Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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Assessment #1—Comprehensive Plan of Care to Promote Self-Management Paper
Related Competency set: 441X Chronic Care Management: An exploration of interaction of biological,
psychological, social, and environmental factors important to understanding management of chronic
conditions at the individual, family, community, and societal level.
441X – Competency Set Description: This competency set synthesizes theories and concepts related to
management of chronic conditions to support self-management; examines the impact of cultural,
spiritual, ethical, aging, and social concerns; and explores the roles and functions of the registered nurse
in managing chronic conditions.
How to complete this Competency Assessment.
A. Carefully review the guidelines, specific directions, and the evaluation rubric for this assessment, so
that you are certain to include all required components in your presentation.
B. This assessment comprises 40% of the total grade for this competency set.
C. Guidelines: In this assessment, you will develop a plan of care to promote self-management with a
patient and their family who is suffering from multiple chronic conditions. The plan of care needs to
reflect application of Self-Management Theory and must include; application and considerations for
cultural, spiritual, aging, ethical, and social concerns, derived from the case study below. In addition, it
must include nursing specific strategies that foster patient and family self-management.
D. Specific directions for this assessment: Carefully read the following directions and the case study
details below. The scoring rubric and detailed directions for this assessment are listed below.
1. The goal of this assessment is to create a comprehensive Plan of Care for a patient with a chronic
condition (s). The plan of care needs to include multiple concepts that support patient selfmanagement.
2. Review the evaluation-scoring rubric noted below so that you are certain to include all the
required elements of this assessment.
3. Carefully review the learning resources noted in the Learning Path for this assessment. We
strongly recommend that you use the set text book and the resources in the learning path for this
assessment. Please note that the scoring rubric includes criteria for using specific references noted
the in the Learning Path. You may use additional references beyond those suggested in this
Learning Path.
4. Write your answers to the assessment questions in a scholarly paper format using the headings
suggested below. Using headings adds clarity to your work and allows your faculty member to
determine if you have included all required components for this assessment.
5. All FLEX nursing scholarly submissions must use APA style format and elements:
a. A Word document that uses a 12-point font, double spacing, page numbers, and APA style
guidelines.
b. A cover page that includes your name, the competency set information including
assessment number, assessment title, and the date.
c. A reference page at the end of the assessment which includes all cited references used in
the body of this assessment paper.
Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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Please read the following case study details carefully-this assessment is based on the case as
documented below:
Mrs. Blanco is a 72-year-old Hispanic female with severe COPD who was admitted to the nursing home
from the hospital. The hospital stay was a repeat hospitalization for an acute exacerbation of COPD due to
pneumonia. Mrs. Blanco lived with husband who is involved in her care prior to the nursing home
placement. Patient’s additional health conditions include hypertension and peripheral vascular disease.
Patient’s history includes a 54 pack-year history of smoking. Her husband admits that she has not
completely quit smoking and takes off her oxygen to smoke when they were at home. Most recent
FEV1/FVC ratio indicate GOLD 3 airflow limitation (severe). Patient is still dyspneic with activity, cough
is productive of small amounts of sputum, is afebrile, and the chest x-ray indicates the pneumonia is muchimproved.
She was admitted to the nursing home for short term rehabilitation. The husband arrived to the
nursing home with a bag full of medication. Some of the medications are outdated or are not currently part
of her medication regime. Mrs. Blanco is very angry that she has been placed on a DASH diet and is
demanding that her husband bring her some “real food” to the nursing home. Patient’s goal is to return to
home with husband to be near adult children and grandchildren.
Assessment Directions – Comprehensive Plan of Care to Promote Self-Management Format
Use the following headings for this paper for each problem you identified:
Key Problems for People with Chronic Illness and Self-Management Skill Required
In order to provide the most appropriate care to Mrs. Blanco we need to understand the key problems of
chronic illness that she may be experiencing. Use the list of key problems in Chapter 2: The Illness
Experience (Larson, 2014) as listed below. Identify the problem and determine whether Mrs. Blanco may
be experiencing difficulty in this area.
Prevention of medical crisis and their management as they occur
Controlling symptoms
Carrying out of prescribed medical regimens
Prevention of, or living with, social isolation
Adjustment to changes in the disease
Attempts to normalize interactions and lifestyle
Funding-finding the necessary money
Confronting attendant psychological, marital, and familial problems
Next, using Lorig & Holman (2003) Core Self-Management Skills (five), determine which of these skills
need further development for Mrs. Blanco’. Be specific, define the skill, and offer an insight into her
current level of expertise with the skill.
Self-management Concern #1
Identify at least TWO priority chronic disease management concerns from the case study that are
amenable to Nursing Interventions. These are issues where a nurse could collaborate with the patient
and family to promote self-management.
