Patient Care Plan
Name: Rebecca Synder
Date: 27/01/2022 Patient Identifier:
Patient Diagnosis: Pain and Nausea due to chemotherapy
Nursing Diagnosis Assessment Data
Goals and Outcome
Rationale Outcome Evaluation and Re- planning
One of the primary pieces of information that led to understanding the extent of illness in Mrs. Snyder’s body symptoms includes the feeling in her head that she was ready to get rest. She claims that what remains is for her to get taken home and rest beside her family members. Therefore, it explains that she had the feeling that she could no longer survive the medical condition she was feeling from inside. Thus, the therapists could understand and tell the level at which the disease had affected her at that moment.
Firstly, there will be reduced anxiety from the patient through improving medication within two days, which will help gain her trust towards achieving the expected medication for better outcomes throughout the medical examination as planned by the medication team.
Secondly, the patient will adapt to the chemotherapy situation and allow her to cope with the experiences it comes along with it instead of giving up, giving her chances of survival until the medical team finds a solution to the problem within four weeks, showing progress to the affected family.
The first nursing intervention towards handling the situation includes counseling the patient regarding her medical condition.
The rationale for the first goal and outcome is to keep the patient away from anxiety. It would result in trusting the medical process within the facility.
The second pertains to the inclusion of better machinery to aid in assessing the client’s condition.
Besides, the second goal would be aiming at one’s adaptation towards chemotherapy, aiding in administering medication appropriately. It plays a role in the proper control of the infection.
The last includes providing measures to help the patient feel relieved from the pain felt without allowing it to get worse.
Through counseling, in that case, she will get encouragement regarding accepting how life is and accepting the present situation. Thus, her emotions would get altered, making one believe that there is still hope regardless of the problem at hand, alongside showing that other people care about the situation (Fye et al., 2022). There should be a developed and appropriate client-clinician relationship in creating the excellent belief.
Assessments will help understand how the patient progresses according to the subjected medication and the possible drugs that might be suitable to bring back her normal condition through feeling relief (Gardona & Barbosa, 2018). By showing improved results to the client and the family, there will be motivation among them.
The measures help the affected person believe in the process of treatment inducing and adhere to the rules and regulations set by the team
The goals, specifically on reduced anxiety, were achieved regarding the outcomes. The patient was not as negative to the medication process from the case study as she had been before. She hoped to feel better since she had a specific facility that would please her in terms of hospitality services, including food provision. However, regarding how I would plan for the care according to the patient’s response to the current plan of care, I would do more patient assessment, involve the patient during planning, implement modern methods, and regularly monitor the situation.
This is a good evaluation section related to the decrease in anxiety outcome. What about the other diagnoses/outcomes?
This is not specific enough. What assessments? What medications? What is a “normal” condition?
This is very unclear to me. What is the intervention for adaptation or coping?
What is meant by “better machinery”? I do not know what you mean with this intervention.
Counseling is a very appropriate intervention.
Adapting to chemotherapy…how would you measure that? Outcomes should be observable. How would you know she is coping better?
Note that a nursing diagnosis is required here followed by the assessments that lead to the diagnosis. What are the nursing diagnoses that could be applied to Mrs. Snyder? I would expect 3 separate diagnoses for this section.
Patient Care Plan
References Fye, H. J., Kim, Y., & Rainey, J. S. (2022). Correlates of wellness, affective distress, and burnout among school counselors. Journal of Counseling &
Gardona, R. G., & Barbosa, D. A. (2018). The importance of clinical practice supported by health assessment tools. Revista Brasileira de
Enfermagem, 71(4), 1815-1816. https://doi.org/10.1590/0034-7167-2018710401
Tawil, S., Iskandar, K., & Salameh, P. (2018). Pain management in hospitals: Patients’ satisfaction and related barriers. Pharmacy Practice, 16(3),
Great job on your APA format!