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Plan of Care

Nur320-6W1

Health Assessment

Ashley Altman

Delaware Technical Community College

August 3, 2022
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During this class, Nur320-Health Assessment, I obtained a full, detailed health

assessment of my patient, Mr. A. In this health assessment, I gathered pertinent information

about Mr. A’s current and past health, along with his family’s health history, and details about

Mr. A’s lifestyle that contribute to his well-being. After finishing Mr. A’s health assessment, I

learned of his current health issue of diabetes mellitus and his risk of hypertension. Based on

these health concerns, I was able to put together a plan of care for Mr. A to help promote his

health.

Health Problems

Mr. A’s highest priority for this plan of care would be his diabetes, which can put him at

a high-risk unstable blood glucose level. Since Mr. A’s body does not properly secrete insulin, he

is at risk of improper levels of glucose (sugars) if not closely monitored (Mayo Clinic, 2020).

During my health assessment, Mr. A mentioned factors that could contribute to his risk of

unstable blood glucose levels. He has stated that his diet is made up of what he is in the mood for

at that time, and that he does not closely monitor his intake. Medication is also a huge factor in

his health, which is a struggle for him to keep up with his medication as instructed due to lack of

transportation to the pharmacy as he and his wife share a vehicle with little children at home. Mr.

A also stated that he faces increased amounts of stress in his life due to the inability to not

properly care for his health, which stress can cause instability within his glucose levels, along

with his physical work life of tree work in the heat of the summer and cold of the winter. These

factors within his life are huge contraindications to a healthy lifestyle. His diabetes and his

lifestyle, puts him at risk of other health-related problems as well.

Another health problem Mr. A is at risk for is hypertension. Due to his diabetes alone,

this can cause blood pressure related issues (CDC. 2021), adding his lifestyle factors into the
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equation and his family history putting him at a higher risk for hypertension. Due to all these risk

factors in place for Mr. A, a plan of care is very important to put into place to help monitor and

assess both possible health risks.

Health Promotion/ Prevention

It is very important for Mr. A to know what needs to be monitored/assessed and how

lifestyle plays a huge role in one’s health. For diabetes, it is highly important to know that blood

glucose levels should be within a satisfying level of 140 to 170 and an A1C lower than 7%. Mr.

A must monitor blood glucose levels before meals and bedtime daily and as needed if feeling

symptomatic due to high (hyperglycemia) or low (hypoglycemia) blood glucose levels (Vera, M.

2022). For his risk of hypertension, Mr. A needs to keep his blood pressure (BP) under safe

limits of 120/80 (CDC, 2021) and that if his BP were to ever exceed 160 (Vera, M, 2022) to

immediately report to his doctor for further evaluation (Vera, M. 2022). For the sake of both

health-related risks, Mr. A needs to readjust some lifestyle factors in his life, such as diet, stress,

exercise, and work-related fatigue (Mayo Clinic. 2020).

To monitor Mr. A’s progress, he would need his A1C checked periodically to obtain

accurate information on his blood glucose levels, check weight with each follow-up appointment

to monitor how dietary lifestyle changes and exercise are being applied and assess blood pressure

at each appointment to ensure safe levels are being maintained. Since Mr. A has stated some life

factors that are causing harm to his health, it is important that resources are put in place.

Resources

Mr. A has provided me with the information that transportation is a huge factor in

interference of his health and lack of knowledge on his risks. Based on this collection of

information, I have been able to locate resources that can further his knowledge of both diabetes
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and hypertension, as well as provide transportation to help him receive the care he needs to

maintain his health. These resources are Delaware Diabetes Coalition at 107 Vollkorn Road

Magnolia, DE 19962, Diabetes Wellness Center at Bayhealth at 640 S. State St. Dover, De, and

American Heart Association of Delaware at 131 Continental Drive, Suite 407 Newark, DE.

Mr. A has the motivation to maintain a healthy lifestyle, as he wants to be able to watch

his children grow and continue to be able to grow old with his wife. He knows that his diabetes

are important to monitor and follow through with care, he just needs the proper resources and

follow up care to be able to do this and prevent further complications. With these resources, I

believe Mr. A can succeed.

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Resources

CDC. (2021). High Blood Pressure Symptoms, Causes, and Problems. Centers for Disease

Control and Prevention. https://www.cdc.gov/bloodpressure/about.htm

Mayo Clinic. (2020). Diabetes - Symptoms and causes. https://www.mayoclinic.org/diseases-

conditions/diabetes/symptoms-causes/syc-20371444

Vera, M. (2022). 6 Hypertension Nursing Care Plans. Nurseslabs.

https://nurseslabs.com/hypertension-nursing-care-plans/6/

Vera, M. B. (2022a, April 3). 17 Diabetes Mellitus Nursing Care Plans. Nurseslabs.

https://nurseslabs.com/diabetes-mellitus-nursing-care-plans/