Interdisciplinary Care Plan For Nur3400 With Professor Maike ✓ Solved

Interdisciplinary Care Plan7class Nur3400professor Maikel Y Porta

Organize literature for the Interdisciplinary Incorporate health outcomes of the health promotion, detection of disease and disease prevention. Organize an interdisciplinary plan of care for your client and the delivery of safe and effective care. Choose a patient, a gender, a medical condition and a situation of patient condition and their disease process and apply standards that are evidenced based which help support for the protection of your client. Incorporate concepts from Care of the Aging weekly powerpoints and the book-Gerontological Nursing and Healthy Aging (Toughy & Jett, 2018). Paper should be 3 pages not including title and reference page. Paper should follow APA guidelines with a minimum of 5 references within 5 year span.

Sample Paper For Above instruction

Introduction

Interdisciplinary care planning is a cornerstone of modern healthcare delivery, particularly for complex patients with chronic conditions such as diabetes and heart disease. An effective interdisciplinary approach leverages the expertise of various healthcare professionals to optimize patient outcomes, prevent disease progression, and promote health and well-being. This paper discusses the development of an evidence-based interdisciplinary care plan for a hypothetical 75-year-old female patient diagnosed with type 2 diabetes and congestive heart failure, incorporating concepts from gerontological nursing, health promotion, disease detection, and prevention.

Patient Profile and Situation

The selected patient is a 75-year-old African American female living independently at home. She has a lengthy medical history significant for type 2 diabetes diagnosed ten years prior and recent worsening of congestive heart failure. She reports recent episodes of dyspnea, fatigue, and irregular blood glucose levels, with multiple hospital visits over the past six months. Her social context includes limited family support, recent mobility challenges, and concerns about managing her complex health conditions effectively. Her physical examination reveals peripheral edema, diminished pedal pulses, and elevated blood glucose and blood pressure readings.

Health Issues and Goals

The primary health goals for this patient are to stabilize blood glucose levels, improve cardiac function, prevent hospital readmission, and promote independence. The patient’s health outcomes will be improved by focused disease detection, health promotion strategies, and prevention measures tailored to her age, comorbidities, and social context. Key outcomes include achieving glycemic control with HbA1c below 7%, reducing episodes of decompensated heart failure, and enhancing medication adherence and self-care capabilities.

Interdisciplinary Plan of Care

Medical Management

Coordination among a primary care physician, cardiologist, and endocrinologist is essential. Evidence-based guidelines recommend optimizing pharmacotherapy, including ACE inhibitors, beta-blockers for heart failure, and antihyperglycemic agents like metformin. Regular monitoring of blood pressure, heart rate, blood glucose, and electrolytes is vital. Adjustments in medications should be based on ongoing assessments, considering potential geriatric pharmacokinetics and polypharmacy risks (Toughy & Jett, 2018).

Nursing Interventions

Nurses play a critical role in education, monitoring, and supporting self-care. Interventions include patient teaching on medication management, dietary modifications, and symptom recognition. Regular assessment of edema, vital signs, and blood glucose levels can detect early signs of deterioration. Nursing also facilitates medication adherence through simplified regimens and use of pill organizers, considering cognitive decline common in aging (American Diabetes Association, 2019).

Dietary and Nutritional Support

Dietitians develop individualized plans emphasizing sodium restriction to manage hypertension and heart failure, as well as carbohydrate control for diabetes. Education on reading food labels and meal planning enhances compliance. Nutritional supplementation may be necessary if deficiencies are identified (Toughy & Jett, 2018).

Physical Activity and Rehabilitation

Physical therapists design low-impact exercise programs adapted to her mobility status to improve cardiovascular health, promote weight management, and prevent deconditioning. Encouraging activity within tolerated limits helps improve functional capacity and reduces falls risk, aligning with gerontological principles of aging and maintaining independence (Naik et al., 2015).

Psychosocial and Support Services

Social workers assess for barriers to care, such as transportation or financial constraints, and facilitate access to community resources. Mental health support is critical given social isolation and the risk of depression, common in older adults coping with chronic illnesses (Toughy & Jett, 2018). Family involvement and caregiver education are also incorporated into the care plan.

Health Promotion, Disease Detection, and Prevention

Preventative strategies include vaccination (e.g., influenza and pneumococcal vaccines), smoking cessation (if applicable), and routine screening for anemia, osteoporosis, and depression, consistent with aging population needs. Education on recognizing early signs of heart failure exacerbation and hyperglycemia empowers self-management, reduces emergency visits, and enhances quality of life.

Implementation and Outcomes

Implementation of this interdisciplinary plan involves regular team meetings, consistent documentation, and patient engagement. Expected outcomes include improved glycemic control, stabilized heart failure symptoms, enhanced functional capacity, and increased patient satisfaction. Continuous evaluation and adjustment of the plan are essential, considering the dynamic health status typical of geriatric patients.

Conclusion

The interdisciplinary care plan for this geriatric patient with diabetes and heart failure encapsulates key principles of evidence-based practice, gerontological nursing, and health promotion. Collaboration among healthcare professionals ensures comprehensive, individualized care, promoting safety, independence, and improved health outcomes. Emphasizing prevention, early detection, and patient education aligns with overarching goals of aging and chronic disease management.

References

  • American Diabetes Association. (2019). Standards of medical care in diabetes—2019. Diabetes Care, 42(Suppl 1), S1–S2.
  • Naik, V., Dave, R., Stephens, J. W., & Davies, J. S. (2015). Evidence-based prevention of type 2 diabetes: Role of lifestyle intervention as compared to pharmacological agents. International Journal of Diabetes and Clinical Research, 2(6), 49-56.
  • Pop-Busui, R., Boulton, A., Feldman, E., et al. (2017). Diabetic neuropathy: A position statement by the American Diabetes Association. Diabetes Care, 40(1), 136–154.
  • Touhy, T., Jett, K., Boscart, V., & McCleary, L. (2018). Ebersole and Hess' gerontological nursing and healthy aging (5th ed.). Elsevier.
  • American Heart Association. (2018). Heart failure: Managing symptoms and improving quality of life. Circulation, 137(7), e270–e271.
  • Clegg, A., Bell, D., & Young, J. (2018). Aging and health: Evidence-based approaches for the older adult. Journal of Aging & Social Policy, 30(2), 117-131.
  • Stewart, S., et al. (2017). Heart failure in older adults: Challenges and treatment strategies. Geriatric Cardiology, 24(4), 311-319.
  • Gerontological Nursing Society. (2015). Frameworks for promoting healthy aging. Journal of Gerontological Nursing, 41(4), 17–25.
  • World Health Organization. (2020). Ageing and health. Retrieved from https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
  • Kalb, D. S., & Johns, T. (2016). Multidisciplinary approaches to managing chronic illnesses in older adults. Clinical Geriatrics, 24(3), 28-34.

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