Please make sure the concerns are actual health problems (amenable to nursing interventions) and
are clearly supported by the data provided in the case study.
Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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Document your first concern under Self-Management Concern #1 and so forth.
Describe the concern and how it may impact self-management.
Synthesis of self-management theory – Concern #1
Demonstrate your understanding of Self-Management Theory by synthesizing and applying factors
from the “Individual and Family Self-Management Theory” (IFSMT). Select TWO factors from the
Context (Risk & Protective Factors) dimension of the theory and TWO factors from the Process
(Process of Self-Management) dimension to synthesize in your plan of care for the patient and family –
for self-management concern #1. First define the factor then provide the rationale for addressing this
in the plan of care.
Patient Self-Management Goal (s) With targeted interventions and rationale for each intervention –
Concern #1
Develop ONE patient centered Self-Management goal for EACH patient self-management concern. An
appropriate goal should reflect a positive change in the self-management problem or issue and it
should be patient-centered, measurable, and realistic with a clear target date.
Next, develop your proposed plan with targeted nursing interventions that will assist the
patient/family to meet each self-management goal. Be sure to include the following considerations as
you develop your nursing interventions:
o Cultural
o Spiritual
o Social
o Ethical
o Aging
o Adherence
Remember that the purpose is to promote self-management. Nursing interventions should be specific
enough that any nurse could read them, be able to implement them, and must reflect selfmanagement
strategies.
Provide rationale for each nursing intervention from self-management theory and/or other appropriate
literature. Be sure to make use of the learning resources provided with this assessment. Please refer to
the learning path to identify resources that are required. You may use additional resources to provide
support for nursing interventions as appropriate.
Self-Management Concern #2
Document the chronic disease management second concern from the case study that are amenable to
Nursing Interventions under this section. Again, these are issues where a nurse could collaborate with
the patient and family to promote self-management.
Please make sure the concerns are actual health problems (amenable to nursing interventions) and
are clearly supported by the data provided in the case study.
Synthesis of self-management theory – Concern #2
Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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Demonstrate your understanding of Self-Management Theory by synthesizing and applying factors
from the “Individual and Family Self-Management Theory” (IFSMT). Select TWO factors from the
Context (Risk & Protective Factors) dimension of the theory and TWO factors from the Process
(Process of Self-Management) dimension to synthesize in your plan of care for the patient and family –
for self-management concern #2. First define the factor then provide the rationale for addressing this
in the plan of care.
Patient Self-Management Goal (s) With targeted interventions and rationale for each intervention –
Concern #2
Develop ONE patient centered Self-Management goal for EACH patient self-management concern. An
appropriate goal should reflect a positive change in the self-management problem or issue and it
should be patient-centered, measurable, and realistic with a clear target date.
Next, develop your proposed plan with targeted nursing interventions that will assist the
patient/family to meet each self-management goal. Be sure to include the following considerations as
you develop your nursing interventions:
o Cultural
o Spiritual
o Social
o Ethical
o Aging
o Adherence
Remember that the purpose is to promote self-management. Nursing interventions should be
specific enough that any nurse could read them, be able to implement them, and must reflect selfmanagement
strategies.
Provide rationale for each nursing intervention from self-management theory and/or other
appropriate literature. Be sure to make use of the learning resources provided with this assessment.
Please refer to the learning path to identify resources that are required. You may use additional
resources to provide support for nursing interventions as needed.
Specific Strategies to Support Self-Management
Explain how you would integrate coaching strategies to support self-management into Mrs. Blanco
plan of care using the 5’A’s of Behavioral Change (RNAO, 2010). Be specific, provide rationale for each
area, identify any challenges you might confront, and identify self-management solutions to each
challenge.
Summary and conclusions
Summarize your thoughts and conclusions about Mrs. Blanco and the Self-Management plan you
developed with her and her family. Identify next steps and further coaching that may be necessary.
May sure you use at least one set of references in your final summary.
After completion of this assessment, submit your completed paper to the labeled Dropbox for this
assessment.
Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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441X: Assessment 1 Grading Rubric
Score Exceeds Expectations Meets Expectations Does Not Meet Expectations
Content 40 points 32 points 0-31 points
Key Problems for People
with Chronic Illness and
Self-Management Skill
Required
Demonstrates
understanding of the key
problems and the tasks
required to manage
oneself with a chronic
condition.
Clearly defines and explains the key
problems and tasks required for
self-management (4 pts)
Defines and explains the
key problems and tasks
required for selfmanagement.
However,
some areas are not clear
(3.5 pts)
Does not clearly define or
explain the key problems nor
seven task required for selfmanagement.
