Week 5 Project


Creating a Plan of Care

Utilizing the information you have gathered over the last four weeks (week1-4 attached) regarding the specific illness group you identified, this week, you will create a plan of care for your chronic illness group.

In a Microsoft Word document of 5-6 pages formatted in APA style, (this page requirement includes the holistic care plan). Include the following in your plan:

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·  Provide a brief introduction describing the chronically ill group you selected and rationale for selecting this illness and the participants.

o  Clearly identify the Healthy People 2020 topic chosen and why this topic was selected.

·  Develop a holistic plan of care including patient, family and friends acceptance of the diagnosis, coping and impact on plan of care.

·  Summarize the information gathered in each week (Weeks 1–4) over 2 to 3 pages. This is should not to be copied and pasted from previous assignments.

·  Create a care plan for your chronic illness group organized using the following headings:

o  Nursing Diagnoses (at least 3 related to topic and interview results)

o  Assessment Data (objective and subjective)

o  Interview Results

o  Desired Outcomes

o  Evaluation Criteria

o  Actions and Interventions

o  Evaluation of Patient Outcomes

·  Identify strategies for the family or caregiver in the care plan and provide your rationale on how they will work.

Support your responses with examples and information from library resources, textbook and lectures.

·  Papers are professional papers so you should use third person.  Try not to use first or second person when completing.  Review APA format.

Please note that the title and reference pages should not be included in the total page count of your paper.

On a separate references page, cite your sources in your work and provide references for the citations in APA format. Support your work, using your course lectures and textbook readings. Helpful APA guides and resources are available in the  University Online Library. Below are guides that are located in the library and can be accessed and downloaded via the  University Online Citation Resources: APA Style page. The American Psychological Association website also provides detailed guidance on formatting, citations, and references at APA Style.

  • HEART DISEASE AND STROKE 1Heart Disease and Stroke 6 







    Heart Disease and Stroke

    Viviana Torres

    NSG 4055 Illiness & Disease Management Across Life Span

    South University

    December 7, 2020



    Heart Disease and Stroke

    Chronic Illness and Rationale for Choice

    A major chronic illness of specific interest, which has been identified as a Healthy People 2020 topic is ‘Heart Disease and Stroke.’ The rationale for choosing this illness is that heart disease is currently termed as the leading cause of death in the US while stroke ranks fifth (Healthy People 2020, 2020). The combination of stroke and heart disease often results in disability, poor life quality, and death. Despite the common nature of these conditions in the country, their prevention is possible through the control of certain risk factors like high cholesterol and high blood pressure. Additionally, ensuring that individuals who experience cardiovascular problems obtain timely treatment is crucial in lowering their risk of death or disability. Thus, Healthy People 2020 (2020) asserts that it is crucial to teach people the basics of recognizing key symptoms of the chronic illness to aid more individuals to obtain the required treatment. At times it may seem unnecessary for some people as they live a healthy lifestyle but heart disease can be genetic too. All of these factors make this disease a silent but deadly killer.


    1. On a scale of 1 to 10, what is your satisfaction level with the healthcare services you get from your healthcare provider with regards to your chronic illness?

    2. Are there any negative side effects of the current medication and therapy you are using to manage your condition?

    3. Are you indulging in preventive measures such as physical activity and eating a healthy diet?

    4. How confident are you in your ability to identify the signs and symptoms of an impending stroke or heart attack?

    5. Kindly list three things that you require from your healthcare provider to enhance your quality of living and help you effectively manage your chronic illness.

    Morbidity and Comorbidity of the Disease

    According to the CDC (2020), “heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States.” Approximately 30.3 million adults have been diagnosed with the problem, a figure that accounts for 12.1 percent of the adult population (CDC, 2020). Every year, 1 in every 4 deaths is related to heart conditions with 655 000 individuals dying annually from cardiovascular disease. The US spends more than $200 billion annually to deal with medicines, various healthcare services, and the lost productivity that arise from death. 6.1 percent of emergency department visits and 6.7 percent of physician office visits are attributed to heart disease. Risk factors for heart diseases include diabetes, physical inactivity, poor diet, obesity, and excessive alcohol consumption.

