NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Name

Capella university

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Comprehensive Needs Assessment

A thorough needs assessment serves as a pivotal component in enhancing patient care within healthcare systems. It enables clinicians to evaluate patient needs systematically and tailor interventions accordingly. This process is particularly vital for individuals dealing with multifaceted health concerns requiring interdisciplinary support. Through such evaluations, care teams can detect service gaps and develop solutions that address both clinical and non-clinical barriers to effective care delivery.

The assessment considers physiological, psychosocial, and environmental influences on health, promoting a patient-centered care model. Tools like the Patient-Centered Assessment Method (PCAM) allow healthcare professionals to explore patients’ personal experiences and health perspectives, enabling individualized care planning (Perazzo et al., 2020). This approach supports collaboration across medical, emotional, and logistical areas, fostering improved patient outcomes and experiences.

Central to this assessment is interdisciplinary collaboration, which unites professionals such as physicians, nurses, and social workers. This teamwork supports seamless transitions between care settings, reduces fragmentation, and boosts care efficiency and satisfaction, ultimately enhancing the quality of care provided.

Current Gaps in the Patient’s Care

Mr. Decker’s case highlights several deficiencies in his care trajectory, especially surrounding discharge planning and ongoing care coordination. These gaps have led to a readmission that might have been avoided with a more structured and proactive approach to care.

Table 1: Gaps Identified in Mr. Decker’s Care

Identified Gaps	Details
Financial Limitations	Mr. Decker’s income constraints limit access to necessary healthcare services.
Discharge Instruction Deficit	Incomplete discharge education led to unaddressed complications.
Lack of Follow-Up Services	Absence of routine monitoring delayed detection of health decline.

The utilization of PCAM facilitated a comprehensive understanding of Mr. Decker’s health concerns by factoring in emotional, cultural, and systemic challenges. This method aligns well with the complexities faced by aging populations and supports the formulation of realistic and responsive care strategies (Perazzo et al., 2020).

Collecting in-depth patient data is essential to refining care delivery. This includes not only clinical records but also information on patient behaviors and emotional wellbeing.

Table 2: Informational Needs for Individualized Care

Required Information	Details
Medical History	Includes chronic illnesses, allergies, age, and previous interventions.
Psychosocial Insights	Captures emotional triggers, lifestyle patterns, values, and stress factors.

Supplementary data can also be gathered through informal interviews with family members, uncovering habits and routines that formal assessments may overlook (Mertens et al., 2020). Integrating electronic health records while adhering to HIPAA guidelines further ensures secure, accurate, and accessible patient data (Shah & Khan, 2020).

Societal, Economic, and Interdisciplinary Considerations

Mr. Decker’s situation underscores the influence of socioeconomic status and societal support systems on health outcomes. Elderly patients often experience conditions such as reduced immunity and impaired recovery capabilities, complicating treatment plans (Liu et al., 2019). Financial hardship also restricts access to medications and therapies, particularly those not covered by insurance plans.

Table 3: Socioeconomic and Support Factors Affecting Care

Factor	Impact on Care
Aging	Age-related health decline prolongs recovery and complicates treatment.
Financial Barriers	Limited funds restrict access to essential supportive healthcare services.
Inadequate Social Support	Minimal family involvement leads to reduced treatment adherence.

The absence of a strong support system compromises Mr. Decker’s ability to manage his care independently, heightening the risk of deterioration (Ko et al., 2019).

Standards from professional organizations help guide and improve coordination in complex cases. The National Quality Forum (NQF) provides safety-focused benchmarks (Namburi & Lee, 2022), while the Agency for Healthcare Research and Quality (AHRQ) emphasizes communication and education during care transitions (Artiga et al., 2020). The Care Coordination and Transition Model fosters team-based, personalized care strategies (Hofmann & Erben, 2020).

Table 4: Relevant Professional Models and Standards

Standard/Model	Role in Coordination
National Quality Forum (NQF)	Sets benchmarks to enhance patient safety and procedural integrity.
AHRQ Care Transition Benchmarks	Focuses on patient education and efficient communication during discharge.
Care Coordination & Transition Model	Promotes teamwork and patient-centered transitions in care.

Evidence-based protocols further enhance the quality and safety of patient care. The GENESIS model facilitates early infection detection, reducing sepsis risk (Kregel et al., 2022), while the “Sepsis Six” bundle provides standardized emergency responses for suspected sepsis (Bleakley & Cole, 2020). Geriatric assessments track functional and cognitive changes to guide age-appropriate interventions (LeRoith et al., 2019).

Table 5: Evidence-Based Practices for Improved Outcomes

Practice	Description
GENESIS Protocol	Enables timely infection detection and lowers sepsis-related mortality.
Sepsis Six Bundle	Standard protocol for managing suspected sepsis through timely interventions.
Comprehensive Geriatric Assessment	Tracks functional decline to guide customized treatment in older adults.