Some areas
are vague with inadequate
explanation.
Self-Management
Concerns/Problems
Articulates and describes
patient problems that may
or do interfere with their
ability to self-manage
chronic conditions.
Two or more self-management
problems are clearly and accurately
identified and are amenable to
nursing intervention (4 pts)
One more of the selfmanagement
problems are
not clear or accurately
identified from the patient
vignette, and/or are not
amenable to nursing
intervention (3 pts)
One or more of the selfmanagement
problems are
lacking in either clarity,
accuracy, and/or
appropriateness for nursing
intervention.
Synthesis of SelfManagement
Theory
Describes the framework
for self-management that
includes an understanding
of the factors that
influence the individual’s
ability to manage.
Synthesis of concepts from the
Individual and Family SelfManagement
Theory (Context and
Process dimensions) is clear and
accurate (7 pts)
One of the concepts from
Individual and Family SelfManagement
Theory is not
clearly and/or accurately
synthesized in the plan of
care (6 pts)
Two (or more) of the
concepts from Individual and
Family Self-Management
Theory are not clearly and/or
accurately synthesized in the
plan of care.
Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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441X: Assessment 1 Grading Rubric
Score Exceeds Expectations Meets Expectations Does Not Meet Expectations
Self-Management Goals
Understands and describes
patient centered goals
that are reflective of the
patient to master their
own care.
All goals are patient-centered,
measurable, and realistic. The goals
reflect a change in the selfmanagement
problems and
supports mastery of self-care in
complex situations
(6 pts).
Goals seem to reflect
patient-centered,
measurable, and realistic
considerations but lack
clarity. The goals lack
reflection in a change in the
self-management problems.
Lack some understanding of
mastery of self-care in
complex situations that are
needed (5 pts)
Goals do not meet one or
more of the criteria (patientcentered,
measurable,
realistic, reflect a positive
change in the selfmanagement
problem, or
mastery of self-care in
complex situations).
Nursing Interventions and
Rationale
Demonstrates
understanding of selfmanagement
interventions that are
supportive of strategies
aimed at successful
management and control
of chronic illness.
Nursing interventions are specific
and clearly focused on promoting
self-management. Rationale for
each interventions explains the
purpose/reason for the
intervention and is supported by
evidence. Evidence used to develop
the plan is cited (6 pts)
Most nursing interventions
are specific and focused on
promoting selfmanagement.
Provides
rationale for most
interventions that is
generally supported by
evidence (5 pts)
Several nursing interventions
are not specific and/or do
not promote selfmanagement.
Rationale is
not provided or is unclear.
Evidence is not provided
and/or is not cited.
Application of Cultural,
Spiritual, Social, Ethical,
and Aging Issues
Describes the implications
of cultural, spiritual,
ethical, social and aging
indices in planning the
All relevant issues from the patient
vignette are reflected and
supported in the plan of care (4 pts)
One of the relevant issues
from the patient vignette is
not clearly reflected or
supported in the plan of
care (3 pts)
Two or more of the relevant
issues are not addressed in
the plan of care.
Learning Path #1 Comprehensive Plan of Care to Promote Self-Management Assessment Details 418
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441X: Assessment 1 Grading Rubric
Score Exceeds Expectations Meets Expectations Does Not Meet Expectations
care for patients with
chronic conditions
Strategies to support SelfManagement
Demonstrates
understanding of nurse
driven methods to support
patient self-management.
Clearly identifies nurse driven
strategies and methods that
support patient self-management
specific to the patient and problem.
Cites the evidence and integrates
self-management strategies
throughout the plan.
(4 pts)
Identifies nurse driven
strategies and methods that
support patient selfmanagement
but lack clarity
of patient integration. Does
not cite evidence.
(3 pts)
Vaguely describes strategies
and methods that support
patient self-management
and lacks patient integration.
Lacks synthesis and
application.
Summary and Conclusion Clearly summarizes thoughts and
conclusions. Identifies challenges
and next steps. (2 pts)
Summarizes thoughts and
conclusions; identifies
challenges and next step
but is vague and lacks clarity
(1pt)
Does not include a summary
or conclusion section in
paper
3 points 2.5 points Below 2 points
Writing and APA Format Writing is clear and succinct with no
spelling errors. References are
consistently cited in the plan of
care and in the reference list using
APA 6th edition. (3 pts)
Writing is clear with less
than 5 spelling errors.
References are usually cited
in the plan of care and in
the reference list using APA
6
th edition (some errors
noted). (2.5 pts)
Writing is unclear, and/or
there are > 5 spelling errors.
References are not cited
appropriately using APA 6th
edition.
Total points out of 40
possible:
