Interdisciplinary Care Plan Class Nur3400 Professor Abstract

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Interdisciplinary care involves collaboration among healthcare professionals to improve patient outcomes by combining leadership, teamwork, patient-centered practice, and effective communication. The approach emphasizes comprehensive assessment, meeting patient needs, and pooling expertise for recovery, reducing readmission rates, and avoiding duplication of duties. This paper develops a care plan for McKay Johnson, diagnosed with diabetes and heart disease, highlighting the significance of coordinated, interdisciplinary treatment.

Paper For Above instruction

The management of chronic conditions such as type 2 diabetes and cardiovascular disease requires a sophisticated, interdisciplinary approach to improve patient outcomes significantly. Johnson's case exemplifies the complexities of managing simultaneously two life-threatening conditions, requiring a comprehensive, team-based care plan. This entails systematic assessments, tailored interventions, patient education, and ongoing monitoring involving multiple healthcare disciplines, including nursing, medical, dietary, and possibly social work.

Background and Medical Profile

McKay Johnson, a man diagnosed with type 2 diabetes in 2013 and subsequently with heart disease in 2016, presents an intricate clinical picture. His medical history reveals struggles with glycemic control, evidenced by previous fasting glucose levels categorized as "borderline diabetes," and symptoms such as abnormal heartbeats, difficulty breathing, and high blood pressure. His current clinical findings include elevated blood glucose (164 mg/dl fasting), hypertension (BP 160/96 mmHg), increased BMI (33.4 kg/m²), and symptoms like lung crackles, swelling in the legs, and diminished vibratory sensation in the forefoot. Laboratory markers indicate poor glycemic control (A1c of 7.5%), dyslipidemia (triglycerides 180 mg/dl), elevated urine microalbumin (42 mg), and increased blood urea nitrogen, all signaling concurrent renal and cardiovascular involvement.

Assessment of Interdisciplinary Needs

Johnson’s multifaceted medical profile necessitates a holistic, collaborative approach. The team must prioritize interventions, monitor various parameters, and educate the patient to achieve optimal health outcomes. Critical issues include glycemic control, blood pressure management, weight reduction, cardiovascular risk mitigation, renal function preservation, and patient engagement.

Prioritization and Planning

Given Johnson’s uncontrolled diabetes and hypertension, these conditions form the core of immediate concern. Elevated blood glucose increases risk for further vascular damage, while hypertensive status potentiates cardiac strain and cerebrovascular risk. The care plan emphasizes strict blood pressure control, blood glucose regulation, medication adherence, lifestyle modifications, and regular monitoring, aligned with guidelines from the American Diabetes Association (ADA) and American Heart Association.

Nursing Interventions and Rationale

1. Assess signs of hyperglycemia—Symptoms such as headache, fatigue, tachycardia, dizziness, or visual disturbances could indicate worsening glucose control. Early detection allows timely intervention to prevent diabetic ketoacidosis or hyperosmolar hyperglycemic state.

2. Monitor glucose levels before and after meals, maintaining levels within target ranges (140–180 mg/dl). This facilitates dose adjustments of insulin or oral agents and prevents episodes of hypoglycemia or hyperglycemia, reducing complications.

3. Evaluate hemoglobin A1c—A target of less than 7% signifies effective long-term glycemic management. Regular assessment guides therapy adjustments.

4. Monitor blood pressure and pulses, aiming to keep systolic pressure below 130 mmHg—optimal for individuals with diabetes and hypertension—thus reducing risks of stroke and cardiac events.

5. Avoid inaccurate temperature readings by refraining from axillary measurements in elderly patients with poor peripheral perfusion, which may be unreliable.

6. Assess extremities for temperature, swelling, color changes, and vibratory sensation, helping detect peripheral neuropathy, ischemia, or edema, which influence mobility and fall risk.

7. Encourage physical activity—Low-impact exercises improve insulin sensitivity, promote weight loss, and enhance cardiovascular health.

8. Administer basal insulin and antihypertensive medications as prescribed, ensuring proper adherence to stabilize glucose and blood pressure levels.

9. Address lifestyle modifications, including dietary adjustments to improve lipid profiles and glycemic control, considering Johnson’s elevated triglycerides and cholesterol ratios.

10. Educate Johnson on disease process, medication adherence, diet, and activity, fostering self-care, which is vital for chronic disease management.

11. Elevate the head of the bed at 45 degrees during rest, reducing pulmonary congestion and dyspnea related to heart failure signs, thereby improving oxygenation.

12. Monitor urine output and microalbumin levels, indicators of renal function and disease progression, guiding therapeutic adjustments.

Treatment Goals

The care plan aims for Johnson to achieve:

- Blood glucose levels consistently below 180 mg/dl

- HbA1c less than 7%

- Blood pressure below 130/80 mmHg

- BMI below 30 kg/m²

- Urine microalbumin less than 30 mg

- Liver and renal function within normal limits by ongoing evaluation

Achieving these targets indicates effective management, lowering the risk of complications like stroke, myocardial infarction, nephropathy, and neuropathy.

Multidisciplinary Collaboration

Realization of Johnson’s treatment goals demands a team approach involving physicians, nurses, dietitians, pharmacists, and physical therapists. Regular interdisciplinary communication ensures consistency in assessment, treatment adjustments, and patient education. Integration of social services may also provide support for home care and medication management, especially since Johnson lives alone and might face adherence challenges.

Patient-Centered Approach

Understanding Johnson’s beliefs, preferences, and lifestyle is critical. Engaging him through education about his conditions enhances motivation and adherence. Tailored plans considering his socioeconomic background, cultural beliefs, and support system foster sustainable health behaviors.

Conclusion

In managing Johnson’s case, an interdisciplinary approach maximizes the potential for improved health outcomes. Combining medical, nursing, dietary, and psychosocial interventions ensures holistic care addressing both disease processes and patient quality of life. Continuous evaluation and adaptability of the care plan are essential to respond to Johnson’s evolving needs, ultimately reducing complication risks, enhancing self-management, and promoting healthier living.

References

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