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Interdisciplinary Care Plan Essay Example





Interdisciplinary Care Plan

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When caring for the elderly, the health practitioners at a hospital need to apply an interdisciplinary approach to managing a condition. Patient-centered care is essential as it ensures that all aspects relating to a patient are covered and that the appropriate care is applied to bring about positive patient outcomes. The interdisciplinary treatment plan is effective as input is sought from experts from different fields to understand the condition better and advise on the best treatment solutions to be taken. The health practitioners work to ensure that proper analysis of the condition is done and that the patient’s medical history is put under consideration. In this way, service providers can develop an effective care plan that will produce the best results. The effectiveness of the interdisciplinary approach will govern how well future healthcare is performed in health facilities. In this paper, the interdisciplinary care approach will be used to treat Emily Blunt, a 69-year old female patient suffering from diabetes and heart disease.

Background Information

Patient Name: Emily Blu

Age: 69 years

Sex: Female

Demographics: Latin

Condition: Diabetes and Heart Disease

Situation: The patient has fallen three times in the Nursing Home

Medical History

Miss Blunt was first diagnosed with type 2 diabetes in 2014. She started noticing the symptoms about six months before visiting the hospital. She observed that she was always feeling very thirsty, hungry, and urinated frequently. She started experiencing blurry vision and extreme fatigue, even when performing light duties. When she started feeling tingling numbness and pain in her feet and hands, she decided to visit our hospital, where she was diagnosed with the condition. From previous medical records, it is seen that she had fasting hyperglycemia indicating that her blood sugar levels were higher than 130mg/dL after eight hours, where she had not eaten or drunk anything.

In 2017, Mrs. Blunt started having heart problems and was later diagnosed with heart disease. Her daughter, who was living with her at the time, reported that her mother started experiencing difficulty breathing, irregular heartbeats, and after a medical checkup, realized she had high blood pressure. She also reported experiencing chest pains while also having pains in the throat and neck area. Her heart rate was recorded at the hospital as 112 per minute, while the nurse recorded blood pressure of 170/98mmHg. Her resting heart rate was recorded as 110 beats per minute (BPM).

During her physical examination her pulse rate was measured to be 90 beats per minute (BPM), blood pressure of 150/90 mmHg and her Body Mass Index (BMI) was found to be 32.8 kg/m2. Her glycated hemoglobin (A1C) test indicated that she had 7.0% A1C level (normal < 5.7%). Her fasting blood sugar test brought 128 mg/dL (normal < 100 mg/dL) while an oral glucose tolerance test showed that she was at 200 mg/dL (normal <140mg/dL). Her total cholesterol results showed that she had 220 milligrams per deciliter (normal < 200 milligrams per deciliter). The LDL cholesterol results were 120 milligrams per deciliter (normal < 100 mg/dL). The patients HDL results were 40 mg/dL (normal > 50mg/dL). Triglycerides levels were found to be 162 milligrams per deciliter (normal < 150 milligrams per deciliter). Her C-reactive protein levels were found to be 3.8 mg/L (normal < 2.0 mg/L).

Medical Assessment

From the results and physical examination, it is clear that Mrs. Blunt is suffering from diabetes and heart disease. Her BMI is > 30 kg/m2. A BMI reading of over 30kg/m2 indicates an obese (Kushnir et al. 2019). Experiencing extreme fatigue and chest pains is a sign of diabetes and heart disease.

Care Plan

Mrs. Blunt has a case of type 2 diabetes and heart disease, which require a multi-disciplinary medical intervention for improved outcomes. An interdisciplinary approach is vital in developing a personalized care plan for patients. It has been shown that a customized Care Plan results in improved outcomes for patients with type 2 diabetes. The interdisciplinary team will first have to start with the most serious risk factors and work towards the less serious ones.

Nursing InterventionRationale
Test for glucose levels after mealsAn oral glucose tolerance test should be below 155 mg/dL as above that value highlights type 2 diabetes condition (Marini et al. 2017). Therefore the team will work to ensure it remains within the acceptable levels.
Monitor the resting heart rate and blood pressureHigher blood pressure than average is an indicator of heart disease and diabetes.
Measure the hemoglobin levelsCheck if it is between 4-7%, which is acceptable and indicates treatment progress.
Notify the doctor of blood above 150 mmHgHigh blood pressure is a standard indicator of heart and diabetes.
Encourage bed restExtreme fatigue is an indicator, and bedrest will be vital for wellness, especially for an aging patient (Touhy, Jett, Boscart, &

McCleary, 2018).

Advice on nutritional and dietary changesDietary changes can lead to an improvement in HbA1C levels ( Sami, Ansari, Butt and Hamid 2017)
Assess the physical activitiesPhysical activities can be an essential step in managing the patient’s weight and getting rid of harmful fats in the body.

Treatment objectives

The treatment plan’s goal will be to ensure that the patient’s BMI falls within the healthy range of < 30.0 kg/m2. Glycated hemoglobin (A1C) level to be below 5.7%, fasting glucose level to be < 100 mg/dL, and total cholesterol of less than 200 mg/Dl. This would show signs of positive progress in her treatment.


Kushnir, M., Choi, Y., Eisenberg, R., Rao, D., Tolu, S., Gao, J., … & Billett, H. H. (2019). Efficacy and safety of direct oral factor Xa inhibitors compared with warfarin in patients with morbid obesity: a single-centre, retrospective analysis of chart data. The Lancet Haematology6(7), e359-e365.

Marini, M. A., Fiorentino, T. V., Andreozzi, F., Mannino, G. C., Perticone, M., Sciacqua, A., … & Sesti, G. (2017). Elevated 1-h post-challenge plasma glucose levels in subjects with normal glucose tolerance or impaired glucose tolerance are associated with whole blood viscosity. Acta Diabetologica54(8), 775-784.

Sami, W., Ansari, T., Butt, N. S., & Ab Hamid, M. R. (2017). Effect of diet on type 2 diabetes mellitus: A review. International journal of health sciences11(2), 65.

Touhy, T. A., Jett, K. F., Boscart, V., & McCleary, L. (2018). Ebersole and Hess’ Gerontological Nursing and Healthy Aging in Canada-E-Book. Elsevier Health Sciences.

Vuohijoki, A., Mikkola, I., Jokelainen, J., Keinänen-Kiukaanniemi, S., Winell, K., Frittitta, L., … & Hagnäs, M. (2020). Implementation of a Personalized Care Plan for Patients With Type 2 Diabetes Is Associated With Improvements in Clinical Outcomes: An Observational Real-World Study. Journal of Primary Care & Community Health11, 2150132720921700.

Last Updated on June 9, 2021

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