    With regards to comorbidity, heart disease is often accompanied by a stroke. This is why Healthy People 2020 (2020) has grouped the two conditions together as a chronic illness. Kendir et al. (2018) assert that comorbidity is a major reason for the high usage of healthcare resources, low quality of life, and increased mortality. Kendir et al. (2018) add that having one particular type of heart disease puts one at a high risk of getting another co-occurring cardiovascular problem. Heart disease is the leading cause of diseases such as ischemia, heart attack, aneurysm, arterial damage, heart arrhythmias. It may difficult to diagnose many of these as the patient may not show many symptoms. Consequently, it is vital for healthcare practitioners to be alert for the risk of a heart disease patient contracting other similar ailments.

    Impact of the Chronic Illness and Patient Morbidity on Overall Health of the Nation

    Heart disease and stroke adversely affect the overall health of the US. This chronic illness is the major reason behind many disabilities and deaths in the country. More so, the chronic illness is attributed as a major reason behind rising healthcare costs and health disparities in the US. The burden of this chronic illness is further exacerbated by the obesity epidemic, aging population, poor control of risk factors, and the limited use of prevention strategies. Thus, Mensah and Brown (2007) note the significance of the country adopting community and clinical-level guidelines with an emphasis on lifestyle, environmental, and policy changes for the facilitation of effective control and prevention of the chronic illness.

    Healthy People 2020 Goals and Objectives

    1. Improve cardiovascular health in adults.

    2. Lower stroke-related deaths.

    3. Lower the deaths related to coronary heart disease.

    4. Increase the number of adult survivors of stroke who are in a rehabilitation program.

    5. Increase the number of adult survivors of heart disease who are in a rehabilitation program.

    These goals are easier said than done. Communicating and having a clear understanding with the patient should be the first step. Most importantly, setting a plan that rightfully fits the patients needs is critical as they must be able to understand that certain lifestyle changes will need to happen in order for progress to happen for the heart disease. Proactivity is a must for the patient at this point. The patient would need to be more active when it comes to recording certain data such as keeping blood pressure charts at home, work or/if they travel to determine if the treatment plan is working or if certain changes still need to be changed.

    Stress levels influence cardiovascular disease and increase the risk for patients without it. The importance of knowing what stress can do to any person should be taught at first instance as a patient should also be aware of the dangers behind this deadly factor. Managing stress with various techniques can help prevent heart disease or keep the patient on the right track in order for the treatment plan to work.

    Part of the treatment is also making sure that the medication works for the patient as it may not interact effectively with others or their body may not accept it as it should. That is why recording data at home is crucial, to make sure the plan takes course.

    The patient should understand the repercussions also if they deviate from the treatment plan. Consequences can occur and worsen over time . Heart is probably the most delicate and most important muscle in the human body. Patients consequences can be acute or chronic kidney failure and/or eventually lead up to a stroke.




















    CDC. (2020, September 8). Heart disease facts. Center for Disease Control and Prevention. https://www.cdc.gov/heartdisease/facts.htm

    CDC. (2020, October 30). Heart disease. Center for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/heart-disease.htm

    Healthy People 2020. (2020). Heart disease and stroke. US Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke

    Kendir, C., van den Akker, M., Vos, R., & Metsemakers, J. (2018). Cardiovascular disease patients have increased risk for comorbidity: A cross-sectional study in the Netherlands. European Journal of General Practice24(1), 45-50.

    Mensah, G. A., & Brown, D. W. (2007). An overview of cardiovascular disease burden in the United States. Health Affairs26(1), 38-48.






