the care plan. In fact, adaptability is measurable based on the frequency of visits to health care professional and time constraint attached to it. It is, thus, a goal that is compliant with the SMART criteria.

Why the patient needs to be at the centre of health care

The diagnostic tests results make it clear that the patient suffers from more than one ailment that fits in the category of chronic ailments. Chronic care models advocates for alteration of the manner in which people afflicted by the chronic illness are cared. Establishing a central position a round healthcare for the patients allows patients to participate equally with the nurses in the establishment of the best ways to manage the health concerns. Apparently, this way, one can take paramount strategies to ensure improvement of quality of health care maintenance of the patient consistently with the maintained care practices. To resolve the old woman’s condition, it is widely necessary to place the sick at the central position of health care and deploy the model advocated for by Wagner: support of clinical work teams in conjunction with the patient as opposed to physician centric approach (Taylor & Lillis 2001, p.47). By doing this, the patient becomes aware and ready to support her care intrinsically and extrinsically the doctor’s office. The exacerbation of illness is, thus, likely to be dwindled since this approach responds well to the patients needs; it is demand centric.

Through making the patients have a central position in health care, she acquires quite a myriad of advantages. Putting the patient around the centre of care infers that the patient has all information relating to her illness. She consequently initiates the acceptance process being one of the vital milestones towards subtle management and controlling chronic ailments. After acceptance, the patient is at a position to deal with the trauma and emotions associated with a chronic ailment both in the short term and in long-term basis. The capacity to cope with the emotions is critical towards ensuring cute management and control of chronic ailments especially by noting that people react in valid ways upon learning about their chronic illness conditions (Taylor & Lillis 2001, p.18.). Nevertheless, the reactions are quite powerful. They range from shocks to relief with a mix of a range of emotions in between the two extremes. Diagnostic tests may indeed be upsetting, in most of instances leading to denial, withdrawal, grief, health losses among others feelings. Ensuring the centering of patients on the health care plans provides a means of addressing these emotional challenges from the client’s dimension. Consequently, the nurse can win and utilize the patient in the care plan appropriately and hence fostering rapid recovery.

Moreover, the patients deserve the central position of health care to inculcate positive coping skills. In the case scenario, the patient neglect frequent visits to GP. This indicates that she inefficiently dealt with crises since she suffered the mixed health problems given in the scenario. Arguably, therefore, she lacks the benefit of having received the help of those around her to acquire strength, and the necessary support to deal with the condition. This infers that the patient sees the chronic illness as only acting to close doors without thinking from an alternative dimension: the chronic illness may also open some other doors in one’s life. Putting the patient at the centre of the healthcare has the advantage of reversing these approaches to chronic illness on the patient’s part. More importantly, the patient finds it easy to take control of some aspects of his or her life. Even though, it may be acceptable that she may feel angry, a condition contributed by recounts of self-mysteries. It is also possible for the patient to re-acquire a feeling of control.

Putting the patient around the centre of the health care, in addition, ensures that patients proactively cooperate with those that provide the health care services. On one hand, the patients help in the establishment of the best plan for him or her. Consequently, one becomes sure that whatever the medical personnel does, is for the sake of finding solutions to one’s medical condition. Even though, Wagner argues various components of the effective interventions of chronic illness, Austin and Korff (1996) as being hard to integrate into a single chronic illness care program (p.511), with the contribution of both the patient and the nurse enormously help in obtaining a plausible solution. Evidence based approaches, care plan, provider roles, improvement of the patients self support management techniques and the vast clinical information at the nurses disposal may thus be harnessed to realize positive responses to the patient’s situations.

Short-term outcomes

Before prescribing a probable short-term outcome, it is perhaps pertinent to differentiate two vital diagnoses: Medical and nursing diagnosis. Nursing diagnosis relies on the patient’s social cultural, spiritual and physical responses to a potential illness or health problem (Meleis 1997, p.122). On the other hand, a medical diagnosis bases itself on conditions only treatable by a doctor with a physician having determined the medical condition. The outcomes of a care plan relate to the diagnosis conducted by the nurse. In nursing practice, the goal is thus to design a care plan in relation to the anticipated observable changes realizable through implementation of nursing orders. This means a goal is, in fact, the desired outcomes or alteration of the condition of the patient. Short-term care plan outcomes are principally required to be realizable within one month of their implementation.

