SDOH Case Study: Care Plan for a Native American Woman
This paper presents a comprehensive plan of care for a 54-year-old Native American woman, examining how social determinants of health (SDOH) — including economic instability, limited healthcare access, cultural practices, and social support — shape her clinical picture. Key assessment findings include stage 1 hypertension, dyslipidemia, overweight BMI, and persistent fatigue. Three nursing diagnoses are developed: ineffective health maintenance related to insufficient resources, ineffective peripheral tissue perfusion related to hypertension, and activity intolerance related to fatigue. The paper proposes evidence-based interventions grounded in Orem's Self-Care Deficit Theory, Roy's Adaptation Model, and Neuman's Systems Model, and emphasizes interprofessional collaboration and culturally competent, person-centered care.
- Introduction: Overview of SDOH-focused holistic care plan
- Patient Data and Physical Assessment Findings: Health history, vitals, labs, and medications
- Social Determinants of Health and Culture: Economic, cultural, and social factors affecting health
- Nursing Diagnoses and Clinical Evidence: Three diagnoses with physiologic and psychological analysis
- Interventions, Outcomes, and Clinical Reasoning: Evidence-based interventions grounded in nursing theory
- Interprofessional Team and Communication Strategies: Team roles and communication approaches for holistic care
- Conclusion: Summary linking SDOH to person-centered care plan
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What makes this paper effective
- Integrates multiple SDOH domains — economic stability, healthcare access, culture, social support, and environment — into a single, coherent clinical picture rather than treating them as isolated factors.
- Grounds each nursing diagnosis in both subjective complaints and objective laboratory/vital-sign data, demonstrating sound clinical reasoning.
- Applies named nursing theories (Orem, Roy, Neuman) to specific diagnoses, showing theoretical-to-practice linkage rather than generic citation of frameworks.
Key academic technique demonstrated
The paper uses a three-part nursing diagnosis structure — physiologic response, psychological response, and evidence — for each problem. This disciplined format ensures every diagnosis is justified with both patient-reported symptoms and measurable clinical findings, a technique that strengthens the logical validity of care plan development at the undergraduate nursing level.
Structure breakdown
The paper opens with patient history and objective assessment data, then maps SDOH factors onto that clinical baseline. Three nursing diagnoses follow, each with physiologic and psychological sub-analyses. The interventions section links each diagnosis to a theory and a concrete management strategy. The paper closes with interprofessional team roles, communication strategies, and a brief conclusion tying SDOH back to person-centered, holistic care.
Introduction
Social determinants of health (SDOH) are a necessary consideration in providing complete, holistic, quality care. This paper presents a comprehensive plan of care for a 54-year-old Native American woman. The plan considers her health literacy needs as well as the SDOH that affect her case, and presents appropriate interventions backed by clinical reasoning.
Patient Data and Physical Assessment Findings
Health History
The patient has no documented history of surgeries or hospitalizations. She has reported occasional episodes of fatigue, which have impacted her job performance as a guide at a Native American heritage museum. She has also gained weight over the past year and has expressed concern about her energy levels.
Medications
There is no specific mention of current medications. However, given her hypertension (BP: 138/84 mmHg) and high cholesterol levels (total cholesterol: 202 mg/dL, LDL: 160 mg/dL), it is possible she may be on antihypertensive and cholesterol-lowering medications, though further information is needed for confirmation.
Physical Assessment Findings
During the physical assessment, several key findings were noted. Her vital signs revealed a blood pressure of 138/84 mmHg, a heart rate of 90 beats per minute, a respiratory rate of 20 breaths per minute, and an oxygen saturation of 99% on room air. Her temperature was recorded at 37.7°C, and her body mass index (BMI) was calculated at 28, which falls into the overweight category.
Laboratory tests from one week prior to her wellness visit showed that her complete blood count (CBC) was within normal limits. Her blood glucose level was 93 mg/dL, blood urea nitrogen (BUN) was 15 mg/dL, and creatinine was 1.2 mg/dL — all within their respective normal ranges. Electrolyte levels were also normal, with sodium at 135 mEq/L, potassium at 3.8 mEq/L, and chloride at 101 mEq/L.
The total protein level was slightly elevated at 8.0 g/dL. Liver function tests indicated an aspartate aminotransferase (AST) level of 25 units/L and an alanine aminotransferase (ALT) level of 48 units/L, with the ALT being slightly above the normal range. Lipid profile results showed a total cholesterol level of 202 mg/dL, an LDL cholesterol level of 160 mg/dL, and an HDL cholesterol level of 40 mg/dL, indicating dyslipidemia with elevated LDL, elevated total cholesterol, and low HDL levels.
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