Purpose: The effective management of chronic illness for individuals and their families/carers requires the registered nurse to have a wide understanding and scholarship in health and social policies, human and nursing sciences to effectively plan care, advocate and support the consumer in their life choices for care and health management. Current population trends have seen an increase in the number of people staying in their own homes for longer and managing their chronic health conditions and care needs through consumer directed initiatives community care. Nurses need to be able empower consumers to self-manage and care for their chronic conditions in the community. This assessment task is designed to assist you to develop skills in analysing issues relating to self-management of care and to assist you to understand how to develop of self-management plan with a consumer living in their communities who have more than one chronic condition or health issue. A self- management plan is often used in conjunction with a nursing care plan and is designed to be consumer focussed.
Step 1 Introduction and SMART Goals – Provide a brief introduction (400 words inclusive of intext citations) of the client and identify their main chronic health issues which need priority attention and care in a self-management plan and why (provide references to justify). Write 3SMART goals for the client in managing chronic illness conditions and the associated care/treatments/medication.
Step 2 Discuss and Critically Analyse Consumer Directed Care/Self- Management Write 800 words (inclusive of intext citations) to discuss and critically analyse how consumer directed care /self-management planning for this client is important for maintaining their independence out in the community. Specifically outline how effective care planning can assist the client to maintain their health and independence with their activities of daily living. Peer reviewed current literature references should be included to support discussion and analysis.
Step 3 Design a Self-Management Care Plan- Write an 800 words (inclusive of intext citations) Self-Management Plan formatted in the template. In this plan, write down the SMART Goals at the top of the template and then write/design at least 6 priority self-management interventions required for the client to undertake with respect to the priority care needs for each goal. Provide clear healthcare instruction for the client as to what they should do to manage the health issues identified in the SMART Goals. Provide rationales/justification for each with support literature references from peer reviewed current database or textbook sources. Referencing in text should follow the APA 7th edition guidelines and format.
Step 1 Introduction and SMART Goals – Provide a brief introduction (400 words inclusive of intext citations) of the client and identify their main chronic health issues which need priority attention and care in a self-management plan and why (provide references to justify). Write 3SMART goals for the client in managing chronic illness conditions and the associated care/treatments/medication.
Step 2 Discuss and Critically Analyse Consumer Directed Care/Self- Management Write 800 words (inclusive of intext citations) to discuss and critically analyse how consumer directed care /self-management planning for this client is important for maintaining their independence out in the community. Specifically outline how effective care planning can assist the client to maintain their health and independence with their activities of daily living. Peer reviewed current literature references should be included to support discussion and analysis.
Step 3 Design a Self-Management Care Plan- Write an 800 words (inclusive of intext citations) Self-Management Plan formatted in the template. In this plan, write down the SMART Goals at the top of the template and then write/design at least 6 priority self-management interventions required for the client to undertake with respect to the priority care needs for each goal. Provide clear healthcare instruction for the client as to what they should do to manage the health issues identified in the SMART Goals. Provide rationales/justification for each with support literature references from peer reviewed current database or textbook sources. Referencing in text should follow the APA 7th edition guidelines and format.
Step 4 Provide a reference list- listing all references cited in the assignment using APA 7th edition referencing style. There should be a minimum of 15 current peer reviewed journal articles or textbook references (no more than 7 years old).
Case Study-
John Blackwell You have been employed as Community Case Manager RN for a local community health service. John is a 65-year-old Italian man with type 2 diabetes with who presented to his GP with difficulties voiding (a slow stream and dribbles) and pain in his lower back. After some medical investigations he was diagnosed with prostate cancer and underwent an urgent radical prostatectomy (with a suprapubic incision to remove some lymph nodes (for cancer screening as well) one week ago. The lymph nodes appeared to have cancer so they were sent for histopathology and testing. The CT scan and MRIs prior to discharge showed the cancer has possibly spread to his sacrum (as there was a suspicious lesion) and he has some suspicious shadowing in the brain. He was commenced on dexamethasone 5mg daily to slow down the spread of the cancer and to help with lower back pain in conjunction with other analgesia. The dexamethasone has impacted his ability to control his blood glucose levels and it has recently risen in the last few days. His BGLs are ranging from 8-14mmol/L but have been as high as 16 mmol/L post operatively in the ward since starting dexamethasone. He was discharge home this morning from hospital and has received a CHSP (Commonwealth Home Care Support Program) home care package of care which the discharge facilitator from the hospital instigated from the local home care service provider (you are employed by this service). John has temporary IDC, with an out-patients appointment and trial of void (TOV) in 6 weeks. His PICC line is insitu for possible use for chemotherapy and it was dressed yesterday in the ward. He is scheduled for an oncologist consultation and planning with the oncology nurse early next week after his surgical wound has had a chance to heal. His prognosis is 2-10year life expectancy depending on chemotherapy outcomes, but the doctors are not entirely sure until the frozen sections and histopathology resections (from surgery) results are returned. This usually takes 10-14 days. The doctors have indicated that the chemotherapy is more likely to be used for life prolonging measures rather than seeking a cure. The family are looking into non-conventional treatment options. John recently retired from the building industry, he lives with his wife and has a large supportive family who live close by. He has four adult sons who are all married with small children. The diagnosis of a life limiting illness has impacted his mental health. He is currently shocked by the diagnosis and has been talking like he is in the denial phase of grief with the pending diagnosis. He stated the tests will come back clear and he will be alright and is looking forward to getting into his garden greenhouse again and getting the lettuce, tomatoes and basil planted as spring is approaching. He is a current smoker, drinks frequently 8-10 standard drinks a week (mostly red wine and Grappa) and eats a Mediterranean diet. He is 171cm tall and weighs 105kg.