A collaborative care model is essential to addressing the multifaceted needs of patients like Mr. Decker. Involving specialists from various disciplines—nursing, psychology, social work—ensures that physical, emotional, and social dimensions of care are addressed. Such models have been shown to reduce hospital readmissions and improve safety metrics by 13% (Ni et al., 2019).

Conclusion

A structured needs assessment plays a vital role in the design and delivery of comprehensive care. Mr. Decker’s experience reveals the value of integrating interdisciplinary collaboration, patient-specific data, and evidence-based protocols into care planning. With the adoption of professional standards and a collaborative model, healthcare providers can ensure safer, more responsive, and effective care pathways.

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References

Artiga, S., Orgera, K., & Pham, O. (2020). Issue brief disparities in health and health care: Five key questions and answers. Deancare.com. https://deancare.com/getmedia/e00c9856-28d0-4c63-b2c0-9bf68cadcebb/Disparities-in-Health-and-Health-Care-Five-Key-Questions-and-Answers.pdf

Bleakley, G., & Cole, M. (2020). Recognition and management of sepsis: The nurse’s role. British Journal of Nursing, 29(21), 1248–1251. https://doi.org/10.12968/bjon.2020.29.21.1248

Hofmann, F., & Erben, M. J. (2020). Organizational transition management of circular business model innovations. Business Strategy and the Environment, 29(6), 2770–2788. https://doi.org/10.1002/bse.2542

Ko, H., et al. (2019). Gender differences in health status, quality of life, and community service needs of older adults living alone. Archives of Gerontology and Geriatrics, 83, 239–245. https://doi.org/10.1016/j.archger.2019.05.009

Kregel, H. R., et al. (2022). The geriatric nutritional risk index as a predictor of complications in geriatric trauma patients. Journal of Trauma and Acute Care Surgery, 93(2), 195–199. https://doi.org/10.1097/TA.0000000000003588

LeRoith, D., et al. (2019). Treatment of diabetes in older adults: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(5), 1520–1574. https://doi.org/10.1210/jc.2019-00198

Liu, X., et al. (2019). The risk factors for diabetic peripheral neuropathy: A meta-analysis. PLOS ONE, 14(2), e0212574. https://doi.org/10.1371/journal.pone.0212574

Mertens, F., et al. (2020). Healthcare professionals’ experiences of inter-professional collaboration during patient’s transfers. Palliative Medicine, 35(2), 174–184. https://doi.org/10.1177/0269216320968741

Namburi, N., & Lee, L. S. (2022). National Quality Forum. EuropePMC. https://europepmc.org/article/med/31751044

Ni, Y., et al. (2019). Effects of nurse-led multidisciplinary team management in diabetes. Journal of Diabetes Research, 2019, 1–9. https://doi.org/10.1155/2019/9325146

Perazzo, M. F., et al. (2020). Patient-centered assessments in dental clinical trials. Brazilian Oral Research, 34(2). https://doi.org/10.1590/1807-3107bor-2020.vol34.0075

Shah, S. M., & Khan, R. A. (2020). Secondary use of electronic health record: Opportunities and challenges. IEEE Access. https://doi.org/10.1109/access.2020.301109

Nursing Diagnosis and Care Plan for Mrs. Snyder

Patient Identifier: 6700891 Medical Conditions: Uncontrolled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia

1. Ineffective Health Management: Diabetes and Lifestyle Habits

Mrs. Snyder, a 56-year-old patient, presents with multiple chronic illnesses, including uncontrolled diabetes and hypertension. Her daily habits, such as frequent consumption of high-sugar snacks like cookies, have significantly impaired her glycemic control. Upon admission to the emergency department, her blood glucose levels ranged from 230 to 389 mg/dL. She reported symptoms such as fatigue, abdominal discomfort, shortness of breath, and polyuria. These indicators, coupled with her dietary behaviors and hypertension, underscore the urgency of managing her metabolic health.

The primary objectives are to normalize her blood glucose and blood pressure levels within the next 30 days and foster long-term improvements in her nutritional habits and general well-being over the following three months (Ramzan et al., 2022). Nursing interventions are tailored to educate, motivate, and empower the patient toward adopting sustainable health behaviors.

Interventions	Description	Rationale
Educate on diabetes self-care	Explain nutritious eating, physical activity, and sleep	Enhances understanding and promotes lifestyle improvements (USC, 2018)
Support monitoring practices	Train on glucose tracking and food logging	Encourages early identification of glucose spikes (Carolina, 2019)
Insulin administration training	Provide instruction on injection techniques	Increases compliance and improves therapeutic outcomes (Heart, 2021)

Progress will be assessed through consistent reviews of blood glucose and blood pressure recordings. Should outcomes fall short, further dietary or pharmacological adjustments will be implemented.

