Running head: PLAN OF CARE 1

Plan of Care

Delaware Technical Community College

NUR 320 Health Assessment

April 23, 2019

Jessica Te

While creating my patient’s plan of care there were two main health problems that I was
able to identify; one of current health problem for my patient was his issues with his chronic
pain. The reason why I chose this as a problem is because this is an issue that my patient has
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been dealing with for many years and has not been able to find a resolution and he has stated that
he would be interesting in finding ways to help relief his chronic pain, he also stated that he has
never done anything for his chronic pain. My patient, Luis has developed chronic pain in his
lower back due to a fracture disc located at C-3 and chronic pain located at his knee; this is from
his previous duties in the army that caused him to developed these issues and it has been some-
thing that he has been struggling with for years but has been ignoring the pains. Luis stated that
the pain worsens at night which causes him to have difficulty sleeping especially with the knee
pain, it often keeps him up at night and takes him a couple hours to be able to fall back asleep.
Upon waking up, he says that the pain is worse in the morning but as the day goes on the pain
will lessen as he moves around. Interventions that I would suggest for Luis would be learning
non-pharmacologic techniques to help relieve his pain and stress. An example would be thera-
peutic massages, studies have shown that 60 minutes of therapeutic massages between two or
three sessions can greatly relieve chronic neck and back pain, it helps by “closing the pain gate”
by stimulating competing nerve fibers and impeding pain messages to and from the the brain.
(Therapeutic Massage for Pain Relief, 2016). Not only does the massage will help my patient
with his pain, the massage can also help him relax and allow him to sleep better at night. Another
intervention that I would include in his plan of care would be having him to do light exercises
because ignoring the pain itself will not pain the pain go away, by limiting your movements it
can be weaken your muscles and causing future problems. By doing light exercises it helps
strengthens supportive muscles and restores flexibility back into the joints and reduces the pain.
Other interventions for his pain could be pharmacological methods and that would be taking
NSAIDS like ibuprofen and aspirin to help him relief his pain temporarily but this can go hand in
hand with his non-pharmacological strategies. Goals that my patient will be able to achieve are
he will be able to state a satisfactory pain level, he will be able to get enough rest, and will be
able demonstrate and report which pain relieving technique that best works for his lifestyle and is
able to be consistent with his regimen. I have also included some referrals that would guide my
patient with his plan of care, one of the referrals would be a primary care doctor that he can set
up an appointment to get an assessment on, the other referral would be to a physical therapy cen-
ter that can help him start a low impact exercise regimen to slowly improve his back/knee pains,
along with the PT this facility can educate him on ways to help reduce his pain using non-phar-
macological methods. I will be able evaluate my interventions by assessing his initial pain levels
without any interventions and compare them to how he feels currently with his new treatment re-
gime.
Another health issue that I noticed from my patient’s plan of care is his inadequate health
management due to poor eating habits and unable to find the time to exercise. I found this to be
an issue because first of all, eating and good nutrition are important factors in having good health
and when someone is not able to achieve this, it can lead to serious health complications like
heart disease and obesity. As for my patient, he stated that due to his busy lifestyle he has not
been able to maintain a healthy regimen and would like to find a way to incorporate a healthier
lifestyle with his busy life as well. While doing my assessment on my patient I notice that he said
that he majority of the meals he eats only include protein and barely any fruits/vegetables he
does not include anything else. Having a high protein diet is not good for your health; by only
having protein in your diet it can cause nutritional deficiencies and high protein in your body can
increase one’s risk for heart diseases and it can also worsen kidney function. By including more
“colors” into one’s diet like fruits and vegetables it can greatly benefit one’s health; that would
include reducing risk for heart diseases, protecting against certain types of cancers, reduces
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blood pressure, decrease bone loss. (Nutrients and Health Benefits, 2016). Interventions would
include, determining my patient’s daily health care regimen by getting an understanding of what
his daily lifestyle is, I can help assist him to obtaining his goals, another intervention would be
by referring him to a nutritionist, that way Luis and the nutritionist can work together to develop
a treatment plan together, and this can help him get a better understanding on healthier eating
and ways he can incorporate healthier food choices into his life. Goals that I included in Luis’s
plan of care would be for him to be able to demonstrate an understanding of maintaining a
heather lifestyle and he will be able to exhibit continuous adherence to the treatment plan and I
will be able to evaluate this by him restating what he has learned from his nutritionist and that he
is currently following through with their treatment regime and doing a health screening.
One specific issue that came across my plan of care would be my patient’s concern about
his chances of getting diabetes and hypertension. My patient stated that his mother currently has
type 2 diabetes and has a history of hypertension, also other members of his family has history of
heart disease and hypertension as well. While knowing this information, there are interventions
that he can do to reduce his risk of getting these diseases. The first thing that can be done is by
making an appointment with a primary care provider and letting them know about the family
health history and the doctor might recommend a health screening for diabetes and hypertension.
The most important and beneficial intervention that can be done would be for my patient to have
a healthy lifestyle; this includes exercising and maintaining a healthy weight, it is important to
try to get at least 30 minutes of physical activity a day. By exercising it can reduce risk for diabe-
tes by keeping blood glucose and blood pressure levels on target. (Preventing Type 2 Diabetes,
2016). Along with the exercise, it is important to have a healthy diet and it’s good to pick health-
ier food options and reduce sugar intake, so instead of reaching for a sugary chocolate bar it is
best to go for a sweet healthier apple and reduce sweeten beverages and start drinking more wa-
ter.
Upon finishing up my plan of care, there are ways I can evaluate my interventions, I can
evaluate my interventions by keeping an update to assessment with my patient and have progress
notes how well he is processing through each treatment. I can develop a goal from initial assess-
ment and see how much progress has been made up until my final assessment of patient and see
how much has changed from the initial assessment and interventions. Throughout my plan of
care assessment, I have learned more about doing holistic assessments and why it is so important
to understand an individual as whole instead of what their conditions are. I have learned about
the importance of asking open ended questions because and this is something that I will do dif-
ferently because it allows us as health care providers to obtain more information on our patients
compare to close ended questions.
References
Nutrients and health benefits. (2016, January 12). Retrieved April 23, 2019, from

https://www.choosemyplate.gov/vegetables-nutrients-health

Physical Activity. (2017, March 21). Retrieved April 23, 2019, from http://www.diabe-

tes.org/are-you-at-risk/lower-your-risk/activity.html
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Preventing Type 2 Diabetes. (2016, November 01). Retrieved April 23, 2019, from

https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-type-2-diabetes

Therapeutic massage for pain relief. (2016, July). Retrieved April 23, 2019, from

https://www.health.harvard.edu/alternative-and-complementary-medicine/therapeutic-massage-

for-pain-relief