NURS FPX 6610 Assessment 4 Case Presentation

Esteemed family members and stakeholders, my name is ________, and I am honored to present the case of Mrs. Rebecca Snyder. This presentation aims to provide an in-depth overview of her current health challenges, including advanced ovarian cancer and unmanaged diabetes. The objective is to communicate the care plans developed for her condition, inform all involved about her medical needs, and ensure collaboration in delivering compassionate, evidence-based, and patient-centered care. We believe that through coordinated efforts, we can significantly improve Mrs. Snyder’s quality of life and overall health outcomes.

Presentation Objectives

The primary aims of this presentation include:

• Discussing the primary goals and the extent of Mrs. Snyder’s care plans

• Explaining how interprofessional collaboration enhances care quality

• Identifying critical factors influencing the patient’s health outcomes

• Highlighting essential resources needed for sustained care delivery

• Concluding with a summary of ongoing efforts for patient-centered interventions

Goals and Scope of the Care Plans

Patient Background

Mrs. Rebecca Snyder is a 56-year-old Orthodox Jewish woman, a mother to five children and a grandmother of seven. She was admitted to the emergency department due to significantly high blood sugar levels, attributed to unmanaged diabetes. Further diagnostic evaluations uncovered an advanced stage of ovarian cancer. As the primary caregiver of her family, Mrs. Snyder’s sudden illness has left her household unprepared, both emotionally and logistically, to handle such a profound health crisis.

Development of the Comprehensive Care Plan

The care plan created for Mrs. Snyder encompasses both her chronic and terminal conditions. Diabetes management is a key priority, involving patient education on self-monitoring of blood glucose levels, insulin regulation, and understanding glycemic targets. According to the American Diabetes Association, optimal pre-meal glucose levels should fall between 80 and 130 mg/dL, while post-meal readings should be under 180 mg/dL (American Diabetes Association, n.d.). The plan includes training on insulin administration and symptom recognition to prevent complications like hypoglycemia or ketoacidosis.

Another important element involves nutritional support that respects her religious dietary laws. A culturally sensitive approach to dietary planning has been adopted by engaging a dietitian experienced in kosher meal preparation. Through personalized guidance and family involvement, the care team aims to maintain nutritional balance and emotional reassurance (Horikawa et al., 2020).

Emotional well-being is equally prioritized. Anxiety from a recent cancer diagnosis is being managed with regular psychological counseling, empathetic communication from healthcare professionals, and community mental health support. Social workers provide a list of local resources and ensure that the patient and family have ongoing emotional and psychosocial support (Grassi et al., 2023).

Transitional Care Plan Overview

Mrs. Snyder’s transition between hospital and home settings requires robust coordination. The transitional care plan ensures that every care component—from medical records to spiritual preferences—is properly communicated. Emphasis is placed on accurate data transfer, medication reconciliation, and patient-centered advance directives. This prevents medical errors, respects the patient’s wishes, and enhances overall satisfaction (Subbe et al., 2021).

Integration of digital tools like blockchain and mobile health apps ensures transparency and allows patients to track their own care in real-time. These tools also empower her to engage actively in her treatment journey (Cerchione et al., 2022). Interdisciplinary communication between providers, caregivers, and community organizations forms the backbone of this seamless transition strategy.

Interprofessional Care Team and Delivery of Quality Care

Collaborative Care Approach

An interprofessional team ensures comprehensive management for Mrs. Snyder. Each professional’s input enriches the care planning and delivery process, making it more holistic. Below is a table outlining the roles of various professionals:

This multidisciplinary approach enables holistic care tailored to Mrs. Snyder’s unique medical, emotional, and cultural needs.

Information Needs of Stakeholders

Effective communication is crucial to ensure that all team members operate cohesively. Each stakeholder group requires specific information to fulfill their roles effectively:

Open communication systems, such as integrated EHRs and secure messaging platforms, enhance collaborative efficiency and reduce fragmentation in care (Fennelly et al., 2020).

Factors Influencing Patient Outcomes

Patient outcomes are shaped by both clinical and external variables. In Mrs. Snyder’s case, the dual diagnosis presents unique challenges. Effective response to cancer treatment is a determining factor in survival and quality of life. Poor glycemic control can further hinder therapeutic outcomes and increase the risk of complications (Marschner et al., 2020).

Treatment adherence is another critical aspect. Stress and emotional trauma from the diagnosis may affect Mrs. Snyder’s ability to consistently follow her care regimen. A strong support system at home can alleviate some of these stressors. Involving family members and providing clear, accessible information improves adherence and reinforces positive health behaviors (Horikawa et al., 2020).

Resources Needed to Implement the Care Plans

Delivering coordinated care to Mrs. Snyder requires a variety of interdependent resources. These are categorized and outlined below:

The integration of these resources ensures that Mrs. Snyder’s physical, psychological, and spiritual needs are comprehensively addressed.

References

American Diabetes Association. (n.d.). Standards of Medical Care in Diabetes—2024. https://diabetes.org/

Borges, A. P., Ramos, D. P., Silva, L. D., & Ribeiro, K. M. (2024). Diabetes self-management: Patient outcomes through education and clinical collaboration. Journal of Clinical Nursing, 33(1), 120–132. https://doi.org/10.1111/jocn.16789

Cerchione, R., Esposito, E., Ricciardi, F., & Chiaroni, D. (2022). Blockchain and health care: A systematic review of benefits, risks, and future directions. Technological Forecasting and Social Change, 180, 121674. https://doi.org/10.1016/j.techfore.2022.121674

NURS FPX 6610 Assessment 4 Case Presentation

Facchinetti, G., D’Angelo, D., Piredda, M., Petitti, T., & Matarese, M. (2020). Continuity of care during hospital to home transition: An integrative review. International Journal of Nursing Studies, 101, 103445. https://doi.org/10.1016/j.ijnurstu.2019.103445

Fennelly, O., Cunningham, U., Grogan, L., O’Neill, S., & Doyle, G. (2020). Electronic health records: Key lessons for implementation. Health Policy and Technology, 9(1), 78–84. https://doi.org/10.1016/j.hlpt.2019.11.003

Grassi, L., Nanni, M. G., & Caruso, R. (2023). Psychological support for cancer patients: New challenges in the era of patient-centered care. Psycho-Oncology, 32(1), 34–42. https://doi.org/10.1002/pon.5992

Horikawa, C., Kodama, S., Fujihara, K., & Yachi, Y. (2020). Diet and diabetes: Cultural influences on adherence and care outcomes. Diabetes Research and Clinical Practice, 169, 108461. https://doi.org/10.1016/j.diabres.2020.108461

Marschner, N., Mielke, A., & Schulz, H. (2020). Impact of comorbidities and glycemic control on cancer therapy outcomes. European Journal of Cancer, 132, 135–142. https://doi.org/10.1016/j.ejca.2020.03.001

Patel, S. J., & Landrigan, C. P. (2019). Communication during transitions: A neglected component of quality care. JAMA, 321(9), 865–866. https://doi.org/10.1001/jama.2019.0791

Subbe, C. P., Duller, B., & Bellomo, R. (2021). Transitions of care: Reducing risks and improving patient safety. BMJ Quality & Safety, 30(5), 397–402. https://doi.org/10.1136/bmjqs-2020-011232

NURS FPX 6610 Assessment 4 Case Presentation

Vat, L. E., Ryan, D., & Etchegary, H. (2019). Integrating patient feedback into health system planning: A patient-centered approach. Health Expectations, 22(4), 849–859. https://doi.org/10.1111/hex.1292