In the given case scenario, a possible short-term care plan goal would be to deploy strategies that would enable the patient resolve the challenge of self-care deficit. The goal is crucial since the long term care plans developments are dependent on the capacity of the patient to have full autonomy of control of his or herself (Taylor & Lillis 2001, p.32). This perhaps relates to the aging process and or the trauma of the chronic illness such as hypertension. This challenge is evident because the patient is unwilling to bath and does not mend her clothes- fix buttons since her clothing were held by safety pins by the time she was accessed.

Necessary activities for realization of the short-term outcomes

According to RN central (2007), as an outcome, the patient is required to bath at some anticipated optimal level (para.6). In case, her physical condition such as obesity fails to permit her to perform this task appropriately and with easiness, the patient needs to demonstrate her employment of various adaptive ways of bathing. A nurse can facilitate the realization of the short-term outcome and hence evaluation of the goal by ensuring routing of the bathing activity at some specified time every day. Where challenges are still evident, the nurse can create opportunities for the patient to learn ways of adapting to new ways of performing noble daily life. This is achievable through:

1. Making provision of the various equipments within the reach of the patient
2. Inculcating the spirit of autonomy in the patient
3. Making consultations for other therapeutic interventions necessary for installation at the patient’s residence

These activities are relevant in the sense that the object of nursing practice is rested squarely on the need to make people with chronic illness end up as being responsible enough to carry on with their daily life activities while still struggling with the implications of their health conditions tasks (Taylor & Lillis 2001, p.32).

In community-based settings, many resources are required in monetary terms to implement these activities especially where the therapeutic interventions require redesign and or modification of the patient’s facilities. Provision of nursing services is also expensive. In most situations, the patient incurs all these expenses. However, in cases where the patients are in elderly homes, this home through partnership with the government and nongovernmental organization may provide a substantial portion of the required resources. The outcome of the activities identified above is a patient who can take responsibility of her daily chores with fewer challenges and or without negligence.

Evaluation measure for the short-term outcome

The rationale behind the evaluation aspect of the short-term outcomes is that it aids in tracing the extent to which the care plan progresses towards achievement of the laid out goals. This helps in making the decision on the nursing interventions vital for termination, changed or even those that are necessary for continuation (Taylor & Lillis 2001, p.111). In this context, evaluation of the care plan short-term outcomes is essential in aiding to reveal the deficits of the care plan in relation to the client requirements. From the nurses’ perspectives, the outcomes evaluation helps in the maintenance of morale of the care plan administrator. This happens especially where results obtained are highly compliant with the anticipated outcomes as forecasted during the inception of the short-term care plan.

With regard to the care plan scenario referred to herein in the paper, perhaps one of the most effective ways of evaluation of the short term care plan is on basis of the actual outcomes realized. Does the care plan make an impact on the patient? If so, does the patient show improvement on self-care deficit and at what frequency? One can measure the frequency through count of the number of times the patient may remember to take a bath, say in a day or on a weekly basis. The nurse may have also prescribed the time that the patient needs to take a bath. Hence, he or she needs to evaluate whether her initial plan is profiled by the actual times that the patient takes bath without the nurses’ reminders. The capacity of the patient to respond to various adaptive ways of conducting noble activities may also evaluated by considering the level of creativity in innovation of the adaptive strategies. For instance, one may consider whether the patient considers issues like stability in the creation of adaptive devices. A three-legged device is less stable than a four-legged device.

Long-term outcomes

The patient in the case scenario had a medical history of hypertension, high cholesterol and obesity. The joint committee for detection, treatment and evaluation of hypertension defines hypertension as blood pressure level more than 140/90 mm Hg. One can accomplish the classification of various forms of hypertension by considering severity degrees. At systolic, pressures above 180 mm/90 Hg and diastolic, pressures of more than 110/90 mm Hg the condition is considered as severe (Thuo 1997, p.2413). The long-term care plan outcome is prevention of sequelae associated with the disease. The specific outcomes are that patients will take part in desired activities, produce increment of activity tolerance coupled with decrement of psychological intolerance signs. One can achieve this by hemodynamic regulation.

