Creating a Plan of Care

Utilizing the information you have gathered over the weeks regarding the specific illness group you identified, this week, you will create a plan of care for your chronic illness group.

Create the plan in a 4- to 6-page Microsoft Word document (the 4–6 pages include the holistic care plan). Include the following in your plan:

  • Start the paper with a brief introduction describing the chronically ill group you selected and provide rationale for selecting this illness and the participants. Clearly identify the Healthy People 2020 topic chosen and why this topic was chosen.
  • You will want to compile the information gathered from Weeks 1–4 over 2 to 3 pages. This should be in APA format and paragraph form. This is not to be copied and pasted from previous assignments. It is to be a summary of each week.  
  • The paper should include the care plan for your chronic illness group organized under the following headings: 
    • Nursing Diagnoses
    • Assessment Data (objective and subjective)
    • Interview Results
    • Desired Outcomes
    • Evaluation Criteria
    • Actions and Interventions
    • Evaluation of Patient Outcomes
  • You will need to ensure that the care plan is holistic and includes at least 3 nursing diagnoses related to the topic and interview results from the previous weeks.
  • Include strategies for the family or caregiver in the care plan and provide your rationale on how they will work.
  • Include a reference page to provide reference for all citations for the paper as well as the care plan.

On a separate references page, cite all sources using APA format.

Assignment components










Provided a brief

introduction describing the chronically ill group you selected and provide rationale for selecting this illness and the participants. Include Healthy People 2020 topic chosen

Introduction vaguely

describes the group selected and rationale

Introduction describes

the group selected and rationale.

Introduction describes

the group selected and rationale but the additional details are needed

Wrote detailed succinct

introduction describing the chronically ill group selected and provided rationale.

[Score x 10 = 40pts]

Created a holistic plan

of care for your chronic illness group.

Identified the chronic

illness of interest; did not discuss morbidity and comorbidity associated with the disease. Did not discuss impact of chronic illness and effect on family dynamics.

Provided questionnaire in attachments.

Identified participant

with chronic illness.

Designed questionnaire.

Discussed minimally the responses to illustrate acceptance of diagnosis and support measures for family, participant, and or family friends.

Identified participant

with a chronic illness.

Administered questionnaire and analyzed the results.

Discussed responses to illustrate where the patients, their families, and friends are in relation to accepting the diagnosis, coping skills, treatment, support, and so forth in relation to

the health or illness definitions.

Discussed how the analysis will direct plan of care.

Provided expert

identification of a participant with a chronic illness.

Administered questionnaire and analyzed the results.

Discussed responses in detail to illustrate where the patients, their families, and friends are in relation to accepting the diagnosis, coping skills, treatment,

support, and so forth in relation to the health or illness definitions.

Discussed how analysis will direct plan of care development for the chosen illness group.

[Score x 10 = 40pts]

NSG4055 Illness and Disease Management across the Life Span

© 2015 South Universi

Running head: DIABETES 1



Tanyanika McMillian

South University

The chronic illness of interest for the purpose of this assignment is diabetes. Diabetes is a metabolic disease distinguished by hyperglycemia emerging from deficiencies in the secretion of insulin, and the ability to produce any or enough insulin (American Diabetes Association, 2014). The lack or insufficient levels of insulin in the body cause sugar levels to increase in the body. The reason for my interest in this chronic illness is its high prevalence in the country and personally in the South where I live. According to data collected in 2014, 9.3 percent or 29.1 million people had diabetes (CDC, 2015). Studies conducted between 2011 and 2012 found out that 50 percent of the American adult citizens are either living with diabetes or pre-diabetes with those diabetes at 12-13 percent and those with pre-diabetes at 37-38 percent (Menke, Casagrande, & Geiss, 2015). Pre-diabetes is a condition in which an individual’s level of glucose in the blood is above the normal levels but not high enough to reach the diabetes state.

The symptoms of diabetes include urinating severally, being very thirsty, feeling hungry, having blurry eyesight, feeling exhausted, rapid loss of weight, sores that take long to heal and having dry and itchy skin.

Type 1 diabetes mostly develops in infancy or young adulthood. However, the illness can also develop in adulthood. The bodies of people with type 1 diabetes do not produce insulin or produce insulin in little amounts. The production of insulin is low in case the body’s immune system kills the organisms that manufacture the insulin.

The type 2 also affects people of any age but more common in middle-aged and older people. It is also prevalent in individuals who are overweight and inactive. Development of this illness begins if the body has insulin resistance. Resistance occurs when the body cells responsible for transporting glucose to the body cells fail to use insulin to transport the glucose. As the blood sugar increases in the body, the pancreas stops the production of insulin. Therefore, type 2 diabetes is characterized by no or little amount of insulin production by the pancreas.