    W4PD-Illness and the Disease Management across Life Span




    Student’s Name

    Department, Institutional Affiliation

    Course Title

    Tutor’s Name






    The successful process of prevention and the treatment of heart disease and stroke is

    achieved through the provision of the knowledge to the patients, informing the population

    about the facilities helping in the treatment and management of the conditions, and ensuring

    that the affected individuals receive the necessary support required to overcome these

    diseases. There are various resources that patients diagnosed with stroke and heart disease

    can rely on. Center for the Disease Prevention and Control (CDC) is making an effort through

    its Division for Heart Disease and Stroke Prevention (DHDSP) to collaborate with the

    partners across the government, public health, healthcare providers, and the private sectors to

    ensure that there is an improvement, detection, and the control of the heart diseases and the

    stroke risk factors. This is done with a focus on hypertension and the high cholesterol level

    (Yarnoff, et al., 2019).

    There are several programs (resources) that are supporting the goals set by the CDC

    through its DHDSP. One of the programs is the Paul Coverdell National Acute Stroke

    Program (PCNASP) which is funding 9 states to ensure that there is a coordination of the

    systems of care to help in the improvement of the quality of healthcare for the patients who

    have been diagnosed with a stroke. The Coverdell program is working to make sure that all

    the citizens of the United States are provided with the highest quality of healthcare for stroke

    by offering support to the coordinated healthcare system for the stroke disease. The creation

    of the effective stroke system of care is important in ensuring that there is the monitoring of

    the improvement in the quality and patient care from the time at which the patient is

    diagnosed with a stroke, through emergency medical services transportation to the healthcare

    facility, during hospitalization, and through their discharge from the facility to the outpatient

    care (Benjamin, et al., 2018). In terms of eligibility, all acute care healthcare facilities that

    serve the general population are considered to be eligible for the program.




    Another program is the Well-Integrated Screening and Evaluation for Women Across

    the Nation (WISEWOMAN program). It helps women in understanding as well as take part

    in the reduction of their exposure to these illnesses. It also provides services that help in the

    promotion of a long-term hear healthy lifestyle. The services offered by the WISEWOMAN

    program are funding the heart and stroke risk screening process for example screening for

    diabetes and hypertension among others. These services are available within the local

    facilities, offices of the physicians, and the community healthcare facilities (National Center

    for Chronic Disease Prevention and Health Promotion, 2020).

    Women found to be having elevated blood pressure, diabetes, and high cholesterol

    levels are assisted by this program. Upon the discussion of the clinical risks, the history of the

    illness, body weight, the nutritional status, and the physical activity; the patients or

    population are motivated to take part in setting their objectives and are then referred to the

    healthy behaviors resource support, educational materials offered through training and

    community-based organizations for example the YMCA. The eligibility for the program

    involves the individuals with low earnings, individuals with no insurance cover, individuals

    who are not fully benefiting from the insurance program as a result of the under-insurance

    especially women of ages 40 to 64 years who had previously benefitted from program

    (National Center for Chronic Disease Prevention and Health Promotion, 2020).

    The Sodium Reduction in Communities Program (SRCP) is another resource that is

    aimed at increasing the availability of lower sodium foods while at the same time engaging

    the food sector in ensuring that there is a reduction in the sodium levels in the packaged and

    restaurant foods. The benefit of this resource is that it ensures that the members of the public

    are safe from the risks of heart diseases and stroke. This is achieved by making sure that the

    packaged and the restaurant food have a lower content of sodium. The CDC through its

    DHDSP is working with the SRCP to ensure that there is teamwork with the foodservice




    distributors and food industries to ensure that there is an increase in the number of low

    sodium foods in the country. There is no eligibility for this program and it is aimed at

    ensuring that all members of the public are benefiting from the services offered to reduce the

    risk of exposure to heart and stroke diseases (National Center for Chronic Disease Prevention

    and Health Promotion, 2020).

    The integration of the resources into a plan of care

    The prevention of heart diseases and stroke involves the promotion of healthy

    lifestyle behaviors. Therefore, SRCP is integrated into the plan of care in educating the

    patients as well as the population to ensure that there is low consumption of salty foods to

    reduce the exposure to the two diseases. The SRCP program can be used to support the

    communities in creating a more healthful food environment that is targeted at expanding the

    evidence-based approaches to address the sodium intake (Long, 2018).