The rationale behind these anticipated outcomes, achievable through a number of ways, rests on the fact that various studies have revealed that hypertension has a close association with persons with obesity and those who take high cholesterol diets (Gaal & Mertens 2000, p.273). Many epistemological scholarly works amplify this position by asserting that a relationship exists between hypertension and body weight. As Gaal and Mertens (2000) reckon, obesity acts as a crucial risk factor for likelihoods of developments of hypertension (p.272). Additionally, various clinical tests give an indication of the capacity of low calories and low cholesterols diets to lead to a substantial body weight loss. Developing a care plan that reduces hypertension also reduces various other complications associated with the hypertension health condition among them cerebrovascular accidents, chronic and acute renal failure and psychosocial challenges among other complications (Thuo 1997, 2415). Considering the priory discussed goal of nursing, the long term outcomes mentioned becomes a necessity for the case scenario under considerations.

Necessary activities for realization of the long-term outcome

To achieve the long-term outcome, the patient and the nurse requires carrying out a number of activities including:

1. Monitoring of blood pressure: While at rest, the nurse needs to measure to blood pressure levels both in thighs and in arms at a certain time interval
2. This needs to be done while the patient is at rest, followed by when she is sitting and finally while standing. This forms the basis for the initial evaluation.
3. The nurse then notes the quality of the peripheral and central pulses.
4. He/she then needs to auscultate breath sounds coupled with heart tones.
5. One should take note of skin color, temperature, moisture and the refill times of the capillaries.
6. A calm surrounding needs to be provides through reduction of environmental activities including noise and the number of visitors and their frequency.
7. The nurse needs to maintain activity restrictions deserve by conducting scheduled periods in which the patient gets the permission to rest without interruptions.
8. He/she needs to avail comfort measures such as head elevation and neck massage.
9. The nurse needs to instruct the patients through deployment of relaxation techniques.

Various rationales guide all these activities. Activity (a) is based on the rationale that by comparing various blood pressure levels, a more precise way of getting a full picture of various vascular involvements are obtained (Wills & Melanie 2002, p.79). This helps in the definition of the scope of the problem under investigation. In case of the patient referred in the case scenario, the condition of hypertension may be classified diastolic incase blood pressure is elevate to 110 mm Hg. Hypertension additionally is taken as a subtle risk factor that may lead to cerebrovascular disease. Activity (b) relies on the rationale that reduction of pulses in the legs may give an indication of vasoconstriction coupled with venous congestion (Wills & Melanie 2002, p.95). The rationale behind activity (c) bases itself on the fact that heart sound in the heights of S4 is common in patients who have hypertension by the virtues of existence of atrial hypertrophy (Gaal & Mertens 2000, p.276). In case the heart sound is to the orders of S3, the patient gives an alert for ventricular hypertrophy and or impaired body functioning.

Wheezes and crackles give signs of congestions of pulmonary, a secondary sign of chronic heart failure (Wills & Melanie 2002, p.107). In the case upon conducting activity (d), the patient has moist skin, prolonged capillary refill times and existence of pallors; the chances are that the patient has peripheral vasoconstrictions. As Gaal and Mertens (2000) posit, activity (e) promotes relaxation (p.277). The rationale behind activity (f) is that it aids in reducing physical tension and stress, which affects the blood pressure levels. While activity (g) may help in diminishing of sympathetic simulations and discomforts, activity (h) diminishes stressful stimuli with the overall effect of reduction of blood pressure levels (Wills & Melanie 2002, p.95).). In all this activities, various resources are required ranging from nursing expenses to the provision of necessary monitoring equipment. While one expects the patient to take care of the nursing expenses, equipments are accessible through health care facilities established within various community settings.

Evaluation measure the long-term outcome

The necessary elements of evaluation in the suggested long term care plan involve anticipated out comes such as the patients will take part in desired activities, produce increment of activity tolerance coupled with decrement of psychological intolerance signs. A nurse consequently endeavors to know whether the outcomes of the patient improve with time or whether it dwindles (Meleis 1997, p.47.). Secondly, it is crucial for the nurse to know whether the patient learns to adhere to established guidelines in coping with her condition. In case the care plan is effective, cost of care provision decreases with time by virtue of decrease of nurse-focused attention since the patient must have acquired basic skills in the management of her health condition herself. This means that the capacity to hold the disease under control has escalated.

