1

Plan of Care Summary

Jessica Clukey

Nursing Department, Delaware Technical Community College

NUR 320: Health Assessment

Mrs. Kate Lind MSN, RN

April 23, 2023

 2

Plan of Care Summary

I completed an assessment of my patient Mr. C. In completing his physical assessment, I

also gathered his medical history and current concerns. From this, I determined there were two

priorities for his care, obesity, and potential sleep apnea. His BMI is 40 which puts him in the

category of obese. Being obese puts him at greater risk of type 2 diabetes, stroke, coronary heart

disease, gallbladder disease, sleep apnea, and certain cancers (Centers for Disease Control and

Prevention [CDC], 2022-a). His family history includes a history of type 2 diabetes in both his

mother and father, cancer in his mother, and coronary heart disease in his father. Given this

family history is it important he watches his diet, exercises, and loses some weight to reduce his

risk factor for developing the above-mentioned conditions.

Evidence-based treatment for obesity includes eating a healthy diet and increasing

physical activity (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK],

2018). For this patient, I set his goal to lose 10 pounds by his next visit in 6 months. According

to the NIDDK (2018), it is recommended to lose around 5 to 10 percent of the patient’s body

weight within the first 6 months of treatment. Losing this weight will lower his risk of

developing other related health conditions (NIDDK, 2018). A research evaluation completed by

Zhang (et al., 2023) found that weight loss in obese patients decreased the risk of type 2 diabetes

by 66 percent. The plan for this patient is he will make dietary changes such as reducing caloric

intake, increasing his intake of fruits and vegetables, and eating lean meats. Additionally, the

patient was encouraged to keep a log of his diet to review at his follow-up visit. The second

intervention includes education on daily exercise with an emphasis on walking at a moderate

pace for 30 minutes. Again, he was encouraged to keep a log of his activity to review at his

follow-up visit. He was provided with a link from the CDC for an activity log he can complete.
 3

Finally, this patient was referred to a nutritionist/dietitian, Wendy M. Gibson at Contemporary

Nutrition, in his community to aid him in setting his dietary goals.

The second identified issue for this patient was his disturbed sleep pattern. During his

assessment, the patient indicated he had trouble falling asleep and staying asleep. He also

reported he woke up gasping for air, experienced periods of holding his breath while sleeping,

experienced morning headaches, and was told by his wife he snores loudly. These findings are

all concerning for possible sleep apnea. As a result, this patient was referred to Jay Dave, DO at

CNMRI in his local community to further evaluate for sleep apnea and complete a sleep study.

His identified goals include vocalizing the importance of obtaining a sleep study by the end of

his visit. He will demonstrate meeting this goal by “teaching back” to the nurse at the end of his

visit the importance of keeping his appointment for this sleep study.

According to the CDC (2022-b), poor sleep is linked to type 2 diabetes, heart disease,

obesity, and depression. Specifically, patients are at an increased risk of cardiovascular disease

and sudden cardiac death due to the strain placed on the heart during periods of apnea (Kim et

al., 2023). Patients with sleep apnea require the use of a CPAP, continuous positive airway

pressure, machine to help them keep their airways open during sleep. Given this patient’s family

history of coronary heart disease in his father as well as sudden cardiac death in both paternal

grandparents it is imperative he seeks treatment for his possible sleep apnea to reduce the

workload on his heart. The use of a CPAP decreases the work the heart must do which decreases

the risk of cardiovascular disease (Kim et al., 2023). In conclusion, both identified health

problems are significant concerns for this patient. The interventions for both problems will

improve each other. Losing weight will decrease the strain on his heart. Treating sleep apnea will

improve his sleep and energy levels as well as reduce cardiac stress.
 4

References

Centers for Disease Control and Prevention. (2022-a). About adult BMI. CDC.

https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html

Centers for Disease Control and Prevention. (2022-b). Sleep and sleep disorders. CDC.

https://www.cdc.gov/sleep/index.html

National Institute of Diabetes and Digestive and Kidney Disease. (2018, February). Treatment

for overweight and obesity. NIH. https://www.niddk.nih.gov/health-information/weight-

management/adult-overweight-obesity/treatment

Kim, S., Seo. J., Kwon, Y., Cho, I., Shim, C., Ha, J., & Hong, G. (2023). Effects of continuous

positive airway pressure therapy on left ventricular performance in patients with severe

obstructive sleep apnea. Scientific Reports, (13)1. https://doi.org/10.1038/s41598-023-

32274-4

Zhang X. Zhu, J., Kim, J. H., Sumerlin, T. S., Feng, Q., & Yu, J. (2023). Metabolic health and

adiposity transitions and risks of type 2 diabetes and cardiovascular diseases: A

systematic review and meta-analysis. Diabetology & Metabolic Syndrome, (15)1, 1-14.

https://doi.org/10.1186/s13098-023-01025-w