Past Medial History
Type 2 diabetes
Hypertension
Peripheral neuropathy,
numbness in feet
Sciatica
Medications
Metformin 1g BD,
Dexamethasone 5mg daily mane
Panadol Osteo 1200mg TDS
Endone 5mg QID PRN as needed for pain for one more week.
Frusemide 40mg BD
Potassium Chlorvescent 1 tablet diluted daily in 150mls of water.
Atacand 16mg Maneaa
Case Study-
John Blackwell You have been employed as Community Case Manager RN for a local community health service. John is a 65-year-old Italian man with type 2 diabetes with who presented to his GP with difficulties voiding (a slow stream and dribbles) and pain in his lower back. After some medical investigations he was diagnosed with prostate cancer and underwent an urgent radical prostatectomy (with a suprapubic incision to remove some lymph nodes (for cancer screening as well) one week ago. The lymph nodes appeared to have cancer so they were sent for histopathology and testing. The CT scan and MRIs prior to discharge showed the cancer has possibly spread to his sacrum (as there was a suspicious lesion) and he has some suspicious shadowing in the brain. He was commenced on dexamethasone 5mg daily to slow down the spread of the cancer and to help with lower back pain in conjunction with other analgesia. The dexamethasone has impacted his ability to control his blood glucose levels and it has recently risen in the last few days. His BGLs are ranging from 8-14mmol/L but have been as high as 16 mmol/L post operatively in the ward since starting dexamethasone. He was discharge home this morning from hospital and has received a CHSP (Commonwealth Home Care Support Program) home care package of care which the discharge facilitator from the hospital instigated from the local home care service provider (you are employed by this service). John has temporary IDC, with an out-patients appointment and trial of void (TOV) in 6 weeks. His PICC line is insitu for possible use for chemotherapy and it was dressed yesterday in the ward. He is scheduled for an oncologist consultation and planning with the oncology nurse early next week after his surgical wound has had a chance to heal. His prognosis is 2-10year life expectancy depending on chemotherapy outcomes, but the doctors are not entirely sure until the frozen sections and histopathology resections (from surgery) results are returned. This usually takes 10-14 days. The doctors have indicated that the chemotherapy is more likely to be used for life prolonging measures rather than seeking a cure. The family are looking into non-conventional treatment options. John recently retired from the building industry, he lives with his wife and has a large supportive family who live close by. He has four adult sons who are all married with small children. The diagnosis of a life limiting illness has impacted his mental health. He is currently shocked by the diagnosis and has been talking like he is in the denial phase of grief with the pending diagnosis. He stated the tests will come back clear and he will be alright and is looking forward to getting into his garden greenhouse again and getting the lettuce, tomatoes and basil planted as spring is approaching. He is a current smoker, drinks frequently 8-10 standard drinks a week (mostly red wine and Grappa) and eats a Mediterranean diet. He is 171cm tall and weighs 105kg.
Past Medial History
Type 2 diabetes
Hypertension
Peripheral neuropathy,
numbness in feet
Sciatica
Medications
Metformin 1g BD,
Dexamethasone 5mg daily mane
Panadol Osteo 1200mg TDS
Endone 5mg QID PRN as needed for pain for one more week.
Frusemide 40mg BD
Potassium Chlorvescent 1 tablet diluted daily in 150mls of water.
Atacand 16mg Maneaa
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