Morbidity and comorbidity of diabetes

Morbidity is a departure from the expected psychological and physiologic well-being and normal functioning (Tulchinsky & Varavikova, 2009).The measure of morbidity is the number of



The Impact of Chronic Illness

Tanyanika McMillian

South University

A chronic ailment refers to a disease that persists for a lifetime, and not preventable by vaccines or cured by medication. The disease affects the patient for a very long time and may need intensive management. Chronic ailments pose several problems to patients including living with the physical effects and disability caused by the disease, dealing with treatments, maintaining emotional balance, along with psychological and financial impacts on the patient’s families and friends. The chronic illness I chose in week 1 was diabetes. This paper administers a questionnaire to a patient living with diabetes, analyzing the responses and an interpretation of how it will affect the planning care for diabetes.


1. When were you diagnosed with diabetes?

I developed the symptoms of diabetes and diagnosed at the age of 32.

2. Do you have people in your family suffering from diabetes?

No, I am the first person in our family to suffer from diabetes.

3. What symptoms did you experience before you were diagnosed with diabetes?

I experienced loss of weight, feeling thirsty all of the time, not much energy, waking up almost four times per night to urinate, always feeling tired and constant hunger despite how much I ate. I was also having dry mouth and skin, which the doctor told me was a result from the loss of water in the body because of urinating all of the time.

4. How many times did you need to urinate on a daily basis before you was diagnosis with diabetes?

A healthy person urinates 4 to 8 times in a day, but I was using the bathroom more than 8 times a day. I would say I felt the urge to urinate almost every one and half hours.

5. How does the need to urinate regularly affect your everyday life?

Frequent urination prevents me from traveling for long distances, and if I have to travel, I am require to make frequent stops to relieve myself. I cannot travel more than two hours, and I also need to relieve myself before starting the journey.

6. Have you suffered any loss of weight?

I lost a lot of weight before my diagnosis and during the first few months of taking medication, but I have added some weight after managing the disease. However, I have to keep checking my weight because the doctor informed me t



Support Needs Analysis

Tanyanika McMillian

South University

How well a patient responds and adjusts to chronic illness is largely dependent on their individual coping responses. However, social and partner support plays a critical part in the patient’s adjustment to the chronic disease. Studies have found that having social support leads to better disease outcomes and have health benefits to the patient over time.

Support Needs for the Participant

The participant has been doing well in managing his condition, and he requires support to encourage him to continue in the same manner or even do better. The caregiver can offer support to the participant by providing patient-centered care. This term relates to a type of care that is in agreement with the patient’s wants, needs, and preferences. The caregiver can support this participant in managing the illness and improving his health status by involving the participant in decision making and offering the care according to his preferences and goals. Such kind of attention moves away from the traditional protocols that did not involve the patient in decision-making. Studies have shown that patients are more committed to their diabetes management plan when the plan incorporates their personal lifestyles preferences (Sarkar, Georgiou, & Marques, 2015). It is important that a patient’s plan of care is individualized specifically to meet his or her needs and encourage compliance with diabetic management.

Another support need for the participant for further or additional education is diabetes self-management. Diabetes self-management education is an unending process that assists in enhancing the knowledge, skills, and capability that helps the patient in diabetes self-care (Weinger & Carver, 2008). Self-management refers to a diabetic’s ability to manage the symptoms, treatment, physical and psychological outcomes, along with the lifestyle changes to enable the individual to live normal with the disease. The caregiver or the nurse can support the participant by continuously educating him of the best diabetes self-management practices and offer updates on the new issues that may arise. This kind of support will make the participant more knowledgeable, which will help him feel in control of his condition, improving his confidence and giving him motivation to do more to improve his status while managing his illness.

How to Implement the Goals of Healthy People 2020



Locating Resources

Tanyanika McMillian

South University

One of the greatest challenges in diabetes care is to design and implementing effective lifestyle modification strategies. In the past, several programs focused on the change in individual behavior without integrating change within the community. This approach has led to poor diabetes outcomes throughout the community. Various studies have found that it is necessary to match the needs of the patients to the availability of community resources to them (Tung & Peek, 2015). Using this approach assists the patients with the ability to manage their diabetes to quickly change their behavior in a better way. This paper discusses some of the national and community resources for people living with diabetes.

Texas Diabetes Council

The Texas Diabetes Council is a body that engages in addressing the issues affecting people living with diabetes in Texas. This also offers advice to the Texas Legislature on the best laws that are necessary to assists the patients to develop and maintain an excellent quality education services for the diabetic patients and the medical professionals who offer diabetes education and treatment (Texas Department of State Health Services, 2016). In addition to providing these services and being a resource for the residents of Texas, this resources also engages in activities held at a national wide level.

TDC together with the Texas Health and Human Services System have a Texas Diabetes Newsletter that interested parties can subscribe to receive news about the TDC treatment practices, and read about resources of patient education. The newsletter also includes information on updates by the National Diabetes Education program, information about other contemporary issues on the treatment and management of diabetes, the available education opportunities in the state and other information concerning diabetes. The person interested in receiving this newsletter subscribes to receive the newsletter through email. The individuals have the right to unsubscribe or re-subscribe at his or her will.

TDC have also partnered with TMF Health Quality Institute in offering the Health for Life Diabetes Initiative which engages some community partners and physicians with an aim to remove the existing health disparities and create more opportunities for the und