Given that the patient has complication such as obesity which are highly attributable to dietary behaviors, the evaluation program needs to incorporate some aspects of patient’s behavior measures. According to Norris et al (2006), in the real world programs, literature has deployed proactive strategies to measure various behavioral changes associated with chronic illness recovery process (p.544). Among the prestigious measurable behavioral changes includes approaches of monitoring dietary regulations, self initiated nurse contacting incase of complications of the patient’s health conditions, deployment of patient initiated management strategies and physician activities among others (Brownson et al 2007, p.211). This means that the evaluation aims to ensure that patient in the long term takes proactive steps to monitor and control her own health. How nurses work collaboratively and support the therapeutic interventions of other health team members within the principles of chronic disease self-management strategies

An essential pillar for collaborative and supportive therapeutic interventions between nurses and other health team members within the principles of chronic disease self-management strategies follows the guidance of the need of creation of a practicing diverse team of health care providers. Various scholarly works are available with the aim of measuring the myriad of ends in the strategies deployed to achieve this noble role of health professionals in term of looking at how the patient mobility is enhanced (Tsai et al. 2005, p.482). The manner in which a nurse may participate in the management of chronic illness with other health professional depends on the health care setting and the degree to which other professional are involved.

In the community settings, a nurse, along with other care professionals, work collaboratively to expand the chronic infections prevention strategies especially to people who are at high risks of suffering from them coupled with the administration of various chronic illness management programs. As a way of example, Meleis (1997) informs that the Robert Jonson care program for diabetes intuitively functions through a collaborative effort of partnerships of clinic communities- nursing as one of the communities (p.123). Several scholarly works such as (Brownson et al 2007) indicate that clinic-communities manage chronic ailments in a modest way as compared to the way a single organization could be. In a collaborative effort with other health care professionals, nurses can function as trained community oriented fitness instructors. In this context, they can aid in the creation of communal focused intervention programs aimed at altering lifestyles of people who pose a high risk factors of chronic illness. As Norris et al (2006) reckons, upon administration of a program initiated through collaboration of various healths professional at YMCA, those who participated recorded much reduction in weight as compared to the original program for diabetes reduction (p.553).

In addition, nurses may participate in a collaborative effort with other health care professional in control of chronic illness through chronic illness management programs. In this end, the collaborating team play pivotal roles in the bridging of the gaps existing between traditional care systems and the much desired chronic illness education and care especially in the communities, which are widely underserved. Nursing diagnosis incorporates social cultural aspects and demand driven responses to certain chronic illness. This means that community’s beliefs, barriers to access of care and undue traditions are available in the diagnosis. Nurses consequently have a noble role to facilitate along with other health professionals the effective and efficient chronic illness management and prevention programs (Norris et al 2006, p.544). This goes a long way in ensuring availability of better and reliable systems of health care to address the challenges of chronic illness. In addition, in chronic care models, nurses form a bridge of all the essential components of the model. As a way of example, in the model proposed by Tsai et al (2005) the various components : delivery systems design, self-management support, decision support, systems of the clinical information, community resources and organization of a health care program requires the competencies of a nurse in collaboration with other health care professional (p.478). This is critical for such a model to be effective.

Reference List

Brownson, A., O’Toole, L., Gowri, S., et al., 2007. Clinic-community partnerships: A foundation for providing community supports for diabetes care and self-management. Diabetes Spectrum, 20(4), pp.209-214. Print.

Gaal, V., & Mertens, I., 2000. Overweight, obesity and blood pressure: the effects of modest weight reduction. Obesity Journal, 8(2), pp.270-278. Print.

Meleis, A., 1997. Theoretical Nursing: Development and Progress. Philadelphia: Lippincott.

Norris, L., Chowdhury, M., & Van Le, K., et al., 2006. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med, 23(5), pp.544-556. Print.

RN Central. 2007. Self care deficit: bathing. Web.

Taylor, C., & Lillis, C., 2001.The Art and Science of Nursing Care. Philadelphia: Lippincott.

Thuo, D., 1997. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med, 157(8), pp.2413–2446. Print.

Tsai, C., Morton, S., Mangione, C., & Keeler, B., 2005. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care, 11(8), pp.478-488. Print.

Wagner, E., Austin, B., & Korff, M., 1996. Organizing Care for Patients with Chronic Illness. The Milbank Quarterly, 74(4), pp.511- 547. Print.

Wills, M., & Melanie, E., 2002. Theoretical Basis for Nursing Philadelphia. Lippincott: Williams and Wilkins.