Objective: To assess and develop a holistic care plan for a 61-year-old African American male with a history of high blood pressure, open heart surgery, diabetes, high cholesterol, depression, and anxiety, factoring in recent life changes such as significant weight loss, divorce, and retirement. Medication List: Metformin 500 mg daily, Atenolol 50 mg daily, simvastatin 40 mg daily, and Norvasc 5 mg daily.
Instructions for Comprehensive Health Assessment and Care Plan Development
1. Introduction
– Begin by introducing the assignment, which aims to assess and develop a holistic care plan for a patient with multiple chronic conditions and recent life changes.
2. Patient Interview and History Taking:
– Your task is to formulate 10 questions to ask the patient during the interview. These questions should cover various aspects of the patient’s health history, medication regimen, lifestyle, and social factors.
Example: “What medical conditions have you been diagnosed with?”
3. Physical Examination:
– Identify key areas to focus on during the physical assessment. You should provide a rationale for each focus area, considering the patient’s age, medical history, and recent changes in health status.
Example: “Cardiovascular assessment: Given the patient’s history of heart disease.”
4. Diagnostic Reasoning:
– Create a list of recommended diagnostic tests for the healthcare provider. Justify each recommendation based on the patient’s history and presentation.
Example: “Lipid profile: To assess cardiovascular risk.”
5. Priority Nursing Diagnosis and Interventions:
– Determine the priority nursing diagnosis based on the patient’s health history and assessment findings. Additionally, provide two nursing interventions to address the identified nursing diagnosis.
6. Referrals and Justification:
Identify specific referrals for the patient and justify each referral. Consider the expertise required for comprehensive care and the patient’s specific needs.
Example: Referral to a dietitian: To provide dietary counseling.
7. Reflective Analysis:
– Reflect on personal experiences and insights gained from completing the assignment. Discuss how this assignment has deepened your understanding of holistic care and interprofessional collaboration in nursing practice.
APA Style and Formatting:
- Write a paper adhering to APA style guidelines, including proper headings, citations, and references formatting.
- Limit your paper to 2 pages to meet the assignment requirements.