Nursing Assignment: Self-Directed Goals and Care Plans for Seniors

This assignment showcases a student's work on nursing care plans for elderly patients, specifically focusing on those with diabetes. The assignment is divided into two main parts. Part A outlines three self-directed learning goals, each designed to improve the student's clinical practice. These goals address time management, the development of a multidisciplinary disease management program, and the adoption of computer-based documentation. Each goal is presented using the SMART framework (Specific, Measurable, Achievable, Realistic, Timely). Part B focuses on developing detailed nursing care plans for seniors with diabetes. Two comprehensive care plans are provided, each addressing multiple nursing diagnoses such as the risk of falls, self-care deficits, knowledge deficits, bowel and urinary incontinence, and impaired skin integrity. Each care plan includes assessments, nursing diagnoses, smart goals, interventions, rationales, and evaluations, providing a thorough approach to patient care. References to supporting literature are also included.

Assignment Name Student ID
Assignment Name
Assignment Code
Student Name
31 Aug 2019
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Assignment Name Student ID
Part a
The first self-directed learning goal is to “manage time-based on work prioritization”.
Specific - Poor time management and work prioritization not only increases the stress of Health
practitioners but also affect care quality (Ding, Park, Nagarajan, & Grafstein, 2019).
Measurable - This can be achieved by implementing Pareto analysis, which is also known as the
80/20 rule, 80% of the productivity can be gained from doing 20% of the tasks.
Achievable - This goal is considered as the SMART objective, as it specifies work plan,
measures work productivity, achieves urgent and important tasks on priority, relevant to
improved patient care.
Realistic - For instance, it is better to focus on 2 out of 10 task which is more important and
urgent and thus will give more productivity. In this way, the important 20% of work is done in
80% of the time, and the unimportant 80% of the work can be completed in the remaining time.
Timely – It is expected to achieve the goal within a time-bound of 2 months.
Second goal is to “develop a multidisciplinary disease management program”.
Specific - Patient with non-malignant chronic pain suffers from acute pain for a longer period of
at least months. Thus, to minimize the number of readmissions of such patients, it is advisable to
develop a disease management program instead of prescribing pain medication (Parent, Pituskin,
& Paterson, 2016).
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Assignment Name Student ID
Measurable - In this case, the self-directed learning goal is to develop a multidisciplinary disease
management program, which focuses on chronic pain. The effectiveness can be accounted with
patient satisfaction from the available service.
Achievable - The program will include a computer registry to keep records of regular follow-up
visits, structured clinical assessment, and measure improvement in healthcare. In this context,
clinical pharmacist, and pain experts are combined in the program.
Realistic - Thus, according to the SMART objective, the progress of each patient determines the
program's productivity.
Timely - Each patient is expected to be fully treated within a time frame of 3 months.
Last goal is “using computer based documentation”.
Specific - In clinical settings, nurses spend almost 50% of the time to maintain patient’s
documents (Ifinedo, 2016). This self-directed learning goal is to shift to digital documentation
from a paper-based approach, thereby using the computers for the documentation.
Measurable - Using computer-based documentation not only saves time but also reduces the
chances of error, thereby increases the healthcare quality as well.
Achievable - The efficiency of this goal can be measured from the increased productivity of
healthcare professionals.
Realistic - Patients will be given their health records and prescription in printed form as well as
through email which will help in keeping the record.
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Assignment Name Student ID
Timely - To implement the system change of documentation in healthcare settings, it requires a
time period of 4 months.
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Assignment Name Student ID
Part b
In the present section, we will discuss the care plan for individual suffering from diabetes in the
senior’ section. Being elderly, the patient is also facing issues related to the “risk of falls”. The
care plan for this issue has been developed as follows:
Nursing Care Plan
Individual’s initials: Medical Diagnosis: Diabetes at elderly stage
Assessment Nursing
Diagnosis
Plan Intervention Rationale Evaluation
Lowering of
blood sugar
level, sore in
the foot, skin
breakdown,
confusion,
sleeplessness
, impaired
balance,
disorientatio
n, are the
issue causing
physical
impairment,
Risk of falls
(Featherstone,
Eurich &
Simpson,
2017)
The
environment
of the patient
should be
assessed to
identify the
factors that
can increase
the risk of
falls.
The light of
the house
should be
kept on and a
The
condition
which can
maximize the
level of risk
to fall should
be accessed.
For example,
the patient's
past history,
sensory
deficits,
changes in
mental status
The elderly
patient will
be free from
the risk of
fall, does not
experience
any fall-
related
injuries,
implement
preventive
message to
escape fall at
home.
The patients
would be
taught with
the unstable
gait of correct
usage of
adaptive
devices.