2. Heightened Anxiety Due to Caregiver Role and Family Conflict

Mrs. Snyder’s mental health is significantly impacted by her roles at home, particularly her duties as the main caregiver for her ailing mother and ongoing issues with her son. This emotional overload has exacerbated her anxiety, leading to physiological symptoms such as elevated blood pressure and rapid pulse. Furthermore, she inconsistently takes her anxiolytics, diminishing their therapeutic effects. The stress of managing household duties and financial responsibilities contributes to her deteriorating psychological state.

Nursing goals include achieving a stable blood pressure of 130/90 mmHg and maintaining her heart rate within the normal range of 60–100 beats per minute within a month. Another crucial aim is to mitigate her anxiety symptoms by encouraging medication adherence and therapeutic intervention (Pegg et al., 2022).

Interventions	Description	Rationale
Ensure anxiolytic compliance	Encourage routine medication use	Aids in controlling physiological anxiety symptoms (Ströhle et al., 2018)
Initiate CBT therapy	Weekly counseling sessions	CBT is known to effectively reduce anxiety (Pegg et al., 2022)
Provide social resources	Connect with local spiritual and emotional support groups	Enhances social connection and emotional resilience (Goodtherapy, 2019)

Outcomes will be monitored weekly, focusing on changes in anxiety levels, physiological parameters, and participation in therapy. Care plans will be modified based on her responsiveness to treatment.

3. Emotional Strain from Cancer Diagnosis and Caregiving Burden

In addition to her chronic illnesses, Mrs. Snyder is coping with a recent diagnosis of ovarian cancer. Her psychological stress is exacerbated by the prospect of chemotherapy and the responsibility of caring for her mother. She reports abdominal discomfort and exertional dyspnea, with a drop in oxygen saturation levels during physical activity.

Short-term objectives include securing alternate caregiving arrangements for her mother within two weeks, enabling her to prioritize her treatment. Long-term goals focus on improving her oxygen saturation and physical strength within three months. Holistic care addressing her physical and emotional stressors is critical.

Interventions	Description	Rationale
Refer to social services	Assist in finding a caregiving facility for her mother	Reduces stress and promotes treatment adherence (Hoyt, 2022)
Monitor pain regularly	Ongoing assessments for treatment-related pain	Ensures timely pain control and enhances functionality
Introduce relaxation techniques	Provide training in meditation, yoga, and guided imagery	Non-drug approaches aid in stress reduction (Sheikhalipour et al., 2019)

Her care plan will be evaluated through improvements in pain control, oxygenation status, and emotional well-being. Adjustments will align with progress in caregiving support and her response to cancer treatment.

References

Cancer. (2021, October 6). Managing diabetes when you have cancer. Cancer.net. https://www.cancer.net/navigating-cancer-care/when-cancer-not-your-only-health-concern/managing-diabetes-when-you-have-cancer

Carolina, C. M. (2019, October 16). Unlocking the full potential of self-monitoring of blood glucose. Uspharmacist.com. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Goodtherapy. (2019, September 23). Therapy for self-love, therapist for self-love issues. Goodtherapy.org. https://www.goodtherapy.org/learn-about-therapy/issues/self-love

Heart. (2021, May 6). Living healthy with diabetes. Heart.org. https://www.heart.org/en/health-topics/diabetes/prevention–treatment-of-diabetes/living-healthy-with-diabetes

Hoyt, J. (2022, May 26). Assisted living & senior placement agencies. SeniorLiving.org. https://www.seniorliving.org/placement-agencies/

Pegg, S., Hill, K., Argiros, A., Olatunji, B. O., & Kujawa, A. (2022). Cognitive behavioral therapy for anxiety disorders in youth: Efficacy, moderators, and new advances in predicting outcomes. Current Psychiatry Reports, 24(12). https://doi.org/10.1007/s11920-022-01384-7

Ramzan, B., Harun, S. N., Butt, F. Z., Butt, R. Z., Hashmi, F., Gardezi, S., Hussain, I., & Rasool, M. F. (2022). Impact of diabetes educator on diabetes management: Findings from diabetes educator assisted management study of diabetes. Archives of Pharmacy Practice, 13(2), 43–50. https://doi.org/10.51847/2njmwzsnld

Sheikhalipour, Z., Ghahramanian, A., Fateh, A., Ghiahi, R., & Onyeka, T. C. (2019). Quality of life in women with cancer and its influencing factors. Journal of Caring Sciences, 8(1), 9–15. https://doi.org/10.15171/jcs.2019.002

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Aerzteblatt Online, 115(37). https://doi.org/10.3238/arztebl.2018.0611

USC. (2018, January 9). What does self-care mean for diabetic patients? Nursing.usc.edu. https://nursing.usc.edu/blog/self-care-with-diabetes/