Patient Care Plan

Overview For this assignment, you will develop a proactive, patient-centered care plan for Mrs. Snyder, using the information gained from your simulated interviews in Vila Health: Care Coordination Scenario I. Focus on care coordination and national care coordination initiatives. You may use an intervention developed as part of your first assignment. Locate applicable current standards and benchmarks as you determine the best way to develop this strategy. Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assignment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback. Instructions The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed. Assess a patient’s condition from a coordinated-care perspective. Consider the full scope of the patient’s needs. Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis. Develop nursing diagnoses that align with patient assessment data. Write two goal statements for each diagnosis. Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific. Consider the psychosociocultural aspect of care. Determine appropriate nursing or collaborative interventions. List at least three nursing or collaborative interventions. Provide the rationale for each goal or outcome. Explain why each intervention is indicated or therapeutic. Cite applicable references that support each intervention. Evaluate care coordination outcomes according to measures and standards. Indicate if the goals were met. If they were not met, explain why. Describe how you would revise the plan of care based on the patient’s response to the current plan. Support conclusions with outcome measures and professional standards. Write clearly and concisely, using correct grammar and mechanics. Express your main points and conclusions coherently. Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan. Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style. Additional Requirements Use the Patient Care Plan Template provided in the Resources list. Cite 3–5 sources of scholarly or professional evidence to support your plan.