This article presents an introduction to a nursing plan of care for Mr. Issler who is diagnosed with various conditions including congestive heart failure, a deep vein thrombosis, and hyper or hypo thyroidism. The plan shows how the AACN Synergy Model and Chronic Care Model can be used to design a care plan that addresses the patient's body, mind, and soul. The three major aspects of this nursing plan are the nursing plan, nursing implementation, and evaluation.
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Issler is a patient who recently moved with his daughter-in-law who is no longer married to his son. As part of her interest in helping to take care of Mr. Issler, she noticed that he was pale and diaphoretic after a two and a half hour flight. The daughter-in-law took him to an emergency room where he was attended to by a cardiologist and set a follow-up check up for an echo cardiogram next week. Mr. Issler has complained of congestive heart failure and a history of deep vein thrombosis. The cardiologist recommended that he seeks out a primary care provider and check up of his thyroid. As the primary care provider, the patient has also expressed his uncertainties on whether he has hyper of hypo thyroidism though he has been under thyroid medication for several years. In addition to being very pale, he has a large bag of medications like metoprolol, lasic, synthroid, and Coumadin. Mr. Issler's condition requires an effective plan of care from a primary care provider to help in managing the illness.
Mr. Issler's Plan of Care:
In developing an effective plan of care for Mr. Issler's condition, the first major step in the process is to identify the vital signs and carry out a lab test of his illness. The vital signs of the patient are pulse (58), b/p (176/84), respirations (22), and pulse oximetry (88). The lab test results are BUN (29), hemoglobin (10.4), hematocrit (29.6%), IND (2.5), and creatinine (2.0). Despite of the history of severe medical conditions, Mr. Issler weighs 147 pounds and he is 72 inches tall.
The main aim of this article is to utilize the AACN Synergy Model and the Chronic Care Model to develop a care plan to deal with the nursing problems of Mr. Issler. According to Hardin & Hussey (2003), the AACN Synergy Model focuses on describing a framework for nursing practice and is based on the linkage of patient characteristics with nurse competencies to realize optimal patient outcomes (p.73). As a result, this model is easily adaptable to the acute care setting, critical care setting for critically ill patients, and the intensive care nurse because it links the nurse's competencies to the characteristics of the patient. Moreover, the AACN Synergy Model enables nurses to manage complex patients experiencing acute vexation of their conditions and work toward lessening the trajectory of the disease.
In contrast, the Chronic Care Model (CCM) is regarded as the best known concept of disease management since it incorporates care coordination, integrated care, and case-management (Drewes et. al., 2012, p.1927). Consequently, the model has been widely embraced as an evidence-based mechanism for improving chronic care. Generally, the Chronic Care Model is usually used in care management to significantly lessen mortality through positive impacts on hospitalization and the patient's quality of life. These effects in care management are always achieved through CCM because the model contains substantial heterogeneity in effectiveness.
Notably, the core concept of the American Association of Critical-Care Nurses (AACN) model is that the patient's needs or characteristics and the influence of his/her family drive nurses' competencies and characteristics (Kaplow, 2008). Synergy in this model is achieved when the patient's characteristics and needs, medical unit, and system are aligned with the nurse's competencies. There are four major components of the AACN model such as the patients' characteristics are of significant concern to nurses and the competencies of the nurses being important to patients. The other components are patients' characteristics guide the competencies of the nurse and the fact that optimal patient outcomes are realized when the characteristics of patients and competencies of nurses are aligned and synergized.
The AACN Synergy Model is guided by various assumptions for patient care including the consideration of patients as biological, social, spiritual, and psychological entities through an examination of body, mind, and spirit. Secondly, the patient, family, and the society play a crucial role in providing the basis for the nurse-patient relationship. Third, patients are described by several characteristics that are linked and contribute to each other, which imply that they cannot be examined in isolation. Fourth, nurses are described on inter-related dimensions that develop the profile of the nurse. The final assumption is that the objective of nursing is to restore the patient to an optimal level of well-being as described by the patient.
The eight patient characteristics in AACN Model for Patient Care that describe the nursing practice include complexity, participation in care, vulnerability, predictability, resiliency, involvement in decision making, stability, and availability of resources. In contrast, the eight nurse competencies in the synergy model include clinical judgment, collaboration, caring practices, facilitation of learning, clinical inquiry, advocacy and moral agency, systems thinking, and response to diversity (Kaplow, 2008).
While Mr. Issler seeks to become as independent as possible from these conditions, some of his major characteristics include shortness of breath, history of congestive heart failure and deep vein thrombosis, several medications, and uncertainty about hyper or hypo thyroidism. The other concerns include decreased oxygen saturation, the death of his wife, mild bradycardia, settling into a new living condition with the daughter-in-law, and addressing the escalating health problems. Therefore, the nursing plan of care is geared towards resolving the current health issues, grieving the death of his wife, and establishing a home environment with the daughter-in-law. In relation to dealing with the patient's history of thyroidism, the primary care provider will mainly rely on the use of assessment skills. This is primarily because assessment skills will help in recognizing the hypermetabolic state of thyroidism in order to avoid treatment delays. According to clinical literature on thyroidism, early recognition of the hypermetabolic state helps in improving outcomes and lessening mortality with thyroid storm (Bray, n.d.).
In Mr. Issler's case, the implementation of the AACN Synergy Model and CCM will involve nursing plan, execution of the plan, and evaluation. The nursing plan involves examining vital signs and changes to physical evaluation, assessing the patient's nutritional intake and fluid status through referral to outpatient CHF clinic, and examining his activity tolerance. The other parts of the plan are evaluating his knowledge of clinical conditions and present treatments, assessing his emotional state in terms of current medical issues, grieving of his wife's death and new living environment, and evaluating the ability of the daughter-in-law to meet his needs.
The execution of the nursing plan for patient care will involve collaboration with the patient, daughter-in-law, home health coordinator and case manager, encourage Mr. Issler to express his feelings about the changes, monitor blood pressure and heart rate, help him with daily activities, assess and record his intake and output, and administer oxygen to maintain enough oxygen saturation. The evaluation of the execution of the nursing plan in Mr. Issler's situation will be based on the major steps of the execution process to determine his progress and areas that need changes or improvement.
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