Actions
would be
encouraged to
stay with the
family
members at
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Assignment Name Student ID
which leads
to fall
(Featherston
e, Eurich &
Simpson,
2017).
call bell is
provided for
safety
purposes.
The bed of
the patient
should gift
on a loop
position as it
reduces the
risk of falls.
The patients
will be
provided
with their
arrest
identification
for reminding
healthcare
providers to
implement
fall
should be
accessed as a
part of fall
precautionary
measures.
the time as it
can decrease
the risk of
falls.
Documentatio
n will be used
to make
evaluation
decision.
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Assignment Name Student ID
precautions.
Nursing Care Plan 2
Assessment Nursing
Diagnosis
Plan Intervention Rationale Evaluation
To check the
risk factors
of high
glucose
level,
decreased
leukocyte
function,
respiratory
or urinary
tract
infection
(Haltbakk et
al., 2019).
Diagnosis
mainly
includes the
clinical
assessment for
infection and
the
effectiveness
of control
measures
against
diabetes.
The timeline
for such
intervention is
more than 6
months.
Measurable –
Observe the
sputum, urine
colour,
flushed
appearance,
and sign of
infection or
inflammation
.
Achievable –
Reduce
cross-
contaminatio
n, prevention
skin
breakdown or
To check the
skin dryness,
redness, and
injuries.
To check the
body
temperature,
fluid volume
estimation,
and infection
symptoms.
Patient and
carer must be
provided
education.
However,
additional
support is
required from
nurses or
carer to the
elderly
patient to
control and
reduce the
infection risk.
Documentatio
n must be
maintained
for any risk of
inflammation,
injury, skin
breakdown,
or
powerlessnes
s.
Routine
checking for
blood glucose
level and
control
measures
must be
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Assignment Name Student ID
risk of UTI. monitored.
Nursing Care Plan 3
Assessment Nursing
Diagnosis
Plan Intervention Rationale Evaluation
To identify
the risk of
impaired
skin integrity
To monitor
the blood
glucose level.
To recognise
hypoglycaemi
a.
Examining the
urine glucose
and ketone
monitoring.
Specific – To
identify risk
of
administering
insulin and
giving self-
knowledge to
patient for
administratio
n.
Measurable –
To record the
dosage,
frequency of
administratio
n, and the
control on
To use
injectable
therapy, such
as use of
insulin and
GLP-1
receptor
agonist.
Identified
problems
related to
insulin
administratio
n, knowledge
of self-
administratio
n, and
complication
Achievable –
Patient along
with family
member are
requisite to
be provided
with learning
and
monitoring
for
administratio
n of insulin.
Realistic –
Patient
should
develop
competency
Documentatio
n must be
maintained
for self-
administratio
n and the
training
provided to
the patient.
To evaluate
the
effectiveness,
routine
check-up for
the insulin
dosage and
body-blood
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Assignment Name Student ID
diabetic
symptoms in
patient.
Record of the
skin
condition in
patient.
Timely –
Patient can
learn
administratio
n in 1 week.
with usage of
syringe must
be
documented
(McKenzie et
al., 2017).
of self-
administering
and
controlling
the insulin
dosage and
administratio
n.
glucose level
must be
examined.
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Assignment Name Student ID
References
Ding, Y., Park, E., Nagarajan, M., & Grafstein, E. (2019). Patient Prioritization in Emergency
Department Triage Systems: An Empirical Study of the Canadian Triage and Acuity Scale
(CTAS). Manufacturing & Service Operations Management.
Featherstone, T., Eurich, D. T., & Simpson, S. H. (2017). Limited Effectiveness of Diabetes Risk
Assessment Tools in Seniors’ Facility Residents. Value in Health, 20(3), 329-335.
Haltbakk, J., Graue, M., Harris, J., Kirkevold, M., Dunning, T., & Sigurdardottir, A. K. (2019).
Integrative review: Patient safety among older people with diabetes in home care
services. Journal of advanced nursing.
Ifinedo, P. (2016). The moderating effects of demographic and individual characteristics on
nurses' acceptance of information systems: a canadian study. International journal of medical
informatics, 87, 27-35.
McKenzie, A. L., Hallberg, S. J., Creighton, B. C., Volk, B. M., Link, T. M., Abner, M. K., &
Phinney, S. D. (2017). A novel intervention including individualized nutritional
recommendations reduces hemoglobin A1c level, medication use, and weight in type 2
diabetes. JMIR diabetes, 2(1), e5.
Parent, S., Pituskin, E., & Paterson, D. I. (2016). The cardio-oncology program: a
multidisciplinary approach to the care of cancer patients with cardiovascular disease. Canadian
Journal of Cardiology, 32(7), 847-851.
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