    Similarly, the choices of a healthy lifestyle to prevent exposure to heart diseases and

    stroke especially among women can also be achieved through the integration of the

    WISEWOMAN program into the plan of care. Through the employment of health trainers,

    women are encouraged to adopt the lifestyle behavioral changes that help in the reduction of

    the risk factors and the symptoms of stroke and heart illness (Long, 2018).

    Fight against heart illnesses and stroke requires collaborative work amongst

    healthcare providers. This includes the participation of the nutritionists to recommend the

    required amount of the salt to be used as well as the physical exercise trainer to educate

    hypertensive patients on the amount of physical exercise to take part in. The integration of

    Paul Coverdell National Acute Stroke Program into the healthcare plan is helping in ensuring

    that there is a culture of teamwork across the healthcare system to improve stroke care and

    save the lives of the population (National Center for Chronic Disease Prevention and Health

    Promotion, 2020).




    The potential advantages and disadvantages for the vulnerable population in seeking the


    One of the advantages of using these resources for the vulnerable population for

    example patients diagnosed with or exposed to stroke or heart disease is the reduction in the

    risk of exposure. The SRCP is helping in ensuring that there is an increased availability of the

    lower sodium foods while engaging the food sector to ensure that there is a reduction in the

    sodium levels in the packaged as well as restaurant foods (National Center for Chronic

    Disease Prevention and Health Promotion, 2020).

    There are also improved healthcare services to the population concerning providing

    care to the patients. The Paul Coverdell National Acute Stroke Program is helping in ensuring

    that there is the existence of stroke systems of healthcare that is important in caring and

    supporting stroke patients throughout their healthcare journey. The Emergency Medical

    Services (EMS) agencies and healthcare facilities are involved in the collection and analysis

    of the data about stroke patients and healthcare. These units share the best practices and data

    thus working to help in improving patient care (National Center for Chronic Disease

    Prevention and Health Promotion, 2020).

    The disadvantage of the SRCP program is that it is not guaranteed that the

    vulnerable population will be safe from the high salt content. Many processed foods are

    directly made at home with an increased level of salts. This makes it impossible for the

    population to be safe since working with the foodservice providers and the food industry

    partners does not guarantee the low consumption of low salt in the remote areas and the

    homes of these vulnerable populations (National Center for Chronic Disease Prevention and

    Health Promotion, 2020).

    Another disadvantage of the resources is that the transition from the EMS might be

    affected by the lower number of healthcare providers for example the nurses. The reduced




    number of nurses to handle the emergency services means that the services offered at the

    emergency services are affected. Poor services at the emergency services due to the

    inadequate healthcare providers leads to the development of the complications of

    hypertension thus leading to heart diseases and the development of stroke. This reduces the

    effectiveness of the PCNASP (National Center for Chronic Disease Prevention and Health

    Promotion, 2020).






    Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., & Cheng,

    S. (2018). American Heart Association Council on Epidemiology and Prevention

    Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke

    statistics—2018 update: a report from the American Heart Association. Circulation,

    137(12), e67-492. https://doi:10.1161/CIR.0000000000000558

    Long, C. R. (2018). Reducing the intake of sodium in community settings: evaluation of year

    one activities in the Sodium Reduction in Communities Program, Arkansas, 2016–

    2017. Preventing Chronic Disease, 15. http://dx.doi.org/10.5888/pcd15.180310

    National Center for Chronic Disease Prevention and Health Promotion. (2020, October 7).

    Heart Disease and Stroke. Retrieved from Center for Disease Control and Prevention:



    Yarnoff, B., Khavjou, O., Elmi, J., Lowe-Beasley, K., Bradley, C., Amoozegar, J., . . .

    Teixiera-Poit, S. (2019). Estimating Costs of Implementing Stroke Systems of Care

    and Data-Driven Improvements in the Paul Coverdell National Acute Stroke Program.

    Prev Chronic Dis, 16, e134. https://doi:10.5888/pcd16.190061

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