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Diabetes and Healthy People 2020 Care Plan


This project has identified the patient vulnerable to the selected health issue of diabetes and assessed one’s health status from the point of view of Healthy People 2020. The patient answered the questionnaire to help detect the support needs. The identified problems were the ideas and behaviors that resulted in the client’s health worsening including the unhealthy diet, insufficient physical activity, and smoking. The paper has listed the suggestions that the nursing professional would need to make to this person and her family members in order to help to improve her health status.


Diabetes is one of the major topic areas identified in Healthy People 2020 (U.S. Department of Health and Human Services, 2016). It is estimated that one out of ten Americans is ill with a certain form of diabetes (CDC, 2016). This condition is a hurtful problem because it bereaves its victim of the quality of life by restricting one’s mobility and leading to a loss of vitality (Fayers & Machin, 2013). The subtlety of this chronic condition is its ability to cause the accompanying problems with the death prognosis such as stroke or infarct (DeBoer, 2013). The main problem in the selected patient’s case is that she is in the risk group to develop uncontrolled diabetes because she has a genetic predisposition, high rates of blood cholesterol and blood sugar, and all types of harmful behaviors that are associated with the risks for this disorder. The following paper will address the selected case of the patient with diabetes from the point of view of Healthy People 2020 and provide the care plan for the affected person with the focus on one’s psychosocial goals.

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Care Plan

Nursing Diagnoses

  1. Controlled diabetes.
  2. Hyperlipidemia.
  3. Obesity.

Assessment Data

The client’s health needs evaluation suggested that she is in the risk group to develop uncontrolled diabetes (Barker, 2015). Her lab results have indicated high cholesterol and blood glucose rates. In addition, she has a genetic predisposition to uncontrolled diabetes and smokes, leads an inactive lifestyle, and has harmful eating habits (Fayers & Machin, 2013).

Interview Results

To identify the patient’s health issues and associated problems in connection with the patient’s family and friends, the following questionnaire was implemented to her and her close ones:

  1. How much physical activity do you have during the day/ week?
  2. How many hours a day do you watch TV?
  3. How many hours do you spend next to the computer daily?
  4. How much fast food and junk food do you have daily?
  5. How many high-sugar and high-fat meals and drinks do you have daily?
  6. How many fruits and vegetables do you have daily?
  7. How much water do you have daily?
  8. Do you have relatives with the history of diabetes?
  9. Do you have excess weight?
  10. Do you often feel tired or depressed without any specific reason?

The client’s replies analysis has suggested that she is in the risk group for the development of uncontrolled diabetes. She does not have sufficient physical activity daily. The person watches over 3 hours of TV each day. She has the harmful eating habits: she eats fast food and junk food daily and has many high-fat and high-sugar meals in her daily diet. Due to the quite low income, the patient is not able to afford to consume enough vegetables and fruits. She also has no habit to drink enough water daily but she prefers the high-sugar drinks instead. Her mother had the history of type 2 Diabetes Miletus. The patient suffers from moderate obesity of the android type and her BMI is exceeded for over 20 %. She has frequent mood swings and admits the gradual loss of vitality with each year. In the personal discussion, the patient has shared her concerns that she has no full access to the screening services she needs to control her lab results because her health insurance does not provide the full coverage and her income is not enough to cover the expenses.

Analysis of the data obtained through the questionnaire identified the health disparities she is subjected to. The social determinants observed are the ethnic and economic status. Due to the limitations imposed by the two factors, vulnerable people in the community have poor access to the quality care and disease prevention help. She and her family members also need systemic education in terms of leading the healthy lifestyle (DeBoer, 2013). A special focus on the smoking cessation and unhealthy eating habits alteration is essential during the care plan development.

Desired Outcomes

The desired outcomes are

  1. cholesterol and blood sugar rates modification;
  2. prevention of uncontrolled diabetes development; and
  3. patient’s quality of life promotion.

Evaluation Criteria

The care plan effectiveness will be analyzed after each month of implementation based on the following criteria:

  1. Patient’s blood values on cholesterol and blood sugar rates;
  2. Patient’s lifestyle modification to build the new healthy habits;
  3. Patient’s idea of her quality of life status change with the implementation of the proposed care plan.

Actions and Interventions

The healthcare provider will prescribe the medicines including Lipitor and Acarbose (Barker, 2015). One will monitor the blood cholesterol and blood sugar rates each month within the frames of the community-based federal program funding for diabetes prevention (Barker, 2015). The nurse will pay special attention to the patient’s education along with instructing the family members to ensure their contribution to the client’s lifestyle modification (Huffman et al., 2012).

Evaluation of Patient Outcomes

The patient’s outcomes will be evaluated every 3 months to build the progression trajectory (Barker, 2015). The variables of focus are

  1. cholesterol and blood sugar rates;
  2. current patient’s risk of uncontrolled diabetes development; and
  3. patient’s quality of life and health progress satisfaction rates.

Strategies for the Family

Since the problem involves every area of the individual’s life, one will not be able to do successfully without the help from the family members (Fayers & Machin, 2013). Therefore, there is a need to educate them on how to help their loved one. The family members will be offered the following specific strategies that help them assist the patient:

  1. Change family eating habits by cooking meals with the minimal fat and sugar rates;
  2. Restructure family budget to allocate more funds on purchasing fruits and vegetables;
  3. Ensure total refusal to purchase cigarettes for the patient and allow her doing so;
  4. Ensure that the patient receives help from the national smoking cessation help desk and sticks to the acquired guidance;
  5. Elaborate the family plan of physical activity
  6. Decrease the time spent by the family next to the TV.

Assignment Report from Week 1 to 4

In week 1, the completed task helped identify the complex issue affecting the health status of my community residents that is diabetes. This project also helped identify how Healthy People 2020 contribute to the resolution of the identified issue.